Psychosocial Issues in Transplantation
Kay Kendall, MSW, LISW-S, ACSW, CCTSW
Kim Ansley, MSW, LSW
Melissa Skillman, MSW, LISW-S
A. Psychosocial assessments have been an integral component of evaluations of patients for solid organ transplantation since the inception of these programs over 30 years ago.
Despite evolution of the medical and psychosocial criteria for listing patients for transplant, no universal criteria have been adopted across programs and substantial variability remains, especially with respect to psychosocial contraindications to transplant.
Research has identified factors that predict survival and quality of life posttransplant.
These findings can help to determine which patients would benefit most from this scarce resource.
Transplant programs do not consistently apply existing knowledge in making decisions regarding individual candidates.
Programs are challenged with the need to balance this knowledge with ethical considerations and a desire to serve patients in immediate need.
Evaluation of patients’ psychosocial status is part of this decision-making process and is critical in caring for patients and families pre- and posttransplant.
This chapter includes a review of the literature pertaining to
Psychosocial contraindications to listing
Predictors of patient outcomes
Difficulties patients and families face before and after transplant
Strategies that are useful in promoting better medical management and patient/family coping.
II. PSYCHOSOCIAL EVALUATION
A. US Requirements
Transplant centers in the United States require that patients undergoing transplant evaluations complete psychosocial assessments with qualified social workers.
In some circumstances, other mental health professionals, such as psychologists or psychiatrists, may be consulted.1
In the United States, an assessment with a social worker is required by Medicare and state Medicaid programs.
Private insurance companies may also request information from such an assessment before they will approve coverage for transplantation.
Pretransplant psychosocial evaluation:
Is conducted primarily to provide the team with information to assist them in distinguishing those patients likely to benefit from transplantation from those whose risk levels may be too high.2,3,4,5,6,7
Alerts the interdisciplinary transplant team to patients who may likely experience individual or family problems during the course of the transplant process.
Reveals need for interventions by other members of the transplant team as they work to prepare the individual for listing, eventual surgery, and reintegration into society.6
Provides an opportunity for educating and counseling patients and their support systems about the transplant process.
Helps to ensure that candidate selection is appropriate, that patients are fully prepared for transplantation, and that the team is addressing the patient’s psychosocial needs.3
This initial assessment between the social worker and patients and their support system serves to establish what may be an ongoing relationship.
The detailed information gathered in this assessment is helpful as these patients may be followed for many years by the same clinician and transplant team members.
Posttransplant psychosocial evaluations
Attention is paid to specific presenting concerns, appropriate treatments, and interventions.
Usually focuses on a specific area of patient need that may be
Disclosed or initiated by the patient
Identified during a hospital admission or an outpatient clinic visit
Tends to focus on the patient’s adjustment to transplantation or needs during a particular phase of care
Evaluates the patient’s overall functioning and perceived quality of life, which are viewed as primary indicators of a successful transplantation1
Pretransplant psychosocial evaluation
Although the timing, format, manner of obtaining information and its use vary among programs and across centers, the content of the assessment is fairly uniform.2,3,4,5,6,7
Generally takes the form of a structured assessment.
The assessment follows an outline specific to the requirements and preferences of the particular assessor and program.
The assessment occurs in tandem with the medical workup.
The social worker typically meets with the patient for 90 minutes to 2 hours.
Some programs may require that a support person be present for all or part of the session.7
Professional interpreters are recommended for interviews with patients not proficient in English, as patient responses may not be accurately conveyed by members of the patient’s support system.
Transplant programs may require that transplant patients sign a separate psychosocial consent form acknowledging their understanding that the psychosocial assessment will be part of the deciding factors regarding their potential transplant candidacy.
The assessment is documented in a structured format.
Findings are shared with the team via the written report and during the team “selection” meeting.
A copy of the evaluation is placed in the patient’s medical record.
Posttransplant psychosocial evaluations
May not include all areas addressed in the pretransplant evaluation.
Documentation placed in patient’s medical record.
Findings are discussed with the team; intervention is instituted; and outcomes are recorded as previously described.
Because information must be understandable to patients and presented at an appropriate level of complexity, the patient’s and his/her support system’s level of attained education and language proficiency must be ascertained.
