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ARTICLE
Psychiatric Evaluation of Children During the Organ Transplant Process

Objectives: Organ transplantation is performed frequently in Turkey. A routine psychiatric examination is performed before all transplant procedures, and psychiatric support is continued during the posttransplant period. In this study, we reviewed the psychiatric consultation records of child and adolescent patients admitted to Başkent University Hospital who underwent or were scheduled to undergo transplant to determine the prevalence of psychiatric disorders in this population.

Materials and Methods: Fifty-nine transplant patients were seen by the Department of Child and Adolescent Psychiatry between 2012 and 2015 and were evaluated based on the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition.

Results: Thirty patients (50.8%) were female, and 29 patients (49.2%) were male. The mean age of the study population was 10.2 ± 4.5 years, and the mean age at transplant was 9.9 ± 4.6 years. In total, 69.5% of participants were diagnosed with a psychiatric disorder. The most common diagnosis was adjustment disorder, with a prevalence of 52.4%.

Conclusions: Our study found that psychiatric disorders are frequently encountered in pediatric transplant patients. This study revealed a higher prevalence of psychiatric disorders during the posttransplant period than during the pretransplant period.


Key words : Child and adolescent psychiatry, Consultation, Organ transplant

Introduction

Transplantation is a tiring process for both patients and their families.1 Psychiatric disorders are common in transplant recipients because of the high expectations of the transplant procedure, difficulties experienced during the transplant period, fear of death, psychiatric side effects of medications used after transplant, and incomplete understanding of the transplant process.1 Therefore, psychiatrists have important responsibilities before and after transplant. The goals of the pre-transplant psychiatric assessment are to detect and treat any psychiatric disorders and to determine whether a patient is resilient enough to withstand the problems and difficulties of the transplant procedure. For this purpose, a cognitive and developmental evaluation is completed first. The family's knowledge of the transplant process and their understanding of the reasons for transplant, as well as their expectations and emotions, are major determinants of treatment compliance during the posttransplant period. The hope of getting well after transplant reduces the rate of psychiatric disorders in transplant recipients.2

An assessment of family functionality has a more important role in children and adolescents, who differ slightly from adult transplant recipients. Previous studies have suggested that physicians provide adult transplant recipients with inadequate information about the transplant process,3 which impairs treatment compliance and adversely affects transplant success.4 If patients do not adequately comprehend the process, they may have unrealistic expectations for the posttransplant period, which may give rise to a number of problems ranging from adjustment disorder to posttraumatic stress syndrome.5 Although patients have a higher prevalence of psychiatric disorders during the pretransplant period, the posttransplant period is also quite troublesome.6 A study comparing pretransplant and posttransplant patients with end-stage renal failure found that posttransplant patients had lower rates of depression and anxiety.7 However, one-sixth of patients who had cardiac transplant had psychiatric and/or psychological disorders.8 Evaluating the difficult process that transplant patients must endure and determining the characteristics of this period would lead to more efficient treatment of these psychiatric disorders.

In this study, we reviewed the psychiatric consultation records of child and adolescent patients presenting to Başkent University Hospital who underwent or were scheduled to undergo transplant to determine the prevalence of psychiatric disorders in this population. We hoped to provide a better understanding of the transplant process in children and adolescents to help them cope with the difficulties related to this process and provide emotional help and support.

Materials and Methods

In this study, we retrospectively reviewed the medical records of 59 patients presenting to Başkent University Hospital before and/or after transplant who consulted with the Department of Child and Adolescent Psychiatry between 2012 and 2015. Sociodemographic characteristics, diagnoses, transplanted organs, psychiatric histories, family histories, and the personal histories of the patients were reviewed. If a patient had been seen before transplant, we investigated the extent to which the patient and his/her family knew about the transplant process and the illness that caused the need for transplant. We also examined the motivation of the patient and his/her family with regard to transplantation and treatment adherence and reviewed the psychiatric history of the patient and his/her family. Data on substance abuse history, family environment, psychosocial support, and relationship with the medical team were also collected. If the medical team detected a problem related to any of these items, the patient was reinvestigated after transplant. We also performed a mental status examination on the patient's current state of mind, including appearance, attitude, behavior, speech, mood and affect, thought processes, thought content, perception, impulse control, cognition (including example orientation, memory, and concentration), insight, and judgment.

