Arranging Inpatient Psychiatric Treatment for a Patient with a Left Ventricular Assist Device.

For patients with a left ventricular assist device (LVAD) as a bridge to transplant, receiving mental health treatment, particularly inpatient treatment, can be challenging due to their complex medical needs. Unfortunately, patients with LVADs have higher rates of depression, anxiety, and suicidality than the general population, making this restricted access to care more problematic. Limited access to full spectrum mental health treatment may negatively impact patients' transplant psychosocial candidacy for transplant. In this article, we present a successful case of arranging inpatient psychiatric treatment for a patient with an LVAD on a medical inpatient unit through a collaborative approach that spans multiple services and programs. This article details the strategic interprofessional process involved in devising the plan that allowed for treatment and successful discharge.

Substance use screening in transplant populations: Recommendations from a consensus workgroup.

Transplant patients are frequently treated with substances that have dependence potential and/or they may have a history of substance use disorders. The Psychosocial and Ethics Community of Practice of the American Society of Transplantation formed a Drug Testing Workgroup with participation from members of the Pharmacy Community of Practice and members of the Academy of Consultation-Liaison Psychiatry. The workgroup reviewed the literature regarding the following issues: the role of drug testing in patients with substance use disorders, for patients prescribed controlled substances, legal, ethical and prescription drug monitoring issues, financial and insurance issues, and which patients should be tested. We also reviewed current laboratory testing for substances. Group discussions to develop a consensus occurred, and summaries of each topic were reviewed. The workgroup recommends that transplant patients be informed of drug testing and be screened for substances prior to transplant to ensure optimal care and implement ongoing testing if warranted by clinical history. While use of certain substances may not result in the exclusion for transplantation, an awareness of the patient's practices and possible risk from substances is necessary, allowing transplant teams to screen for substance use disorders and ensure the patient is able to manage and minimize risks post-transplant.

The Clinical Conundrum of Cannabis: Current Practices and Recommendations for Transplant Clinicians: An Opinion of the Immunology/Transplantation PRN of the American College of Clinical Pharmacy.

Cannabis, or marijuana, comprises many compounds with varying effects. It has become a treatment option for chronic diseases and debilitating symptoms, and evidence suggests that it has immunomodulatory and antiinflammatory properties. Transplant centers are more frequently facing issues about cannabis, as indications and legalization expand. As of February 2020, 33 states and the District of Columbia have legalized medical cannabis, and 14 have legalized recreational cannabis. Moreover, 8 states have passed legislation prohibiting the denial of transplant listing solely based on cannabis use. Studies demonstrate the potential for significant pharmacokinetic and pharmacodynamic interactions between cannabis and immunosuppression. Additionally, safety concerns include increased risk of myocardial infarction, ischemic stroke, tachyarrhythmias, malignancy, neurocognitive deficits, psychosis, other neuropsychiatric disorders, cannabis use disorder, respiratory symptoms, and infection. A recent retrospective database study found a negative association between documented cannabis use disorder and graft survival, but little additional evidence exists evaluating this relationship. In the absence of robust clinical data, transplant centers need a clear, reasoned, and systematic approach to cannabis. The results of our national survey, unfortunately, found little consensus among institutions. As both recreational and medicinal cannabis become more ubiquitous nationwide, transplant centers will need to develop comprehensive policies to address its use.

The Rochester Relapse Risk Scale: Developing a Standardized Approach to Predicting Substance Relapse in Liver Transplant Candidates.

OBJECTIVES: Substance abuse is a risk factor for nonadherence and graft failure after orthotopic liver transplant. This study aimed to evaluate the ability of an internally developed tool, the Rochester Relapse Risk Scale, to predict substance relapse in liver transplant candidates. MATERIALS AND METHODS: This single-center, retrospective, observational study included adult patients evaluated for orthotopic liver transplant using the Rochester Relapse Risk Scale. Primary outcome was rate of substance relapse, as measured by the risk scale, which stratified patients into relapse risk levels based on the number of factors present. RESULTS: In total, 303 patients (71.6% men, 90.4% White, median age of 55 years [interquartile range, 49-60 y]) were included. Median follow-up time was 212 days (interquartile range, 73-661 d). Seventy-four patients (24.4%) relapsed at 127 days (interquartile range, 55-461 d) after evaluation, with 60.8% who relapsed within 6 months. Relapse rates correlated with assigned risk level, with 8.3% relapsing at low, 19.0% at low-moderate, 25.3% at moderate, 33.8% at moderate-high, and 40.0% at high risk. High-risk cohorts had significantly shorter median time to relapse versus low-risk cohorts (104 vs 154 days; P = .001). CONCLUSIONS: Assignment of relapse risk level according to the Rochester Relapse Risk Scale aligned with rates of relapse. Additional studies are needed to refine the tool, assess inter-rater reliability, and confirm findings in prospective, multicenter studies.

Predicting success after gastric bypass: the role of psychosocial and behavioral factors.

BACKGROUND: Success after bariatric surgery requires behavioral modification. This study analyzes outcomes after Roux-en-Y gastric bypass surgery performed by a single surgeon between 1994 and 2002, and correlates preoperative factors with long-term outcome. METHODS: A bariatric database has been maintained since 1994. Beginning in April 1997, patients completed preoperative and annual postoperative questionnaires that collected an array of psychosocial information. We hypothesized that certain attributes are predictive of success after surgery. RESULTS: Of the 243 patients in our database, 181 enrolled after 1997. A total of 149 were seen for follow-up at 1 year. Life Experiences Survey (LES) scores and sexual satisfaction improved significantly. Perceived obesity-related health problems, motivation unrelated to social distress about obesity, a Sense of Coherence (SOC) score >110, and an LES score <-1 each independently predicted better weight loss (P<.05). A history of sexual abuse correlated with poorer weight loss (P<.05). Patients with more confidants, multiple previous dieting attempts, and greater anticipated postoperative diet-related stress tended toward better weight loss, but these data did not reach significance. CONCLUSIONS: Intrinsic motivational factors appear to predict greater weight loss after surgery. Ongoing follow-up will help determine the utility of preoperative evaluations and the role of preoperative intervention in those with poor predictive factors.

Treating depression: psychiatric consultation in cardiology.

Depression is the most common psychiatric disorder in coronary artery disease, and it can worsen cardiac outcomes. Also, cardiac disease predisposes patients to the development of depression. Assessment of depression is an important part of ongoing patient contacts. It can be easily done through the regular use of a self-report screening tool and the clinical interview. Treatment can consist of antidepressant use, psychotherapy and mindfulness-based group therapy. The antidepressants known as the selective serotonin reuptake inhibitors can generally be used safely in cardiac patients. They are a mainstay in the treatment of moderate to severe depression. Individual cognitive-behavioral therapy can treat milder forms of depression and can augment antidepressant use in more severe cases. Mindfulness-based group therapy can provide patients with additional means of handling distress while offering social contact and support, both of which are important in the treatment of depression. The use of consulting psychiatric services offers the cardiologist a collaborative team approach when treating patients with depressive illnesses.

The impact of a history of sexual abuse on weight loss in gastric bypass patients.

A history of sexual abuse has been associated with failure at weight loss. The authors sought to determine whether a history of sexual abuse influences success after gastric bypass surgery. Presurgical self-report questionnaires collected information, including sexual abuse history and previous psychiatric hospitalization, and 27% reported a history of sexual abuse. A history of sexual abuse correlated with (nonsignificantly) less loss of excess weight at 12 and 24 months after surgery. No significant difference in excess-weight loss was detected among those with history of sexual abuse. Therefore, such abuse histories should not preclude surgery for these patients.