Patient education information is often too difficult for patients to understand. It is estimated that more than one third of individuals don’t have the knowledge to make medical decisions. This can lead to missed appointments, delayed recovery, and frequent emergency department visits.8
It is imperative to determine health literacy of the patient and his/her support system and assess how well the information that has been provided is understood. Lack of understanding can significantly compromise a patient’s ability to give informed consent for the transplant procedure itself as well as make sound self-care decisions following transplantation.
Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.8
It involves more than simply asking patients and members of their support systems if they can read and write. How well patients read does not determine how well they understand what they are told about health care.
Factors that affect health literacy include
Access to resources
Experience with the health care system
Measures to assess health literacy include the following:
Short Assessment of Health Literacy (SAHL-S and E)9
Rapid Estimate of Adult Literacy in Medicine-Short Form (REALM-SF)10
Identifying how the patient learns can strengthen the care partnership between the patient and the interdisciplinary transplant team. Transplant programs can offer patient education in a number of different formats that are appropriate to the patient’s level of health literacy.
A common method in hospital settings to assess if a patient is comprehending information is the “teach back” method.
This method asks patients to repeat and summarize the medical information and instructions they have received.
III. COMPONENTS OF THE PRETRANSPLANT PSYCHOSOCIAL ASSESSMENT
A. The content of the evaluation is rooted in the literature.1,2,3,4,5,6,7 Basic elements include assessment of the following:
Demographic data/identifying information
History of adherence
Motivation for treatment
Mental health and psychiatric history
History of use of alcohol, substances, and nicotine products.
B. Demographic data/identifying information
Information on the patient’s identity and background is obtained early in the assessment interview.
Full name, marital status, age, and gender are included as factual information.
Persons with whom the patient resides
If married, number of marriages
Number of children and their ages
Status of parents and siblings of patient
Alive or deceased
If deceased, cause of death
C. Family/Relationship History
A family/relationship history gives a snapshot of the patient’s family of origin, current family and living arrangements, friendships, and community and religious networks.
This history includes information regarding family members and friends who are positive factors in the patient’s life, as well as persons with whom the patient has conflicts or from whom the patient receives little support.
Awareness of any difficult or unstable relationships is useful to the interdisciplinary transplant team, as these relationships could create concerns
for the patient or become barriers to medical care or patient adherence. Discussion with other care providers and nursing staff can yield helpful information.
Patients may discuss important past events, quality of relationships, and histories of abuse and losses, all of which are significant to the interdisciplinary transplant team in helping them understand patient concerns and stressors.
D. Assessment of support systems
Definition of social support: “the network of relationships that provide concrete, emotional and informational assistance to meet the perceived subjective or objective needs of the patient”11(p. 262)
This assessment includes the identification of
Sources of support
One important assessment goal is to identify specific individuals or organizations that will be able to offer emotional support and practical help such as in-home support and transportation.
Intended roles of support persons and organizations
Members of the patient’s support system are educated during the pretransplant process regarding their roles.
In the pre- and posttransplant period, support persons or organizations may be required to
Obtain the patient’s prescriptions
Monitor the patient’s adherence to the medical regimen with regard to medications, dietary restrictions, etc.
Attend medical appointments with the patient to ensure understanding of information
Help the patient with meal preparation, keeping track of medical appointments, etc.
Provide ongoing emotional support to minimize psychological distress.
Transplant centers may require members of the patient’s support system to sign a document acknowledging the expectations of their role as a support person(s) during the pre- and posttransplant phases.
Potential gaps in the plan that could become barriers to pre- or posttransplant care.
Where there is insufficient support, the social worker helps the patient/support system to assess the available alternatives and recommends agencies to fill in the gaps when support is limited.
Often, patients are educated on benefits of home health care, transportation assistance, support groups, and/or mentoring programs. The social worker counsels patients and their support system about these options and eligibility criteria as they prepare for surgery.
E. Assessment of financial resources
Questions regarding employment status, sources of income, and monthly income may reveal areas of potential financial concern.
Insurance coverage for medications, oxygen, hospital admissions, clinic visits, and other potential surgical and medical expenses must be determined and any additional financial needs clarified prior to listing.
Patients are advised about procedures for obtaining these necessary resources.
Additional expenses faced by patients may include costs associated with
Relocation, travel, parking, and meals away from home
Loss of income for patient and family members
Care for dependent members of the family
Patients and their families need to be aware of the financial implications of the transplant process so they are able to plan appropriately.
