Depression Common in Patients Awaiting Lung Transplant

Kate Johnson

October 30, 2015

MONTREAL — Patients waiting for a lung transplant can suffer from depression, anxiety, and stress — which can potentially affect transplant outcome — but a previous diagnosis of a mood disorder is not predictive of who is at risk, new research suggests.

There is a "need for new measures to screen patients while they're waiting for lung transplant," said study investigator Abhay Vakil, MD, from the Mayo Clinic in Rochester, Minnesota.

"Essentially, it is thought that if someone has a history of depression or anxiety, they're more likely to suffer from those symptoms while awaiting transplant, but that is contrary to what we found," he told Medscape Medical News here at CHEST 2015.

In their retrospective study, Dr Vakil and his team evaluated patients awaiting lung transplantation from 2002 to 2013.

They used pretransplant questionnaires to assess patient-reported anxiety, stress, and depression-related emotional symptoms, which include anhedonia, difficulty concentrating, irritability, low mood, and suicidal ideation, as well as depression-related physical symptoms, which include sleep disturbance, and change in libido or pain.

Anxiety was defined as nervousness or fear, and stress was measured on a 5-point Likert scale.

Of the 102 patients who completed the questionnaires, 42% experienced no psychologic symptoms during the wait for lung transplantation and 58% experienced symptoms of depression, anxiety, or stress in various combinations. The median age of the patients was 57 years, and 50% were men.

History of psychologic symptoms was an unreliable predictor of current status; 17.6% of patients with depressive symptoms reported this in their history, and 46.1% of patients with anxiety had a previous diagnosis of anxiety.

Depression and Poor Outcomes

"It is known that people who have more anxiety, stress, or depression after lung transplant have poor outcomes, but what is not known is whether having active symptoms before transplant is also associated with poor outcomes," said Dr Vakil. "That is what we are looking at next."

If that is the case, "then it becomes essential to identify and treat these patients with stress reduction or active psychiatric consultation before transplant," he added.

The evidence is mounting that patients who undergo lung transplantation and transplant candidates are at risk for depression, anxiety, and other types of distress, said Mary Amanda Dew, PhD, from the University of Pittsburgh School of Medicine.

Dr Dew was involved in a recent meta-analysis that showed that depression increases the risk for poor outcomes, including mortality, after organ transplantation (Transplantation. Published online October 21, 2015).

"The identification of individuals with elevated levels of distress is the first step in terms of offering interventions and care that may help to maximize patients health outcomes and their overall quality of life," she told Medscape Medical News.

"I believe it would be a mistake for care providers to assume that high distress levels in transplant candidates or recipients are just "normal" reactions to extreme stress," she added.

"To the extent that these individuals could benefit from supportive care and psychotherapeutic interventions, transplant teams should monitor patients' mental health and offer resources that might be helpful," she explained.

"There is often a concern about adding more medications, such as antidepressants, to these patients' already complex medication regimens. However, there are other strategies, such as specific psychotherapies and group support, that may be beneficial either alone or in combination with psychopharmacologic measures."

Patrick Smith, PhD, from Duke University Medical Center in Durham, North Carolina, had a similar reaction to the study.

"These findings add to an increasing body of evidence suggesting that depression, anxiety, and distress are common among lung transplant candidates, and are not limited to individuals with a history of psychiatric illness," he told Medscape Medical News.

"The identification and management of these symptoms may be important. Several recent studies have suggested that elevated rates of depression and distress following lung transplant may be independently associated with adverse clinical outcomes," he said.

Post-Transplant Psychologic Functioning

Dr Smith pointed out that although pretransplant psychologic functioning is associated with post-transplant functioning, the "relationship is not as strong as many might think." In a study he was involved in, only about half of the participants who were depressed before transplantation remained depressed after (Chest. 2014;145:604-611).

"This has not been rigorously examined, in my opinion, but preliminary evidence suggests that there are significant changes in psychologic functioning from pre- to post-transplantation, the significance of which is only partially understood," he said.

"Most of our evidence suggests that nearly all patients experience significant improvements in physical quality of life, such as less shortness of breath and less physical limitation, and although most experience improvements in psychologic quality of life, such as anxiety and depression, these improvements are not as consistent, and many patients continue to report postoperative psychologic impairments," Dr Smith reported.

"Variations in post-transplant psychologic functioning are likely influenced by a number of different factors, including coping, continued distress associated with treatment, such as expensive medications and postoperative pain, expectations regarding treatment, and role changes following transplant, such as return to work," he explained.

"Taken together, you could say that while pretransplant psychologic functioning is certainly important, the few studies that have examined the relationship between psychologic functioning and clinical outcomes seem to suggest that psychologic functioning following transplant is a more important predictor," he said.

Dr Vakil, Dr Dew, and Dr Smith have disclosed no relevant financial relationships.

CHEST 2015: American College of Chest Physicians Meeting. Poster 3693. Presented October 28, 2015.

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