Psychosocial Diagnosis and Treatment Before and After Organ Transplantation

Abstract

Background

This new clinical practice guideline concerns the psychosocial diagnosis and treatment of patients before and after organ transplantation. Its objective is to establish standards and to issue evidence-based recommendations that will help to optimize decision making in psychosocial diagnosis and treatment.

Methods

For each key question, the literature was systematically searched in at least two databases (Medline, Ovid, Cochrane Library, and CENTRAL). The end date of each search was between August 2018 and November 2019, depending on the question. The literature search was also updated to capture recent publications, by using a selective approach.

Results

Lack of adherence to immunosuppressant drugs can be expected in 25–30% of patients and increases the odds of organ loss after kidney transplantation (odds ratio 7.1). Psychosocial interventions can significantly improve adherence. Meta-analyses have shown that adherence was achieved 10–20% more frequently in the intervention group than in the control group. 13–40% of patients suffer from depression after transplantation; mortality in this group is 65% higher. The guideline group therefore recommends that experts in psychosomatic medicine, psychiatry, and psychology (mental health professionals) should be involved in patient care throughout the transplantation process.

Conclusion

The care of patients before and after organ transplantation should be multidisciplinary. Nonadherence rates and comorbid mental disorders are common and associated with poorer outcomes after transplantation. Interventions to improve adherence are effective, although the pertinent studies display marked heterogeneity and a high risk of bias.

Organ transplantation is indicated in patients facing end-stage organ failure due to severe chronic disease or acute organ injury and for whom no other equivalent treatment options are available for the improvement of their health status. In addition, transplant patients are confronted with physical, mental, and social challenges and stressors in all phases of the treatment process (1). These may be comorbid mental health disorders such as depression and anxiety disorders that accompany or precede the physical disease and negatively impact the entire disease course (2, 3). In a certain proportion of transplant patients, mental health factors are also causally linked to the development and deterioration of the physical disease and therefore require adequate medical treatment. Examples include dependence disorders involving, for example, alcohol and nicotine, with their known physical sequelae such as alcohol-related liver disease, alcohol-related heart failure, and chronic obstructive pulmonary disease.

The treatment of transplant patients should be carried out in a multidisciplinary approach in close collaboration between organ medicine, mental health professionals (MHP, eBox), transplant care, hospital pharmacists, and self-help organizations.

The new clinical practice guideline (4) deals with the psychosocial diagnosis and treatment of patients before and after organ transplantation, including living organ donation. Its objective is to establish standards for psychosocial diagnosis, for establishing the indication, and for the delivery of psychosocial treatments, as well as to issue evidence-based recommendations that will help to optimize decision-making in the psychosocial diagnosis and treatment of transplant patients. The guideline is designed to complement the guidelines on transplant medicine issued by the German Medical Association (Bundesärztekammer).

This publication examines more closely the following central questions (key questions 1–3):

• Is nonadherence a risk factor for the prognosis of patients after organ transplantation?

• Can psychosocial interventions improve adherence after organ transplantation?

• What are the risk factors for a poor prognosis after transplantation?

Methods

The guideline was developed in line with the requirements of the German Association of Scientific Medical Societies (Arbeitsgemeinschaft der wissenschaftlichen medizinischen Fachgesellschaften) for an S3 guideline (5). The German Society for Psychosomatic Medicine and Medical Psychotherapy (Deutsche Gesellschaft für Psychosomatische Medizin und Ärztliche Psychotherapie e. V., DGPM) and the German College of Psychosomatic Medicine (Deutsche Kollegium für Psychosomatische Medizin e. V., DKPM) are the responsible and publishing scientific societies. A broad-based, representative guideline group made up of 17 medical, psychological, pharmaceutical, and nursing societies from Germany and Austria and involving the participation of patient and family representatives was responsible for the development of the new guideline (eTable 1, eTable 2).

eTable 1. Participating scientific societies and patient organizations with mandate holders (from S3 Guideline).