Because transplantation necessitates a commitment to lifelong treatment, many transplant centers require patients to meet with a financial counselor for education on
Potential costs of immunosuppressive medications
Possible loss of funding resources posttransplant
Development of a financial plan prior to listing.
Social workers are able to advocate on their behalf with institutions and community agencies when requested to do so by patients.
F. Advanced Directives
During the evaluation process, patients are asked if they have completed a durable power of attorney for health care and a living will.
If completed, a copy is requested so that it can be scanned into the patient’s electronic medical record.
It is essential to document the names and contact information for the next of kin and any designated substitute decision maker.
For patients with dependent children or dependent adults, plans for care of these children/adults should be discussed and families counseled regarding the needs of the children for emotional support, planning, and resources.
If not completed, patients are asked if they would like to complete these documents. Patients are
Educated on the importance of completing an advanced directive to identify a health care decision maker and the patient’s end-of-life wishes.
Informed of the benefits of completing these documents, which can
Potentially avoid additional stress for their support system
Ensure that the patient’s end-of-life wishes are followed.
Encouraged to discuss their preferences regarding life support and their decisions related to end-of-life care in the event of a poor transplant outcome and their inability to make their own health care choices.
G. Adherence history
Patients’ past and current adherence to medical regimens and response to their current illness are assessed.12
Learning about patients’ ability to care for themselves and follow medical recommendations is important in determining their ability to care for themselves posttransplant. This assessment includes
Identifying any physical or cognitive deficits that may prevent the patient from being self-directed with his/her own care
The social worker can help the patient and the patient’s support system identify such barriers and potential ways of overcoming them through either education or resources.
Asking who sets out the patient’s medications helps the social worker determine if the patient is independent with this task or if the patient relies on a family member to do this.
If the patient does not manage this task independently, it is important to explore why the patient relies on others. Is it because of illiteracy or does it reflect a dependence on a family member because of an established familial role?
Assessing the patient’s knowledge about and compliance with his/her medications. Does the patient
Know the name, purpose, and dose of each of medication?
Consistently take medications at the prescribed dose and time?
Keep track of medications by using a pillbox?
Determining how the patient keeps track of medical appointments (e.g., by using an electronic calendar, appointment book, etc.).
This is an opportunity for the social worker to suggest and encourage patients to use tools that can help them manage their self-care.
Additional important assessment questions include the following:
Does the patient keep scheduled medical appointments?
Was there ever an extended time when the patient did not receive medical care and what were the reasons for that gap in care?
In the past, has the patient ever left the hospital against medical advice?
Does the patient alert his/her care provider of changes in condition? Or, does the patient rely on a family member or other support person to notify care providers of changes in the patient’s condition?
Is the patient compliant with other aspects of self-care such as daily weights, blood pressure monitoring, glucose testing, personal hygiene, etc.?
Does the patient have a history of multiple hospital admissions due to medical nonadherence?
Is the patient able to identify his/her medical diagnosis or the cause of his/her organ failure?
H. Motivation for transplantation and comprehension of illness and risks associated with transplantation
This component of the psychosocial evaluation involves assessment of the following:
The patient’s motivation and readiness to proceed with the transplant process
Some patients may
Perceive that their current health status does not yet warrant transplantation
Experience difficulty in resolving conflicting feelings, beliefs, or values, which may lead to ambivalence about transplantation
Be responding to pressure from others or be extremely fearful
Ambivalence and/or lack of motivation require further assessment.
The patient’s understanding of transplant risks and possible complications
Patients need to have realistic expectations of transplantation.
Transplant teams must make efforts to ensure that potential recipients fully understand the risks of transplantation.
Transplant recipients need to be aware that the organ they receive may not function optimally or insure them a determined period of survival.
Surgical and medical risk factors should be discussed, as well as the possible side effects and complications associated with immunosuppressive medications.
The patient’s religious beliefs regarding such issues as
Accepting blood products
Having a living donor versus a deceased donor
A finding that a patient’s expectations of transplantation are not realistic indicates the need for intervention and additional education.
