Objectives: Organ transplant is the surgical process of removing an organ that cannot fulfill its function despite medical treatment and transplanting the corresponding organ from a donor to a recipient. Our study examined whether demographic variables such as sex, age, education status, or socioeconomic status and psychosocial variables including sensory processing sensitivity, attachment style, resilience, social support, and neuroticism predict depression, anxiety, and stress levels of living donors in the preoperative stage.
Materials and Methods: Data were collected from potential organ donors aged 18 to 60 years who voluntarily applied to the Ankara Bilkent City Hospital Organ Donation and Transplantation Center Unit. A total of 69 participants (21 kidney, 48 liver) were included in the analyses.
Results: According to the results, sex was the only demographic variable that significantly correlated with depression, anxiety, and stress, showing that female donors feel more depression, anxiety, and stress than male donors. According to regression analyses, the model including sex and other psychosocial variables was significant and explained 37% of the variance for depression. Higher levels of resilience were linked with lower levels of depression. For anxiety, similarly, the model including sex and other psychosocial variables was significant and explained 33% of the variance, that is, a higher level of resilience was associated with less anxiety. For stress, the model including sex and other psychosocial variables was significant and explained 40% of the variance. In addition to resilience, which significantly predicted anxiety, neuroticism was a marginally significant predictor, that is, high resilience and low neuroticism predicted lower levels of anxiety.
Conclusions: The findings emphasize the importance of interventions to increase the psychological resilience of potential organ donors and show that psychological support, especially for female donors and donors with high levels of neuroticism, can improve the process.

Key words : Organ donation, Psychological symptoms, Resilience

Introduction
Organ transplant is the removal of an organ that is unable to function despite medical treatment and the transfer of the corresponding organ to a recipient from a willing donor.¹ It is noteworthy that few studies have been conducted to examine the effects on the psychological health of donors, and there is no consensus in the literature regarding organ transplant donors. Livers donors were found to feel healthier compared with the general population before transplant. However, their physical health and living conditions worsened.² According to a review on kidney donors, donors experienced an increased level of depression, anxiety, stress, and health concerns after transplant.³ However, another study showed that psychological symptoms of kidney donors do not change before and after surgery.⁴ A systematic review conducted on both living organ donor groups emphasized that, although the posttransplant increase in the incidence of these symptoms is not high, psychological health of donors after surgery should not be overlooked, in accordance with the principle of nonmaleficence. Thus, attention has been drawn to the importance to identify factors that negatively affect psychological health of donors, because organ donation may cause anxiety and depression for donors.⁵ For this assessment, it is important to understand the effects on living organ donors by the transplant process and to determine which factors may affect the psychological health of living organ donors. In this regard, factors that may affect the psychological health of donors, such as gender,^6,7 sensory processing sensitivity,⁸ attachment,⁹ resilience,¹⁰ social support,³ and neuroticism,⁶ were included in this study. For determination of the variables, we considered studies conducted on donors as well as psychological health studies outside the context of organ transplant. Our study aimed to determine the factors that predict depression, anxiety, and stress levels in living organ donors during the preoperative stage. Within this scope, the predictive roles of demographic variables (sex, age, educational status, and socioeconomic status) and psychosocial and psychological variables (sensory processing sensitivity, attachment style, psychological resilience, social support, and neuroticism) on the preoperative stage of living donors were examined.

Materials and Methods

Participants
The participants of the study consisted of potential living organ donors (volunteers for organ donation who had not yet undergone surgery) who applied to the Organ Donation and Transplantation Unit of Ankara Bilkent City Hospital for living organ donation. The inclusion criteria for sampling were age between 18 and 60 years, an absence of diagnosed cognitive impairment, and a healthy or near-healthy body weight. In our present preliminary study, a total of 69 individuals (48 liver, 21 kidney) aged between 18 and 60 years (mean 35.03 years, SD = 9.14 years) were included in the analyses. Table 1 shows the demographic information of participants.

