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Dr. Luis Pintor Coordinador de la Unidad de Psiquiatría de Enlace Hospitalaria

This article explores the importance of considering psychosocial factors in pre-transplant assessments, focusing on risk factors and their impact on compliance. It also discusses evaluation tools and provides insights from the Hospital Clínico of Barcelona.

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Dr. Luis Pintor Coordinador de la Unidad de Psiquiatría de Enlace Hospitalaria

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  1. Psychosocial issues in pre-transplant assessment Dr. Luis Pintor Coordinador de la Unidad de Psiquiatría de Enlace Hospitalaria Hospital Clínico de Barcelona

  2. Index • Introduction • Is there evidence to talk about “Psychosocial risk factors”? • How to evaluate these psychosocial factors? • Our experience in the Hospital Clínico of Barcelona • Conclusion

  3. 1. Introduction

  4. Therewas no literatureonoutcomes of hearttransplants in patientswithschizophrenia. Havingschizophreniaisanautomaticexclusioncriterionforhearttransplant in themajority of transplantprogramsworldwide. Havingschizophreniamakespeople vulnerable, and with areducedlikelihood of complyingwithcomplex post-transplanttreatment. Transplant had initially been denied by the Ethics Committe of the hospital

  5. Psychosocial factors to be considered I recently completed my residency and started a practice. I have been asked by a local surgeon to evaluate patients for liver transplant. What are the crucial components of such an evaluation? Reply from Jennifer G. Gotto, M.D., Director of CL Service at Cedars Sinai, Consultation-Liaison Service, Department of Psychiatry and Mental Health, Cedars-Sinai Medical Center, Los Angeles, California: Psychiatrichistory and currentsymptoms. Compliance Social support Personality and coping Cognitive status and understanding of transplant Expectations, commitment and motivation

  6. 2. Is there evidence to talk about “Psychosocial risk factors”?

  7. Are theylinkedtocompliance?

  8. Depression ----------------------------- a psychiatricdisorder Hostility--------------------------------- a psychological variable Motivation, Engagement-----------decreasedpurpose in life Thesewereassociatedwithsubsequentincreasedrisk of all-causedmortality Are theylinkedtocompliance?

  9. Psychosocial factors to be considered Medical and psychiatrichistory and currentsymptoms. Addictivedisorders Social support Personality and coping Cognitive status and understanding of transplant Expectations, commitment and motivation Compliance

  10. Non compliance in organtransplantrecipients • Overall non complianceratesvaryfrom 20% to 50% (Laederach-Hofmann and Bunzel, 2000) Admittedtobenonadherenttoimmunosuppresivetherapy: 40% Ratefound in theliterature: 20-37%

  11. How to evaluate psychosocial factors?

  12. Pre-transplant assessment tools PschosocialAssessment of CandidatesforTransplantation (PACT, 1989) - Consists of 8 items; equallyrated; on 5-point scale - Predictivevalidity has notbeenwellestablished - OnlyusedforBonemarrowtransplant and smallnumber of lung. Transplantevaluation Rating Scale (TERS, 1993) - Consists of 10 items, 3-point scale; no eachequallyrated - Predictivevalidity has notbeenwellestablished - TERS has onlybeenstudied in Bonemarrowtransplant Stanfordintegratedpsychosocialassessmentfortransplant (SIPAT, 2009) - Consists of 18 items, notequallyrated - Liver, heart, lung, kidneytransplantation - Predictivevalidityisgoodforrejection, hospitalization, non adherence - Cons: . Notbeabletopredictorganfailure and mortality. . Non adherenceinferredfrom notes of clinicians.