I. Mental health and psychiatric history and current status
In this component of the psychosocial evaluation, the social worker obtains information regarding the patient’s
Current or history of mental health symptoms
Current or history of psychiatric diagnosis
Current or history of suicidal ideation or attempts
Current or history of homicidal attempts or ideation
Current or history of mental health counseling and/or history of psychiatric hospitalization
Current or history of use of psychotropic medications
In addition, the social worker
Determines if the patient is fully oriented, has appropriate insight, and displays sound judgment
Identifies areas of concern requiring immediate or possible future intervention
Mental health status also affects patients’ abilities to understand the transplant process, appreciate their own responsibilities for self-care, and give informed consent.
Cognitive status may be affected by such factors as preexisting conditions or the end-stage organ disease itself.
Impaired cognitive function that interferes with the patient’s daily functioning requires further assessment (such as a formal neuropsychological evaluation).
Patients experiencing common somatic complaints as panic attacks, depression, or serious sleep disturbances will require further evaluation and possible psychiatric treatment to better prepare them to cope with the stressors associated with the transplant process.
Those with serious psychological instability or dysfunction may be considered too high risk for transplantation.
J. Substance use history and current status
A history is taken of the patient’s past and current use of alcohol, tobacco, over-the-counter drugs, prescription medications, and illegal drugs.
A history of or current substance use disorder may be a contraindication to transplantation in some programs, as it may have caused or contributed to the organ failure and it may become a source of potential damage to the transplanted organ.2
Most lung and heart transplant programs require patients to be abstinent from smoking for a specified time prior to listing for transplant. Most commonly, this is a minimum of 6 months of documented abstinence.
Transplant programs may defer listing patients with a diagnosis of alcohol dependence until they have ceased alcohol consumption for a prescribed time and completed a treatment program.13
K. The ultimate goal of the pretransplant psychosocial evaluation is to permit the interdisciplinary transplant team to enter into informed decision making regarding patient selection.
Identification of potential patient vulnerabilities allows monitoring and/or intervention by the team throughout the complex and demanding transplant process.
Identification of any gaps in the patient’s plan enables the team to assist the patient in overcoming potential barriers to treatment.
IV. ASSESSMENT INSTRUMENTS
A. When solid organ transplant programs began in the early 1980s, a variety of assessment methods were used to evaluate patients’ psychosocial status.
An assessment was completed by a social worker and a psychiatrist.14
It was not unusual for patients to be evaluated by a psychologist or a neuropsychologist or to undergo an evaluation with a chemical dependency counselor.
B. As transplant teams gained more experience with the evaluation process, the assessment process was streamlined to avoid redundancies and other disciplines were consulted based on information obtained in the psychosocial evaluation.
C. Today, at most transplant centers in the United States, a master’s level social worker at the highest level of licensure in his/her state of practice completes an initial assessment and then determines which other professionals need to be consulted to complete the evaluation process.
All patients may not need a chemical dependency evaluation, nor do all patients require a battery of psychological/neuropsychological tests.
Standardized assessments of psychosocial status are useful in evaluating some patients and in conducting research on quality of life and outcomes pre- and posttransplant.
D. Standardizing psychosocial evaluations-transplant-specific scales
Psychosocial Assessment of Candidates for Transplantation (PACT) scale
The seminal work in standardizing psychosocial evaluations was done by Olbrisch and Levenson who developed the Psychosocial Assessment of Candidates for Transplantation (PACT) scale in the late 1980s with the goal of standardizing psychosocial criteria.15
This PACT scale:
Was developed to identify psychosocial criteria and to assess how centers viewed the importance of these criteria in the selection process
Has also been used to measure pre- and posttransplant quality of life
Has been used by a number of centers to study the clinical decisionmaking process and to help with consistent interpretation of criteria16
Characteristics of the PACT scale
This tool consists of eight items with an initial rating and a final rating score. The eight items measure aspects of psychosocial functioning including support, lifestyle factors, compliance, psychological health, and substance abuse.
The initial and final ratings are on a scale of 0 to 4 with a lower number indicating more problematic or concerning behavior.
The information to rate candidates is obtained in the psychosocial evaluation.
After the interview is complete, one general rating is made before considering each of the individual ratings. This is followed by a final rating.
The scale has been shown to have a high degree of interrater reliability.
Transplant Evaluation Rating Scale (TERS)17
Developed in the early 1990s, the TERS is a standardized measure that rates the following psychosocial characteristics on a 3-point scale:
Prior psychiatric history DSM-III-R Axis I
Prior psychiatric disorder DSM-III-R Axis II
Quality of family/social support
Prior history of coping
Coping with disease and treatment
Quality of affect
Mental status (past and present)
Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT)18
This 18-item standardized scale is based on a comprehensive literature review of the psychosocial factors that influence transplant outcomes.