The psychiatric disorders of the patients were diagnosed based on the Diagnostic and Statistical Manual of Mental Disorders (4th edition). Patients with suspected cognitive problems were assessed using the Wechsler Intelligence Scale for Children-Revised.

Statistical analyses
Sociodemographic data, diagnosed disorders, transplanted organ, disease duration, time from transplant, psychiatric diagnoses, and treatment modality were analyzed using descriptive statistics. The Bonferroni test was used to examine differences related to the identity of the transplanted organs. The relationship between the use of living-donor or deceased-donor organs and psychiatric disorders was examined by Spearman correlation analysis. Comparative analyses were performed with the independent-samples t test, and a P value < .05 was considered significant. The SPSS 16.0 statistical software package (SPSS Inc., Chicago, IL, USA) was used for all statistical calculations.

Results

Of the 59 patients from age 0 to 18 years who were evaluated, 41 patients were seen both before and after transplant and 18 patients were seen during the posttransplant period for irrelevant transplant problems.

Thirty patients (50.8%) were female, and 29 patients (49.2%) were male. The mean age of the study population was 10.2 ± 4.5 years, the mean age at transplant was 9.9 ± 4.6 years, and the mean time from disease onset to transplant was 5 ± 4.3 years. The mean number of siblings was 2.8 ± 1.3, and patients were, on average, the second child in their family. Parents of 23 patients (39%) were in a consanguineous marriage. Nine patients (15.3%) could not attend school. Thirty-one patients (52.6%) were assessed before transplant, 20 (33.9%) were assessed after transplant, and 8 (13.5%) were assessed both before and after transplant. Four patients were seen immediately after transplant.

Nineteen patients (32.2%) had liver disorders, 20 (33.9%) had kidney disorders, and 20 (33.9%) had heart disorders. The primary indications for organ transplant are summarized in Table 1. Twelve patients (20.3%) died before transplant or during posttransplant follow-up (7 before transplant, 4 after transplantation, and 1 during surgery). The distribution of psychiatric diseases in patients is shown in Table 2.

An analysis of the psychiatric history of the patients revealed that 11 patients (18.6%) had been previously evaluated by the Department of Child and Adolescent Psychiatry. Ten patients (16.9%) had a family history of a psychiatric disorder. A consultation was requested from our department for 28.4% of patients who had undergone a transplant within a 3-year period. Furthermore, a psychiatric disorder was detected in 69.4% of the patients seen by our department. No statistically significant difference was observed between the identity of the transplanted organ and the psychiatric diagnosis of the transplant recipient (83.3% of kidney transplant patients, 68.4% of liver transplant patients and 55% of heart transplant patients had psychiatric disorders). Eleven patients had 2 or 3 comorbid psychiatric disorders. Twenty-four patients (40.7%) had sleep disturbances, and 22 (37.3%) had appetite problems.

Thirty-one patients (52.5%) were started on medications, 5 (8.5%) received play therapy, and 3 (5.1%) were referred for special education. Twenty patients (34%) were deemed not to require any therapy. The patients were examined an average of 2 times. In total, 20 antidepressants (fluoxetine, sertra­line, citalopram, escitalopram, and imipramine), 16 antipsychotics (haloperidol, risperidone, aripip­razole, and quetiapine), 5 anxiolytics (clonazepam and diphenhydramine), and 1 psychostimulant (methylphenidate) were prescribed. These drugs (antidepressant + antipsychotic, antidepressant + anxiolytic, or antipsychotic + psychostimulant) were used in combination in 5 patients. Drug changes were made in 5 patients.

No differences in psychiatric disorders were detected before and after transplant (P = .16); however, psychiatric illnesses were more common after heart transplant (P = .01). A psychiatric disorder was observed in 15 of 31 patients (48.4%) before organ transplant, with 19 of 20 posttransplant patients (95%) having a psychiatric disorder. Wait time before transplant did not affect the frequency of psychiatric illness (P = .59).