  13. Total score: 0 - 170

  14. Knowledge &Understanding of the Medical Illness Process (that caused specific organ failure). 0 Excellent understanding --- 2 ---- 4 ----- 6 ---- 8 Poor understanding 2. Knowledge & Understanding of the Transplant Process. 0 Excellent understanding --- 2 ---- 4 ----- 6 ---- 8 Poor understanding 3. Willingness/Desire for Treatment (Transplant). 0 Excellent --- 1 ---- 2 ----- 3 ---- 4 Poor 4. Treatment Compliance/Adherence (Pertinent to medical issues). 0 Excellent --- 2 ---- 4 ----- 6 ---- 8 Poor • Lifestyle Factors (Including diet, exercise, fluid restrictions; and habits according to organ). 0 Self iniciated --- 1 ---- 2 ----- 3 ---- 4 Resistant Score: 0 - 32

  15. 6. Availability of Social Support System 0 Excellent --- 2 ---- 4 ----- 6 ---- 8 Poor 7. Functionality of Social Support System 0 Excellent --- 2 ---- 4 ----- 6 ---- 8 Poor 8. Appropriateness of physical living space & environment 0 Excellent --- 1 ---- 2 ----- 3 ---- 4 Poor Score: 0 - 20

  16. 9. Presence of Psychopathology (mood, anxiety, psychosis & others) 0 None --- 2 ---- 4 ----- 6 ---- 8 Extreme psychopathology 9a -Depression 0---2---6----8 9b -Anxiety 0---2---6----8 9c -Mania 0---2---4---6----8 9d -Psychosis 0---2---4---8 10. Organic Psychopathology or Neurocognitive Impairment (Current or History):Illness or treatment/medication induced psychopathology (e.g., encephalopathy, Rx-induced psychosis) 0 None --- 2 mild ---- 6 moderate ---- 8 severe 10a. Assessment of Current Cognitive Functioning (in the absence of Intellectual Disability)(Use Montreal Cognitive Assessment [MoCA]) 0 Normal --- 3 borderline ---- 5 Impaired 10b. Assessment of Current Intellectual Functioning (based on IQ) 0 None --- 1 Borderline ---- 2 mild disability ----- 3 ---- 4 severe---- 5 profound 11. Influence of Personality Traits vs. Disorder 0 None --- 2 minimal ---- 4 mild ----- 6 moderate ---- 8 severe 12. Problems withTruthfulness or Deceptive Behavior during treatment or evaluation process 0 None --- 2 minor ---- 4 mild ----- 6 moderate ---- 8 severe 13. Overall Risk for Psychopathology (including items 9 - 12) 0 None --- 1 minimal ---- 2 mild ----- 3 moderate ---- 4 severe Score: 0 - 78

  17. 14. Alcohol Use Disorder(AUD) 0 None --- 2 no problematic ---- 4 mild ----- 6 moderate ---- 8 severe 15. Alcohol Use Disorder – Risk for Relapse 0 None --- 2 low risk ---- 4 moderate ---- 6 severe ----- 8 extreme risk 16. Substance Use Disorder– Including Prescribed & Illicit Substances 0 None --- 2 minimal ---- 4 mild ---- 6 moderate ----- 8 severe drug use disorder 17. Substance Use Disorder – Risk for Relapse 0 None --- 2 low risk ---- 4 moderate ---- 6 severe ----- 8 extreme risk 18. Nicotine Use Disorder 0 None --- 2 past use ---- 6 recent use ---- 8 active use Score: 0 - 40

  18. The Stanford Integrated Psychosocial Assessment for Transplant (SIPAT)

  19. 4. Our experience with SIPAT

  20. The Spanish version of the Stanford Integrated Psychosocial Assessment for Transplant (SIPAT): adaptation and reliability

  21. 5. Conclusions

  22. Psychiatric disorders are not the only, or even, the most important psychosocial risk factors in transplant processses. • Psychosocial domains to be considered for organ transplantation are: psychiatric disorders, lack of social support, cognitive impairment, personality disorders, and abuse of drugs. • Related with all of the above is compliance. • Compliance/Adherence could be a final common pathway to produce bad prognosis in organ transplantation. • Different tools have been used to evaluate candidates from a psychosocial point of view. SIPAT seems to be the most appropriate nowadays. • SIPAT consists of 4 domains: readiness level, social support, psychiatric/cognitive/personality disorders, and addictive disorders. • Spanish validation of SIPAT works well.

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