Received: July 4, 2008 Revised: October 12, 2008
Accepted: October 19, 2008
Published online: February 14, 2009
Abstract
An increasingly number of transplant centers have
integrated a psychological assessment within their
protocol for evaluation of patients being considered for
transplantation. This paper highlights the psychological
criteria for inclusion or exclusion for listing, briefly
discusses the psychological dynamics of patients, and
addresses possible psychotherapy and pharmacological
therapy, before and after transplant.
© 2009 The WJG Press and Baishideng. All rights reserved.
Key words: Liver transplantation; Psychology;
Contraindications; Cognitive behavior therapy
Peer reviewer: Justin Nguyen, MD, Mayo Clinic, 4500 San
Pablo Road, Jacksonville 32224, United States
Morana JG. Psychological evaluation and follow-up in
liver transplantation. World J Gastroenterol 2009; 15(6):
694-696 Available from: URL: http://www.wjgnet.
com/1007-9327/15/694.asp DOI: http://dx.doi.org/10.3748/
wjg.15.694
INTRODUCTION
Orthotopic liver transplantation (OLTx) is a major
surgical procedure that can precipitate distress, anxiety
and depression. The experience of the last few years
of many transplantation centers has highlighted the
importance of a thorough and routine psychological
assessment before considering the patient as a possible
candidate for listing[1] . The importance of identifying
psychological/psychiatric, and/or possible psychosocial
problems is necessary in order to eliminate or prevent
the insurgence of possible psychological problems post-transplant.
Most transplant centers have included an
initial psychological evaluation in their work-up protocol,
to evaluate the psychological strengths and possible
liabilities of the patient who is being considered for an
OLTx, so as to provide interventions such as: smoking
cessation therapy, drug/alcohol rehabilitation, and
improvement of compliance; that is, behavior that needs
to be resolved before surgery, in order to reduce possible
behavioral liabilities after transplantation [2].
The transplant itself has deep psychological
implications, which may exist within the affective, social
and interpersonal realm of the individual’s personality. In
the postoperative phase, there may be manifestations of
adjustment disorders, psychopathological disturbances,
problems with compliance, as well as non-adherence
to the therapeutic plan [3]. To reiterate, it is therefore
necessary to carry out an accurate evaluation of the
psychological and personality profile of each individual
being considered for listing for possible OLTx.
PSYCHOLOGICAL ASSESSMENT OF
THE POTENTIAL CANDIDATE FOR
TRANSPLANT
During the initial interview, the psychologist’s main goal
is to determine how much the candidate knows or is
aware of his/her medical status, or better yet, whether
he/she has accepted his/her medical condition. The
communication of the necessity of a liver transplant
automatically induces the patient to think that
conventional therapies and/or less invasive surgery
are no longer an option. In such a case, the patients’
psychological-emotional reactions take a course of their
own, for example, they start experiencing: (1) sense of
despair; (2) concerns for his/her medical status and
sense of imminent death; (3) reactive and/or correlated
psychopathology.
During the course of the psychological evaluation,
then, patients may find themselves living two traumatic
events (both real), at the same time: (1) sense of imminent
death or (2) rebirth through the transplant. During this
phase, it has been observed that patients most often feel a
sense of doubt, anxiety, ambivalence, fear and frustration,
Morana JG et al . Psychological aspects of liver transplantation 695
www.wjgnet.com
which, if associated with a high level of psychological
distress, can have consequences that can even lead to nonacceptance
of the transplant. A careful psychological
evaluation (cognitive, emotional and interpersonal) allows
for an accurate course of psychotherapy [4].
The therapist must take into consideration those
needs, deficits and assets that the patients possess
in order to bring them step by step toward the final
objective, which is the transplant. The specific,
individualized treatment plan allows for an improvement
of the quality of life (QOL) of the patient who will
undergo a transplant and, specifically, during the
postoperative period [4].
Ethically, the ability to give informed consent
comprises three key elements: adequate information,
adequate decision-making capacity, and freedom from
coercion (President’s Commission for the Study of
Ethical Problems in Medicine and Biomedical and
Behavioral Research, 1982) [5]. Therefore, to this end, it
appears fundamental to the psychologist’s evaluation,
whose goal is to evaluate the degree of the patient’s
knowledge and understanding of the various items on
the informed consent. To this extent, it is fundamental
that the patient’s ability for decision-making is
evaluated. If there is a suspected inability to do this
(because of mental retardation or social deficits, etc),
then, it is imperative that further testing be done
using standardized tools for the evaluation of IQ (e.g.