Two of 20 kidney transplant recipients, 5 of 19 liver transplant recipients, and all 20 heart transplant recipients received organs from deceased donors. However, the rate of psychiatric illnesses in children with liver failure was higher in living-donor recipients than in deceased-donor recipients (P = .08, r = 0.66).

We found that 12 patients who died during follow-up had been diagnosed with a psychiatric disorder. Of the 6 patients (5 heart and 1 liver transplant recipient) who received psychiatric treatment, 5 were started on medications, and 1 was referred for play therapy. An analysis of the deceased patients who were diagnosed with psychiatric disorders revealed that these patients were evaluated at our clinic an average of 2.1 times. The patients who died during the pretransplant period had worse psychiatric medication compliance and did not regularly use their psychiatric medications.

Discussion

According to the literature, the most common liver disorders causing liver failure and leading to liver transplant in children are biliary atresia, Wilson disease, and fulminant hepatitis.9-11 Vesicoureteral reflux has been shown to be the most common cause of kidney failure in children,12 and dilated cardiomyopathy has been shown to be the most common type of cardiomyopathy that leads to heart transplant in childhood.13,14 Our study also identified these disorders as the most common indications for organ transplant. Hence, our study sample accurately reflected the general transplant population.

The prevalence of consanguineous marriage in Turkey is 20.9%,15 whereas this study found that 39% of married couples were consanguineous. Because the prevalence of recessively inherited genetic disorders increases in consanguineous marriages, there may be a higher prevalence of consanguineous marriage among parents of children with organ failure than among the general population.9 Thus, it is of great importance that, when possible, consanguineous parents be provided with genetic counseling and genetic screening to prevent genetic diseases within a family.

Our study detected a 15.3% rate of school absenteeism. A previous study reported a prevalence of 5.5% for the same parameter in patients who consulted a child and adolescent psychiatry clinic in southeastern Turkey for various reasons.16 The three-fold increased prevalence in our study suggests that disorders requiring transplant severely impair patient functionality. In our population, school absenteeism resulted from prolonged hospital stays, accounting for the possible impact of the primary disorder on cognitive skills and physical complaints. A family-based care approach should be adopted to prevent children from falling behind their peers, and therapeutic play, child life services, hospital-based schools, and pain control should be incorporated into treatment.17 A previous study indicated that pediatric transplant candidates experience school adaptation problems, which also contribute to school absenteeism.18 Therefore, interventions for patients with existing psychiatric disorders would support efforts to facilitate their school adaptation, increase their quality of life, and help them lead more independent lives.

Among all pediatric and adolescent patients undergoing transplant, a psychiatric consultation is the most commonly requested for heart transplant recipients. This is primarily because heart transplant can be only performed with organs from deceased donors. Previous research has suggested that the anxiety level of pediatric patients increases as the waiting period for heart or lung transplant procedures is prolonged.19,20 Transplant procedures with organs from deceased donors can be anxiety provoking, as the exact date of the transplant is entirely unclear. Moreover, children are continuously anxious because they could die at any moment during the waiting period for a suitable organ. One study reported that concerns experienced during the waiting period are related to thoughts of death, physical pain, and tissue rejection.21 However, the incidence of psychiatric illness in patients with hepatic failure is higher in patients who receive transplants from living donors, which is due to the guilt related to organ retrieval from a living donor.6 Overall, we observed that both living-donor and deceased-donor transplant procedures may increase the risk of psychiatric illness.

The prevalence of psychiatric disorders is as high as 60% among heart, kidney, and liver transplant candidates.22 In our study, the rate of consultation requests for transplant patients was 28.4% during a 3-year period. Furthermore, 69.4% of the patients seen were diagnosed with a psychiatric disorder. According to the National Psychiatry Action Plan issued by the Republic of Turkey Ministry of Health between 2011 and 2013, the rate of clinically significant problematic behavior among children and adolescents was 11%.23 Such a high rate of psychiatric disorders compared with the general population should be considered when examining patients undergoing or being scheduled for transplant. Indeed, all patients should undergo a psychiatric evaluation before and after transplant.

