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here for Article 1 This article is the second in a series featuring Rebecca Cogwell Anderson, PhD, who serves as director of Transplant Psychological Services at the Medical College of Wisconsin. As part of her many responsibilities, Rebecca Cogwell Anderson, PhD, conducts psychological evaluations of organ transplant candidates and potential donors. “We need to ensure that both the transplant recipient and the donor are stable psychiatrically, medically and socially before the surgery—and that they have adequate resources to support them post-operatively,” she says. The majority of these procedures are liver and kidney transplants. With kidney transplant candidates, Anderson sees patients based on referrals from a medical team member who has a concern about the patient’s possible non-compliance, substance abuse, eating disorder, or psychological problems such as depression or anxiety. With liver transplant patients, Anderson evaluates all candidates since these individuals are often very sick and the illness may have a significant impact on their quality of life.
As part of evaluating transplant patients, Anderson administers the MBMD™ (Millon™ Behavioral Medicine Diagnostic) and the BSI® (Brief Symptom Inventory) tests at the first session. The MBMD test helps assess for several issues that are critical with transplant candidates. “A primary concern is to ensure that transplant patients have adequate social support,” says Anderson. “Many people think a transplant is an instant cure, but it’s a process. Patients need time to get their strength back and they may have emotional ups and downs post-operatively. If a patient doesn’t appear to have sufficient support, I will try to involve family members in our discussions to make sure there is a plan in place.” In addition, the MBMD assessment helps Anderson identify whether the patient may have issues with compliance. Anderson describes the case of a male patient in his mid-50’s who was waiting for a liver transplant. “His MBMD results indicated that compliance was likely to be a problem because of his passive indifference to his medical condition,” she says. “However, the patient had a supportive wife and family. We conducted a family session in which we talked to the patient about the importance of recognizing his symptoms and reporting them to his doctor. The patient admitted that he wasn’t particularly good at staying on track with this responsibility. So, we made a verbal contract with him and his wife. We asked him, “Will you agree that it’s okay for your wife to remind you to call the doctor and take your meds and that you won’t get mad at her for doing so?” Gaining his willing consent to this arrangement allowed us to take his wife out of the ‘nagging’ role and fostered a spirit of teamwork for the couple.” The MBMD test also provides Anderson with health history information, including whether the patient may have problems with drugs or alcohol—a vital issue with transplant patients. And, the test helps identify whether there is the potential for decompensation post-operatively. “If the MBMD results point to a concern in this area, I’m going to alert the medical team—particularly because steroids, which are often used with transplant patients, can increase a patient’s risk for decompensation,” she says.
Anderson also administers the BSI test to transplant patients, which gives her perspective on psychological symptoms during a specific timeframe. “If there are significant scale elevations on the BSI scales, I might refer the patient to a psychiatrist for medication therapy, incorporate the information when developing a psychological treatment plan, or in some cases administer the MCMI-III™ (Millon™ Clinical Multiaxial Inventory-III), which provides an in-depth assessment of psychopathology.” The BSI test often illuminates issues that a patient might not readily share. As an example, Anderson relates the case of a male patient who was referred to her for evaluation prior to a second kidney transplant after the first kidney transplant had failed. During Anderson’s initial meeting with the patient, he presented as somewhat typical. But on his BSI results, the paranoid ideation and psychoticism scales were both very elevated. “While elevation on one of these scales doesn’t necessarily mean that the patient is hallucinating or psychotic, we’re concerned when both scales are markedly elevated,” she says. “When I went over the test results with him—as I do with all patients who are tested—I asked him about whether he’d had irrational thoughts or hallucinations,” she says. “He admitted that he was having auditory hallucinations, which had begun after his first transplant. He said he’d never told anyone that he heard voices because he was afraid they’d think he was crazy.” Anderson talked with the transplant doctors, who reduced the patient’s steroid levels, and referred him to a psychiatrist, who prescribed an antipsychotic medication. In addition, Anderson conducted therapy with the patient. As a consequence of these steps, the patient’s symptoms resolved. “Because the patient was functioning, he probably would have been approved for the transplant list and experienced the same positive surgical outcome, even if we had not detected that he was having hallucinations,” says Anderson. “But he would have continued hearing voices–and thinking he was crazy because of it. Information obtained from the BSI enabled us to significantly improve his quality of life.”
Anderson has found the BSI test useful for other applications beyond initial assessment. On occasion, she readministers the test to transplant patients if they have been on the waiting list for a long time and she is concerned that their coping skills might be deteriorating. “Since the BSI is a point-in-time assessment, I can compare current and past results to see whether the patient is improving or having more difficulty.” In addition, Anderson readministers the test to patients who report that their coping difficulties have increased following surgery. “If the BSI test indicates that the patient is doing better, I can go over the results with the person; seeing progress in black and white often helps improve the patient’s state of mind. On the other hand, if the BSI confirms that the patient’s distress has increased, I can share the test and retest results with the team to help them determine next steps.”