Wechsler Adult Intelligence Scale-Revision). If mental
deficiency is found, then it becomes a legal issue, that
is, it is necessary to assign a legal guardian who can
represent the patient, in order to protect his/her rights.
In the absence of a cognitive defect, if it is evaluated
that the patient has not fully understood the context of
such a document because of difficulty in perceiving such
information, or in the event that there is resistance in
accepting such information, then it becomes imperative
that the patients undergoes a psycho-educational
process, in order to induce them to adjust their nonfunctional
behavior or lifestyle in accordance with
the expectations of the transplant team. For example,
patients might need to be educated on topics such as
maintaining adequate personal hygiene, given that they
will be treated with immunosuppressant medication for
the rest of their lives.
Table 1 outlines the absolute and relative
contraindications for transplant listing. Although each
item needs detailed discussion, for the purpose of
this paper, the discussion will focus on alcohol/drug
addiction and psychopathology, which are the two
contraindications that need the most active intervention
of the psychologist. The candidacy of patients who have
an addiction has varied within each transplant center;
however, in recent years, there has been an attempt
to formalize the criteria for such patients. In Italy, the
Director of the National Transplant Institute
assigned a group of psychologists
and psychiatrists to work on the guidelines to be
applied in transplant centers across the country. This
group (GLI PSI TO), of which the present author
is a member, debated and focused a lot of time and
energy in determining the criteria for listing patients
with addiction. The consensus was, also following the
lead of guidelines set forth by the United Network for
Organ Sharing, that patients may be considered for
listing after 6-12 mo abstinence, and that they have to
be active participants in a rehabilitation center (even as
an out-patient). With such patients, during this period
of abstinence at our center (Istituto Mediterraneo
per Trapianti e Terapie ad alta Specializzazione;
ISMETT), the treatment is two-fold: patients are sent
to a rehabilitation center closest to their residence,
where the main focus is the toxicological component
of the problem; while at ISMETT, the psychologists
work in full synergy with such centers in an attempt to
give patient support, in order to access those possible
psychosocial resources that are needed for a positive,
favorable prognosis.
With regard to psychopathology, it is important
to note that it is not always a contraindication for
transplantation per se. In fact, if patients manifest an
active psychosis, not well compensated even with
pharmacological therapy [6], it is obvious that this would
be an absolute contraindication, especially since there is
an absence of the necessary resources needed to undergo
an OLTx. In other cases, however, such as in mood
disorders and anxiety disorder, psychopharmacological
therapy in conjunction with psychotherapy may
ameliorate the disturbance to the point at which
patients are placed in a condition in which they can
reach a functional emotional, affective equilibrium that
allows them to manage the eventual distress related to
the transplant. Such patients, however, need constant
support before, during and after transplantation. During
the pre-transplantation phase, specifically for sensitivity
to stress; in the post-transplant phase, most importantly
because of immunosuppressant therapy that might
precipitate mood swings, irritability, mania and anxiety
Psychotherapy and/or psychotherapy in conjunction
with pharmacological treatment might be indicated
during all the phases of the transplant process. Cognitive
behavior therapy is the psychotherapeutic approach
implemented at ISMETT, an approach which has been
evaluated as being most beneficial with these patients,
as they are individuals who tend to manifest traits such
as depression, anxiety and phobia. Anxiety reduction
techniques, autogenic training, systematic desensitization,
relaxation techniques, guided imagery, pain management
and hypnosis are techniques that might be implemented,
and that normally bring more immediate results for the
management of those symptoms already mentioned as
those being manifested by patients during the transplant
process (table 2).
CONCLUSION
The role of the psychological assessment and monitoring
during the pre- and post-transplant phases, as well
as the ongoing follow-up intervention, is generally
highly valued by organ transplant teams because of the
significant health consequences of organ transplant
failure. Identifying and reducing psychological risk
factors can play an important role in overall long-term
success of transplantation.
REFERENCES
1 Widows MR, Rodrigue JR. Clinical practice issues in solid
organ transplantation. In: Llewelyn S, Kennedy P, eds.
Handbook of Clinical Health Psychology. Oxford: John
Wiley & Sons, 2003
2 Everhart JE, Beresford TP. Liver transplantation for
alcoholic liver disease: a survey of transplantation programs
in the United States. Liver Transpl Surg 1997; 3: 220-226
3 Dew MA, Dunbar-Jacob J, Switzer GE, DiMartini AF, Stilley
C, Kormos RL. Adherence to the medical regimen in organ
transplantation. In: Rodriguez J, edtor. Biopsychosocial
Perspectives on Transplantation. New York (NY): Kluwer/
Plenum Publishers, 2001: 93-124
4 Dew MA, Goycoolea JM, Switzer GE, Allen AS. Quality
of life in organ transplantation: effects on adult recipients
and their families. In: Trzepacz PT, DiMartini AF, eds. The
transplant patient: Biological, Psychiatric and Ethical Issues
in organ transplantation. Cambridge: Cambridge University
Press, 2000: 67-145
5 President's Commission for the Study of Ethical Problems
in Medicine and Biomedical and Behavioral Research.