Measures
Within the scope of this study, the following scales were administered to the participants. Participants completed a demographic information form that included questions on participant’s age, sex, marital status, educational level, perceived socioeconomic status, occupation, any past or present psychological diagnoses, the type of organ volunteered for donation, the degree of kinship between the potential donor and the recipient, and the donor’s personal characterization of the relationship with the recipient. The Sensory Processing Sensitivity Scale, which measures the tendency to process various sensory stimuli intensely and deeply,¹¹ consists of 27 items rated on a 7-point Likert scale. Higher scores indicate a higher level of sensory processing sensitivity. The original form has a single-factor structure, and the Turkish adaptation studies revealed a 4-factor structure, consisting of sensitivity to external stimuli, harm avoidance, aesthetic sensitivity, and sensitivity to overstimulation.¹² The Cronbach’s alpha coefficients for the Turkish version range between .⁵⁵ and .⁸⁶ across subscales. In our present study, the total score was used. The Basic Personality Traits Inventory, which was developed to measure personality characteristics of individuals,¹³ comprises the following 5 basic personality traits: openness to experience, conscientiousness, extraversion, agreeableness, and neuroticism, along with an additional trait, negative valence. For the Basic Personality Traits Inventory, the internal consistency coefficients calculated for the personality traits range between .⁷¹ and .⁸⁹, indicating good reliability.¹³ In our present study, only the neuroticism subscale was used. The Multidimensional Scale of Perceived Social Support was developed to measure perceived social support from 3 different sources¹⁴ and consists of 12 items rated on a 7-point Likert scale. Higher scores indicate higher levels of perceived social support. The latest Turkish version of the scale was adapted by Eker and colleagues in 2001.15 The Cronbach’s alpha coefficient of this form is .⁸⁹.15 In our present study, the total perceived social support score was used. The Experiences in Close Relationships Inventory-II scale was developed to assess adult attachment dimensions¹⁶ and consists of 2 subdimensions (anxiety and avoidance) and a total of 36 items. Each item, which reflects individuals’ thoughts about their close/romantic relationships, is rated on a 7-point Likert scale, and anxiety and avoidance scores are computed for each participant. Lower scores on the subdimensions indicate a secure attachment style. In the Turkish adaptation of the scale, high internal consistency was reported for both dimensions, with Cronbach’s alpha coefficients of .⁸⁶ for anxiety and .⁹⁰ for avoidance.¹⁷ In our present study, the scale was used as a total score. The Depression, Anxiety, and Stress Scale was originally developed as 42-item scale.¹⁸ The short version of the scale consists of 21 items rated on a 4-point Likert scale and includes 3 subscales, that is, depression, anxiety, and stress.¹⁹ Each item is scored from 0 (never) to 3 (almost always) based on the frequency of the symptoms experienced, and higher scores indicate higher levels of symptoms. In the Turkish adaptation of the scale the internal consistency coefficients were reported as .⁸² for the depression subscale, .⁸¹ for the anxiety subscale, and .⁷⁶ for the stress subscale.²⁰ In our present study, all 3 subscales were used. The Connor-Davidson Resilience Scale Short Form was developed to assess individuals’ psychological resilience.²¹ The short form of the scale was revised as a unidimensional structure comprising 10 items on a 5-point Likert scale.²² Higher scores indicate higher levels of psychological resilience. In the Turkish adaptation of the short form the Cronbach’s alpha internal consistency coefficient of the scale was reported as .⁸¹.23

Procedure and data analyses
Ethical approval for our study was obtained from the Ankara Hacı Bayram Veli University Ethics Commission. Permission was also obtained from the Ankara Bilkent City Hospital Organ Donation and Transplantation Center Unit through the Ankara Provincial Health Directorate. Written informed consent was obtained from the participants before data collection, and all participation was voluntarily. Data were collected via Google Forms in an online format. After data collection from volunteer potential organ donors, we conducted correlation and hierarchical regression analyses with SPSS software (version 22).

Results
According to the correlational results, participants’ sex was the only demographic variable significantly associated with depression, anxiety, and stress (r =.-28, P < .⁰⁵; r = .-27, P < .⁰⁵; and r = .-29, P < .⁰⁵; respectively), showing that female donors reported higher levels of depression, anxiety, and stress versus male donors. For depression, anxiety, and stress, we conducted 3 separate multiple hierarchical regression analyses. According to the regression analyses, for depression, the model including sex and other psychosocial variables was significant and explained 37% of the variance (R2 = .³⁷, F[5,⁶²] = 7.63; P < .⁰⁰¹). Resilience was the only significant predictor (β = -.²⁴, t = -2.13; P < .⁰⁵), and a high level of resilience predicted a low level of depression. Because sex was significant in correlation analyses, it was added in the first step of the regression model, but the significance of sex disappeared when the other variables were added. For anxiety, similarly, the model including sex and other psychosocial variables was significant and explained 33% of the variance (R2 = .³³, F[5,⁶²] = 6.57; P < .⁰⁰¹), and resilience was the only significant predictor of anxiety (β = -.²⁵, t = -2.11; P < .⁰⁵), showing that a high level of resilience predicted a low level of anxiety. For stress, the model including sex and other psychosocial variables was significant and explained 40% of the variance (R2 = .⁴⁰, F[5,⁶²] = 8.45; P < .⁰⁰¹). In addition to resilience, which significantly predicted anxiety (β = -.³², t = -2.91; P < .⁰¹), neuroticism was a marginally significant predictor (β = .²⁴, t = 1.94; P = .⁰⁶), meaning that a high level of resilience and a low level of neuroticism predicted a low level of anxiety. Results are summarized in Table 2.