The SIPAT is used to rate the following:
Patient’s Readiness Level
Knowledge and understanding of medical illness process
Knowledge and understanding of the transplant process
Willingness/desire for transplantation
Lifestyle factors (e.g., diet, exercise)
Social Support System Level of Readiness
Availability of social support system
Functionality of social support system
Appropriateness of physical living space and environment
Psychological Stability and Psychopathology
Presence of psychopathology
History of organic psychopathology or neurocognitive impairment
Influence of personality traits versus disorder
Effect of truthfulness versus deceptive behavior in presentation
Overall risk for psychopathology
Lifestyle and Effect of Substance Use
Alcohol use/abuse/dependence: risk for recidivism
Substance use/abuse/dependence (including prescribed and illicit substances)
Substance use/abuse/dependence: risk for recidivism
The SIPAT is highly correlated with the PACT scale and is highly predictive of transplantation psychosocial outcomes.
E. Several other established instruments commonly used with the general population are frequently used to evaluate patients prior to transplant and to assess posttransplant outcomes.
The Beck Depression Inventory (BDI) is a self-rating instrument used widely in both medical and psychiatric settings.19
The Millon Behavioral Health Inventory (MBHI), a self-report instrument designed to assess psychological adjustment, has been used to predict posttransplant outcome.20
The Health Status Questionnaire (HSQ) is a measure of physical health and the impact of the patient’s physical condition on social functioning, mental health, fatigue, and pain.21
The Psychosocial Adjustment to Illness Scale (PAIS) rates patients’ orientation to health care, functioning at work and home, and sexual and social functioning.22
The Short Form 36 (SF-36) is a widely used instrument designed to evaluate health-related quality of life.23
This self-administered assessment of health status measures several healthrelated domains, such as physical status, social functioning, pain, and role limitations due to physical problems.
Another commonly used psychiatric diagnostic measure is the Symptoms Checklist 90 (SCL-90), a self-report instrument that assesses multiple types of psychological distress.24
V. PSYCHOSOCIAL CRITERIA FOR TRANSPLANTATION
Psychosocial assessments have been a component of transplant evaluations since the inception of solid organ transplant programs.25
Initially, transplant team members were unclear how the information obtained from these assessments would be applied to the decision-making process and how the assessment findings could impact posttransplant survival.
Transplant teams felt that it was important to know about patients’ support systems, how they coped and took care of themselves, and about past or present behaviors that might lead to medical management problems after transplant.
However, these assessments also raised ethical dilemmas such as
Concerns that transplant programs were making judgments about individual worth
Inconsistencies among programs25
Variable views on contraindications to transplant
Variations in experiences in following patients after transplantation have led to differing perspectives on candidacy.
Denying transplant on the basis of psychosocial concerns alone
Most transplant teams have been uncomfortable with denying a physiological need based on psychosocial concerns.
Clinical experience supports the need to consider some patients as being at high risk for complications or death following transplant, though few studies have formally researched the criteria used to make these judgments.
As morbidity and mortality rates have changed over the years and as transplant programs established medical and psychosocial eligibility criteria, patients who did not meet these criteria were not placed on the transplant waiting list.
B. Relative and Absolute Psychosocial Contraindications
In their landmark 1991 article, Olbrisch and Levenson described absolute, relative, and irrelevant psychosocial contraindications. Today, each transplant program establishes its own medical and psychosocial eligibility criteria for transplantation. This information is available for public view.
Contraindications may be categorized as “social” or “psychopathological.”
Potential relative psychosocial contraindications26:
Patient has no or limited social support.
Patient has experienced a recent death or loss.
Patient is currently a felony prisoner.
Patient has a history of significant criminal behavior.
Family history of mental illness.
History of or current affective disorder.
History of suicide attempt (distant).
Mental retardation: intelligence quotient <70.
Mental retardation: intelligence quotient <50.
Potential absolute psychosocial contraindications26
Active schizophrenia/active psychosis
Current suicidal ideation
Multiple suicide attempts
Recent suicide attempt
Individual transplant programs may consider these contraindications to be absolute, relevant, or irrelevant.14
C. Research on psychosocial criteria (selected studies)
Olbrisch and Levenson
In commenting on the responsibility to fairly evaluate patients and to predict outcome, Olbrisch and Levenson noted that “the science of prediction cannot be divorced from philosophical questions”25(p. 239).