Washington (DC): United States Government Printing
Office, 1982
6 Triffaux JM, Wauthy J, Bertrand J, Limet R, Albert A,
Ansseau M. Psychological evolution and assessment in
patients undergoing orthotopic heart transplantation. Eur
Psychiatry 2001; 16: 180-185
S- Editor Li DL L- Editor Kerr C E- Editor Yin DH
696 ISSN 1007-9327 CN 14-1219/R World J Gastroenterol February 14, 2009 Volume 15 Number 6
Informed consent
Personality profile
Psychopathology
Past/present psychiatric history
Effect of illness on daily life activities
Defense mechanism employed and coping skills
Motivation for surgery
Treatment compliance
Support from the family
Socioeconomic support (together with social worker’s evaluation)
Awareness of information regarding the actual surgical event and
future treatments
Use/abuse of alcohol and/or drugs (see paragraph on this topic)
QOLTable 2 Domains of the pre-transplant psychological evaluation
Josephine G Morana
Online Submissions: wjg.wjgnet.com World J Gastroenterol 2009 February 14; 15(6): 694-696
wjg@wjgnet.com World Journal of Gastroenterology ISSN 1007-9327
doi:10.3748/wjg.15.694 © 2009 The WJG Press and Baishideng. All rights reserved.
Josephine G Morana, Department of Clinical Psychology,
Mediterranean Institute for Transplantation and Advanced
Therapies (ISMETT), University of Pittsburgh Medical Center,
Via Tricomi 1, Palermo 90127, Italy
Author contributions: Morana JG wrote the manuscript.
Correspondence to: Dr. Josephine G Morana, Mediterranean
Institute for Transplantation and Advanced Therapies (ISMETT),
University of Pittsburgh Medical Center, Via Tricomi 1,
Palermo 90127, Italy. jmorana@ismett.edu
Telephone: +39-91-2192111 Fax: +39-91-2192344
giovedì 10 dicembre 2009
Psychological evaluation and follow-up in liver transplantation
Received: July 4, 2008 Revised: October 12, 2008
Accepted: October 19, 2008
Published online: February 14, 2009
Abstract
An increasingly number of transplant centers have
integrated a psychological assessment within their
protocol for evaluation of patients being considered for
transplantation. This paper highlights the psychological
criteria for inclusion or exclusion for listing, briefly
discusses the psychological dynamics of patients, and
addresses possible psychotherapy and pharmacological
therapy, before and after transplant.
© 2009 The WJG Press and Baishideng. All rights reserved.
Key words: Liver transplantation; Psychology;
Contraindications; Cognitive behavior therapy
Peer reviewer: Justin Nguyen, MD, Mayo Clinic, 4500 San
Pablo Road, Jacksonville 32224, United States
Morana JG. Psychological evaluation and follow-up in
liver transplantation. World J Gastroenterol 2009; 15(6):
694-696 Available from: URL: http://www.wjgnet.
com/1007-9327/15/694.asp DOI: http://dx.doi.org/10.3748/
wjg.15.694
INTRODUCTION
Orthotopic liver transplantation (OLTx) is a major
surgical procedure that can precipitate distress, anxiety
and depression. The experience of the last few years
of many transplantation centers has highlighted the
importance of a thorough and routine psychological
assessment before considering the patient as a possible
candidate for listing[1] . The importance of identifying
psychological/psychiatric, and/or possible psychosocial
problems is necessary in order to eliminate or prevent
the insurgence of possible psychological problems post-transplant.
Most transplant centers have included an
initial psychological evaluation in their work-up protocol,
to evaluate the psychological strengths and possible
liabilities of the patient who is being considered for an
OLTx, so as to provide interventions such as: smoking
cessation therapy, drug/alcohol rehabilitation, and
improvement of compliance; that is, behavior that needs
to be resolved before surgery, in order to reduce possible
behavioral liabilities after transplantation [2].
The transplant itself has deep psychological
implications, which may exist within the affective, social
and interpersonal realm of the individual’s personality. In
the postoperative phase, there may be manifestations of
adjustment disorders, psychopathological disturbances,
problems with compliance, as well as non-adherence
to the therapeutic plan [3]. To reiterate, it is therefore
necessary to carry out an accurate evaluation of the
psychological and personality profile of each individual
being considered for listing for possible OLTx.