Discussion
Our present study examined whether demographic variables predict depression, anxiety, and stress levels of living donors in the preoperative stage and indicated that sex was the only demographic variable significantly correlated with these psychological variables. Correlation analyses revealed a significant negative association between participants’ sex and these variables, demonstrating that female donors reported higher levels of psychological symptoms than male donors. This finding is consistent with previously published studies that have identified female sex as a risk factor for anxiety⁶ and negative psychological outcomes.⁷ Thus, our present findings reinforce the established view that female sex is associated with elevated levels of psychological distress among living donors. However, regression analyses did not show a significant correlation between sex and the outcomes. It could be that psychosocial factors are more prominent predictors versus sex to explain the variance of the outcomes. According to the regression analyses, psychological resilience was found to be a significant negative predictor of the levels of depression, anxiety, and stress. High levels of resilience were associated with lower levels of all 3 psychological symptoms, which supported the emphasis in the literature regarding the protective role of resilience for donors and its function as a buffer in reducing adverse outcomes.¹⁰ Donors have been noted to be generally psychologically resilient individuals.¹⁰ Moreover, the resilience levels of kidney transplant donor candidates are predictive indicators of preoperative quality of life.²⁴ That is, individuals with high resilience levels have been found to possess better preoperative physical and psychological health, social relationships, and environmental conditions.²⁴ Consequently, previously published studies have supported the findings of our present study on the importance of the protective role of resilience on stress, anxiety, and depression. These findings highlight the importance of interventions aimed to enhance psychological resilience defined as the ability to recover from stress and adapt positively in response to difficulties in the living organ donation process. In addition to these findings, neuroticism was identified as a marginally significant predictor of stress levels. Studies in the literature have shown that donors with high neuroticism levels are more vulnerable to stress²⁵ and posttransplant anxiety symptoms.^6,26 The finding in our present study supports and extends the literature. Considering that neuroticism is a significant risk factor for anxiety,²⁷ it is understood that the tendency toward emotional instability complicates the psychological adaptation of donors. Other psychosocial variables (sensory processing sensitivity, secure attachment, and social support) were not found to be significant predictors for depression, anxiety, and stress in the hierarchical regression analyses. The possible reason could be that the study focused on a period of the pretransplant process with high levels of uncertainty. During the pretransplant period, psychological resilience and neuroticism may predominate, whereas the effects of variables such as social support or secure attachment may become more evident in the postoperative phase. Furthermore, donors may tend to possess high altruism, good psychological resilience, and a generally healthy psychological profile.⁹ It can be argued that data collection immediately before surgery could create a bias. In addition to their high psychological resilience, donors may have attempted to portray themselves as more capable by denial of their actual psychological state with an aim to avoid disruption of the process. It is possible that this situation reduced the likelihood of finding significant relationships among the other variables included in the research. Therefore, further analyses with data to be collected in the postoperative period could more clearly reveal the roles of these variables on long-term psychological adjustment. The limitations of our study were its small sample size and cross-sectional design. Future studies with larger samples and a longitudinal design to examine the preoperative versus postoperative psychological health of this donor group will contribute to the knowledge in this field.

Conclusions
Our study revealed that psychological resilience is a strong predictor of the preoperative psychological health indicators among living organ donors. High resilience was significantly associated with lower levels of depression, anxiety, and stress. The fact that neuroticism is a significantly important predictor of stress and that female donors generally reported higher psychological symptoms indicates the presence of at-risk groups. Considering these findings, it remains critical for transplant center support programs to focus on interventions aimed to increase psychological resilience and to provide personalized counseling services by identification of potential at-risk donor candidates at an early stage. Psychological support, especially for female donors and individuals with high levels of neuroticism (emotional instability, sensitivity to stress) may help improve overall well-being of donors throughout the donation process.