Adjustment disorder is the most common psychiatric diagnosis made in pediatric transplant patients,1,24 and our study consistently found a high prevalence of this condition. Depression and anxiety disorders are also common among pediatric patients undergoing transplant.25-28 Adjustment disorder, anxiety, and depression impair quality of life and may even cause patients to commit suicide, thereby contributing to the high morbidity and mortality rates.29 Adjustment disorder, which is characterized by the development of emotional or behavioral symptoms in response to an identifiable stressor or stressors, is the most common psychiatric diagnosis (50% of diagnoses) associated with an increased incidence of attempted and completed suicide among hospitalized patients.30 Consequently, a psychiatric evaluation is important not only for patients with moderate psychiatric symptoms but also for those with mild psychiatric symptoms.

Organ transplant is costly in terms of its impact on the economy and workforce, and failure to recognize a psychiatric disorder in this population can lead to a loss of patients and workers.

According to our analysis of the pharmacologic interventions administered to transplant patients with psychiatric disorders, monotherapy was usually sufficient, although additional therapy was needed by 5 patients. A switch in medications was made in only 5 patients, suggesting that psychiatric problems can be effectively treated when appropriately addressed.

The presence of comorbid psychiatric disorders during the posttransplant period is an important risk factor for organ rejection.31 Patients with psychiatric disorders have a low rate of medication compliance and an increased health risk. Our results indicate that patients who died before undergoing transplant had worse medication compliance. Poor medication compliance indicates poor treatment compliance and appears to affect transplant success, albeit indirectly. However, this study showed a higher prevalence of psychiatric disorders after transplant, and psychiatric disorders were detected even after successful transplant procedures. Such paradoxical psychiatric disorders usually follow transplants from living donors,6 suggesting that guilt may be responsible for this phenomenon. In this context, even patients undergoing a successful transplant procedure should be carefully evaluated by a psychiatrist.

It was previously demonstrated that post­transplant psychosocial status is strongly correlated with pretransplant psychosocial factors.32 Thus, although it is not legally binding (original date of May 29, 1979, No. 2238; Official Gazette Date of June 3, 1979, Official Gazette No. 16655; Law on Organ and Tissue Harvesting, Preservation, and Transport), an evaluation of pediatric patients by a practitioner with expertise in psychiatry before transplant is considered to be of great importance. Indeed, a psychiatric disorder was detected in 15 of 31 patients (48.4%) evaluated before the transplant procedure.

The retrospective design of the study and the lack of neuropsychologic testing for all patients are limitations of our study. Nevertheless, this is the first study to review the consultation records maintained by the Department of Child and Adolescent Psychiatry on organ transplants in children in Turkey.

In conclusion, chronic conditions and the transplant process itself cause psychiatric problems in pediatric and adolescent patients both before and after transplant. This study highlights the impor­tance of a psychiatric evaluation for ensuring the quality of life and independence of transplant patients. This study revealed a higher prevalence of psychiatric disorders during the posttransplant period than during the pretransplant period. A thorough psychiatric evaluation during the pretransplant period may help prepare patients for the transplant process and reduce the prevalence of posttransplant psychiatric problems. Organ transplant is a treatment modality that can achieve favorable outcomes only when performed with a multi­disciplinary approach.


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DOI : 10.6002/ect.2017.0056


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From the 1Department of Child and Adolescent Psychiatry, the 2Unit of Pediatric Nephrology, Department of Pediatrics, the 3Unit of Pediatric Gastroenterology, Department of Pediatrics, the 4Department of Cardiovascular Surgery, and the 5Department of General Surgery, Faculty of Medicine, Başkent University, Ankara, Turkey
Acknowledgements: The authors have no conflicts of interest to disclose and received no funding for this study.
Corresponding author: Burcu Akın Sarı, Başkent University Hospital 10. Sk. No:38 Hayırlı Apt. Bahçelievler 06490 Ankara, Turkey
Phone: +90 505 322 7070
E-mail: carpediemburcu@yahoo.com