PSYCHOLOGICAL ASSESSMENT OF
THE POTENTIAL CANDIDATE FOR
TRANSPLANT
During the initial interview, the psychologist’s main goal
is to determine how much the candidate knows or is
aware of his/her medical status, or better yet, whether
he/she has accepted his/her medical condition. The
communication of the necessity of a liver transplant
automatically induces the patient to think that
conventional therapies and/or less invasive surgery
are no longer an option. In such a case, the patients’
psychological-emotional reactions take a course of their
own, for example, they start experiencing: (1) sense of
despair; (2) concerns for his/her medical status and
sense of imminent death; (3) reactive and/or correlated
psychopathology.
During the course of the psychological evaluation,
then, patients may find themselves living two traumatic
events (both real), at the same time: (1) sense of imminent
death or (2) rebirth through the transplant. During this
phase, it has been observed that patients most often feel a
sense of doubt, anxiety, ambivalence, fear and frustration,
Morana JG et al . Psychological aspects of liver transplantation 695
www.wjgnet.com
which, if associated with a high level of psychological
distress, can have consequences that can even lead to nonacceptance
of the transplant. A careful psychological
evaluation (cognitive, emotional and interpersonal) allows
for an accurate course of psychotherapy [4].
The therapist must take into consideration those
needs, deficits and assets that the patients possess
in order to bring them step by step toward the final
objective, which is the transplant. The specific,
individualized treatment plan allows for an improvement
of the quality of life (QOL) of the patient who will
undergo a transplant and, specifically, during the
postoperative period [4].
Ethically, the ability to give informed consent
comprises three key elements: adequate information,
adequate decision-making capacity, and freedom from
coercion (President’s Commission for the Study of
Ethical Problems in Medicine and Biomedical and
Behavioral Research, 1982) [5]. Therefore, to this end, it
appears fundamental to the psychologist’s evaluation,
whose goal is to evaluate the degree of the patient’s
knowledge and understanding of the various items on
the informed consent. To this extent, it is fundamental
that the patient’s ability for decision-making is
evaluated. If there is a suspected inability to do this
(because of mental retardation or social deficits, etc),
then, it is imperative that further testing be done
using standardized tools for the evaluation of IQ (e.g.
Wechsler Adult Intelligence Scale-Revision). If mental
deficiency is found, then it becomes a legal issue, that
is, it is necessary to assign a legal guardian who can
represent the patient, in order to protect his/her rights.
In the absence of a cognitive defect, if it is evaluated
that the patient has not fully understood the context of
such a document because of difficulty in perceiving such
information, or in the event that there is resistance in
accepting such information, then it becomes imperative
that the patients undergoes a psycho-educational
process, in order to induce them to adjust their nonfunctional
behavior or lifestyle in accordance with
the expectations of the transplant team. For example,
patients might need to be educated on topics such as
maintaining adequate personal hygiene, given that they
will be treated with immunosuppressant medication for
the rest of their lives.
Table 1 outlines the absolute and relative
contraindications for transplant listing. Although each
item needs detailed discussion, for the purpose of
this paper, the discussion will focus on alcohol/drug
addiction and psychopathology, which are the two
contraindications that need the most active intervention
of the psychologist. The candidacy of patients who have
an addiction has varied within each transplant center;
however, in recent years, there has been an attempt
to formalize the criteria for such patients. In Italy, the
Director of the National Transplant Institute
assigned a group of psychologists
and psychiatrists to work on the guidelines to be
applied in transplant centers across the country. This
group (GLI PSI TO), of which the present author
is a member, debated and focused a lot of time and
energy in determining the criteria for listing patients
with addiction. The consensus was, also following the
lead of guidelines set forth by the United Network for
Organ Sharing, that patients may be considered for
listing after 6-12 mo abstinence, and that they have to
be active participants in a rehabilitation center (even as
an out-patient). With such patients, during this period
of abstinence at our center (Istituto Mediterraneo
per Trapianti e Terapie ad alta Specializzazione;
ISMETT), the treatment is two-fold: patients are sent
to a rehabilitation center closest to their residence,
where the main focus is the toxicological component
of the problem; while at ISMETT, the psychologists
work in full synergy with such centers in an attempt to
give patient support, in order to access those possible
psychosocial resources that are needed for a positive,
favorable prognosis.