These authors began researching the psychosocial evaluation process in the early 1980s26 and noted that psychosocial screening was a component of patient evaluation at most transplant centers, but that criteria for determining candidacy for transplant were informal, unpublished, and likely varied from center to center.
In the early 1990s, they surveyed the evaluation methods used at 204 heart transplant programs.26
They asked these programs to identify psychosocial criteria and to rate each criterion as a relative or absolute contraindication to transplantation.
Examples of the psychosocial criteria identified by these programs were a psychiatric diagnosis, smoking, substance use, obesity, and nonadherence with medical recommendations.
These researchers found agreement among the centers on several absolute contraindications including
Current suicidal ideation
History of multiple suicide attempts
Current substance abuse
The centers disagreed, however, with respect to the use of criteria such as smoking, controlled schizophrenia, or affective disorders.
In a second study, Olbrisch and Levenson14 expanded the groups surveyed to include liver and kidney transplant teams along with heart programs and found that
Heart transplant programs applied the most stringent psychosocial selection criteria and that kidney programs were the least restrictive.
Significant variations existed across all programs.
As the number of solid organ transplants increased in the 1980s, researchers began to examine pre- and posttransplant behaviors as predictors of posttransplant outcomes.
Researchers investigated questions such as
Would a patient who did not take medications and follow through with physician recommendations prior to transplantation do the same posttransplant?
Would the lack of a support system affect a patient’s survival?
Would a certain psychiatric diagnosis lead to more medical management problems posttransplant?
The results of these early studies were mixed:
Some researchers failed to find an association between pretransplant psychological distress and mortality, graft rejection, or infections27
Other studies demonstrated that some patients are at higher risk for poor outcomes than others.
In a prospective study of 125 adult patients undergoing heart transplantation, Shapiro and colleagues reviewed psychosocial evaluation data and reported the following:
There were significant associations between personality disorder, living arrangements, global psychosocial risk, and history of substance abuse and posttransplant compliance problems.
Substance abuse and global psychosocial risk were significant predictors of compliance. Of note, patients with known substance abuse histories who had short remission periods and had only stopped using substances when their conditions declined were particularly at high risk for poor compliance.
Paris and colleagues28 examined the incidence of psychosocial factors before and after heart transplantation and the influence of posttransplant psychosocial factors on clinical outcomes. These researchers concluded that
Psychosocial difficulties prior to heart transplantation (nonadherence, psychiatric problems, excessive weight) were likely to continue posttransplant.
Recipients with posttransplant psychiatric problems had a significantly higher risk of infection during the first posttransplant year.
Posttransplant nonadherence and psychiatric problems were related to more frequent hospital readmissions and higher medical costs.
Chacko and colleagues-199629
This study examined the correlation between pretransplant Axis I and II diagnoses and psychosocial adjustment and health status in heart (n = 148), kidney (n = 109), liver (n = 22), and lung/heart-lung (n = 31) candidates.
Candidates completed in-depth pretransplant psychosocial evaluation and psychometric testing.
Over 60% of the candidates met criteria for a DSM-III-R Axis I diagnosis.
There was a significant difference in the overall frequency of current Axis I diagnoses among organ types.
Axis I diagnoses were most common in liver transplant candidates (83%) followed in decreasing order by lung (68%), heart (62%), and kidney (51%) transplant candidates.
Although 32% of candidates met criteria for a current Axis II disorder, there was no significant difference in the overall frequency of Axis II diagnoses across organ types.
Axis II diagnoses were most common in liver transplant candidates (50%) followed in decreasing order by kidney (34%), heart (29%), and lung (23%) transplant candidates.
Approximately 25% of candidates had dual Axis I/Axis II diagnoses.
Relationship between Axis diagnosis and outcomes:
An Axis I diagnosis was significantly associated with poorer psychosocial adjustment and poorer health status.
An Axis II diagnosis was significantly related to both global nonadherence and specific lack of adherence regarding diet, appointment keeping, medications, and avoiding smoking and drug misuse.
A combined Axis I/Axis II diagnosis was not significantly associated with poorer psychosocial adjustment or health status. However, these candidates were an important subgroup in that they had the poorest social support and coping ability and could potentially strain transplant team resources.
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