The BSI and MBMD tests also help Anderson evaluate a number of psychosocial factors that are as important to consider in the donor as in the transplant recipient—factors that donors might not think to discuss with the team. “Potential donors may be selfless people who are highly focused on the needs of the transplant recipient, not on their own needs,” says Anderson. “And, they may be reticent to reveal any concerns about themselves for fear that it will disqualify them as donors.” To help surface these issues, Anderson administers the MBMD and BSI tests to all potential donors. “If the tests identify any concerns, Anderson and the transplant coordinator make the decision about whether to ask the person to come in for a clinical interview. For any donor with whom they conduct a clinical interview, they share the test and interview findings with the medical team so that they can develop a treatment plan if needed. “About 85% of the time we are able to eliminate any concerns that have been raised,” says Anderson. “For example, if the BSI indicates that the donor is experiencing depression, we might refer the person to his or her family doctor to address this issue before undergoing surgery.” The MBMD test helps Anderson assess such factors as whether the donor will be able to deal with the stress of surgery, can manage possible complications, and has sufficient social support. “If the MBMD brings issues to light, we can talk with the donors to make sure that they have clear expectations about the surgery—and we can take practical steps to address concerns,” she says.
Anderson cites the case of a female donor whose MBMD results indicated she would have a difficult time coping if medical complications occurred that might extend her stay at the hospital. Following up on this concern in the clinical interview, Anderson discovered that the woman was very fearful of hospitals because she’d had some negative experiences while previously hospitalized for an unrelated issue. “We developed a treatment plan to help reduce her anxiety about the hospital stay. As part of this plan, we sat with her in an empty hospital room so that she could become more comfortable in a simulated patient situation.” The MBMD test also helps Anderson identify the presence of serious psychiatric or psychosocial distress. “In these cases, we might determine that the individual needs more time to deal with a psychiatric issue or to move beyond stressful circumstances such as a difficult job or family situation,” she says. “This doesn’t necessarily mean the person will never qualify to be a donor—simply that now isn’t a good time.”
Anderson has discovered multiple benefits in using the MBMD and BSI tests—both with transplant recipients and donors. And, she notes that her colleagues have come to appreciate the tests as well. “When I refer patients to the psychiatrist who works with our transplant patients, I provide him with a summary of the MBMD and BSI results. He’s told me that the test findings are useful in helping him make decisions about the best course of treatment for our patients.”
Several industry groups have issued guidelines to promote quality care for both transplant recipients and donors. The recommendations give increased recognition to the value of psychological evaluations and the important role of mental health professionals in meeting the needs of these patients. CMS issues Final Rule on new CoPsEffective June 28, 2007, CMS introduced Medicare Conditions of Participation (CoPs) for heart, heart-lung, intestine, kidney, liver, lung, and pancreas transplant programs. A transplant center that wishes to continue as Medicare-approved or is seeking initial Medicare approval must be in compliance with the new CoPs, reports the Association of Perioperative Registered Nurses (AORN). The CMS rule stipulates that both patient and living donor selection criteria must include psychosocial evaluation. The regulation states that: “A psychosocial evaluation…screens for issues that could affect the patient’s compliance with the post-transplant treatment that is necessary to maximize the chance of a successful transplant, such as substance abuse or behavioral or psychiatric issues.”
Continuing the trend, “…the Joint Commission for the Accreditation of Healthcare Organizations (Joint Commission) announced proposed criteria for a transplant center accreditation program that closely track the Medicare proposed transplant center requirements issued in February of 2005,” reports the Summer 2007 Regulatory and Reimbursement Report issued by the American Society of Transplant Surgeons (ASTS) Regulatory Counsel. “As the number of organ transplantations increase, so too does the need for quality oversight of the transplant centers that are performing these life-saving procedures,” the Joint Commission said in announcing the proposed requirements. To be considered for the certification, transplant centers must ensure that “prospective transplant and living donor candidates receive a psychological evaluation.” A Certificate of Distinction will be awarded to health care organizations that meet the requirements and results will be publicly disclosed, giving consumers third-party information to support their health care decisions.
In addition, the American Journal of Transplantation 2007 reports that “Under the auspices of the United Network for Organ Sharing, the American Society of Transplant Surgeons and the American Society of Transplantation, a meeting was convened on May 25, 2006…to develop guidelines for the psychosocial evaluation of prospective living kidney donors who have neither a biologic nor longstanding emotional relationship with the transplant candidate.” Recommendations from the conference include a mandatory, detailed on-site psychosocial evaluation for all prospective unrelated donors. Required components of the evaluation would include an assessment of the donor’s psychological status, motivation, social support, and knowledge, understanding and preparation for the procedure. To learn more about the Guidelines for the Psychosocial Evaluation of Living Unrelated Kidney Donors in the United States, click here.
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