With regard to psychopathology, it is important
to note that it is not always a contraindication for
transplantation per se. In fact, if patients manifest an
active psychosis, not well compensated even with
pharmacological therapy [6], it is obvious that this would
be an absolute contraindication, especially since there is
an absence of the necessary resources needed to undergo
an OLTx. In other cases, however, such as in mood
disorders and anxiety disorder, psychopharmacological
therapy in conjunction with psychotherapy may
ameliorate the disturbance to the point at which
patients are placed in a condition in which they can
reach a functional emotional, affective equilibrium that
allows them to manage the eventual distress related to
the transplant. Such patients, however, need constant
support before, during and after transplantation. During
the pre-transplantation phase, specifically for sensitivity
to stress; in the post-transplant phase, most importantly
because of immunosuppressant therapy that might
precipitate mood swings, irritability, mania and anxiety
Psychotherapy and/or psychotherapy in conjunction
with pharmacological treatment might be indicated
during all the phases of the transplant process. Cognitive
behavior therapy is the psychotherapeutic approach
implemented at ISMETT, an approach which has been
evaluated as being most beneficial with these patients,
as they are individuals who tend to manifest traits such
as depression, anxiety and phobia. Anxiety reduction
techniques, autogenic training, systematic desensitization,
relaxation techniques, guided imagery, pain management
and hypnosis are techniques that might be implemented,
and that normally bring more immediate results for the
management of those symptoms already mentioned as
those being manifested by patients during the transplant
process (table 2).
CONCLUSION
The role of the psychological assessment and monitoring
during the pre- and post-transplant phases, as well
as the ongoing follow-up intervention, is generally
highly valued by organ transplant teams because of the
significant health consequences of organ transplant
failure. Identifying and reducing psychological risk
factors can play an important role in overall long-term
success of transplantation.
REFERENCES
1 Widows MR, Rodrigue JR. Clinical practice issues in solid
organ transplantation. In: Llewelyn S, Kennedy P, eds.
Handbook of Clinical Health Psychology. Oxford: John
Wiley & Sons, 2003
2 Everhart JE, Beresford TP. Liver transplantation for
alcoholic liver disease: a survey of transplantation programs
in the United States. Liver Transpl Surg 1997; 3: 220-226
3 Dew MA, Dunbar-Jacob J, Switzer GE, DiMartini AF, Stilley
C, Kormos RL. Adherence to the medical regimen in organ
transplantation. In: Rodriguez J, edtor. Biopsychosocial
Perspectives on Transplantation. New York (NY): Kluwer/
Plenum Publishers, 2001: 93-124
4 Dew MA, Goycoolea JM, Switzer GE, Allen AS. Quality
of life in organ transplantation: effects on adult recipients
and their families. In: Trzepacz PT, DiMartini AF, eds. The
transplant patient: Biological, Psychiatric and Ethical Issues
in organ transplantation. Cambridge: Cambridge University
Press, 2000: 67-145
5 President's Commission for the Study of Ethical Problems
in Medicine and Biomedical and Behavioral Research.
Washington (DC): United States Government Printing
Office, 1982
6 Triffaux JM, Wauthy J, Bertrand J, Limet R, Albert A,
Ansseau M. Psychological evolution and assessment in
patients undergoing orthotopic heart transplantation. Eur
Psychiatry 2001; 16: 180-185
S- Editor Li DL L- Editor Kerr C E- Editor Yin DH
696 ISSN 1007-9327 CN 14-1219/R World J Gastroenterol February 14, 2009 Volume 15 Number 6
Informed consent
Personality profile
Psychopathology
Past/present psychiatric history
Effect of illness on daily life activities
Defense mechanism employed and coping skills
Motivation for surgery
Treatment compliance
Support from the family
Socioeconomic support (together with social worker’s evaluation)
Awareness of information regarding the actual surgical event and
future treatments
Use/abuse of alcohol and/or drugs (see paragraph on this topic)
QOLTable 2 Domains of the pre-transplant psychological evaluation
Josephine G Morana
Online Submissions: wjg.wjgnet.com World J Gastroenterol 2009 February 14; 15(6): 694-696
wjg@wjgnet.com World Journal of Gastroenterology ISSN 1007-9327
doi:10.3748/wjg.15.694 © 2009 The WJG Press and Baishideng. All rights reserved.
Josephine G Morana, Department of Clinical Psychology,
Mediterranean Institute for Transplantation and Advanced
Therapies (ISMETT), University of Pittsburgh Medical Center,
Via Tricomi 1, Palermo 90127, Italy
Author contributions: Morana JG wrote the manuscript.
Correspondence to: Dr. Josephine G Morana, Mediterranean
Institute for Transplantation and Advanced Therapies (ISMETT),
University of Pittsburgh Medical Center, Via Tricomi 1,
Palermo 90127, Italy. jmorana@ismett.edu
Telephone: +39-91-2192111 Fax: +39-91-2192344
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