Participating scientific societies and organizations	Mandate holders
German College of Psychosomatic Medicine (Deutsches Kollegium für Psychosomatische Medizin e. V., DKPM) (Lead scientific society)	Prof. Dr. med. Martina de Zwaan (Chair) Klinik für Psychosomatik und Psychotherapie, Medizinische Hochschule Hannover, Germany
	PD Dr. med. Frank Vitinius (Deputy) Klinik und Poliklinik für Psychosomatik und Psychotherapie, Universitätsklinikum Köln, Germany
German Society for Psychosomatic Medicine and Medical Psychotherapy (Deutsche Gesellschaft für Psychosomatische Medizin und Ärztliche Psychotherapie e. V., DGPM) (Lead scientific society)	Prof. Dr. med. (TR) Yesim Erim Psychosomatische und Psychotherapeutische Abteilung, Universitätsklinikum Erlangen, Friedrich-Alexander Universität Erlangen-Nürnberg, Germany
	Dr. med. Per Teigelack (Deputy) Universitätsklinik für Psychosomatische Medizin und Psychotherapie, LVR Klinikum Essen Westdeutsches Zentrum für Organtransplantation (WZO), Universitätsmedizin Essen, Germany
German Society of Medical Psychology (Deutsche Gesellschaft für Medizinische Psychologie e. V., DGMP)	Dr. phil. Sylvia Kröncke Institut und Poliklinik für Medizinische Psychologie, Universitätsklinikum Hamburg-Eppendorf, Germany
	Dr. phil. Katharina Tigges-Limmer (Deputy) Medizinische Psychologie, Klinik für Thorax- und Kardiovaskularchirurgie, Herz- und Diabeteszentrum NRW, Bad Oeynhausen, Germany
German Association for Psychiatry, Psychotherapy and Psychosomatics (Deutsche Gesellschaft für Psychiatrie und Psychotherapie, Psychosomatik und Nervenheilkunde e. V., DGPPN)	PD Dr. med. Daniela Eser-Valeri Klinik für Psychiatrie und Psychotherapie, Klinikum der Universität München, Germany
German Society for Behavioral Medicine and Behavior Modification (Deutsche Gesellschaft für Verhaltensmedizin und Verhaltensmodifikation e. V., DGVM)	PD Dr. med. Mariel Nöhre Klinik für Psychosomatik und Psychotherapie, Medizinische Hochschule Hannover, Germany
German Society for Addiction Research and Addiction Therapy (Deutsche Gesellschaft für Suchtforschung und Suchttherapie e. V., DG-Sucht)	PD Dr. phil. Angela Buchholz Institut und Poliklinik für Medizinische Psychologie, Universitätsklinikum Hamburg-Eppendorf, Germany
German Psychological Society (Deutsche Gesellschaft für Psychologie e. V., DGPs)	Prof. Dr. rer. nat. Tanja Zimmermann Klinik für Psychosomatik und Psychotherapie, Medizinische Hochschule Hannover, Germany
	Prof. Dr. phil. Heike Spaderna (Deputy) Pflegewissenschaft, Abteilung Gesundheitspsychologie, Universität Trier, Germany
German Transplantation Society (Deutsche Transplantationsgesellschaft e. V., DTG) Psychosomatic Commission	Assistant Prof. Dr. rer. medic. Christina Papachristou Philosophische Fakultät, Abteilung für Psychologie, Aristoteles Universität von Thessaloniki, Greece
	Unscheduled Prof. Dr. phil. Hans-Werner Künsebeck (Deputy) ehem. Klinik für Psychosomatik und Psychotherapie, Medizinische Hochschule Hannover, Germany
German Transplantation Society (Deutsche Transplantationsgesellschaft e. V., DTG) Heart/Lung Commission	Prof. Dr. med. Jan Gummert Klinik für Thorax- und Kardiovaskularchirurgie, Herz- und Diabeteszentrum NRW, Bad Oeynhausen, Germany
	Dr. phil. Katharina Tigges-Limmer (Deputy) Medizinische Psychologie, Klinik für Thorax- und Kardiovaskularchirurgie, Herz- und Diabeteszentrum NRW, Bad Oeynhausen, Germany
German Transplantation Society (Deutsche Transplantationsgesellschaft e. V., DTG) Kidney Commission	Prof. Dr. med. Barbara Suwelack Sektion Transplantationsnephrologie, Medizinische Klinik D, Universitätsklinikum Münster, Germany
	Prof. Dr. med. Mario Schiffer (Deputy), Medizinische Klinik für Nephrologie, Universitätsklinikum Erlangen, Germany
German Transplantation Society (Deutsche Transplantationsgesellschaft e. V., DTG) Liver/Intestine Commission	Prof. Dr. med. Susanne Beckebaum Klinik für Innere Medizin, Gastroenterologie und Hepatologie, Helios Kliniken Kassel, Germany
	Prof. Dr. med. Silvio Nadalin (Deputy) Universitätsklinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Tübingen, Germany
German Society of Transition Medicine (Gesellschaft für Transitionsmedizin e. V., GfTM)	Prof. Dr. med. Lars Pape Klinik für Kinderheilkunde II, Universitätsmedizin Essen, Germany
German Society for Thoracic and Cardiovascular Surgery (Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie e. V., DGTHG)	Prof. Dr. med. Wolfgang Albert Abteilung Psychosomatik, Deutsches Herzzentrum Berlin, Germany
	Dr. phil. Katharina Tigges-Limmer (Deputy) Medizinische Psychologie, Klinik für Thorax- und Kardiovaskularchirurgie, Herz- und Diabeteszentrum NRW, Bad Oeynhausen, Germany
German Association of Neuropsychopharmacology and Pharmacopsychiatry (Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie e. V., AGNP)	PD Dr. med. Alexander Glahn Klinik für Psychiatrie, Sozialpsychiatrie und Psychotherapie, Medizinische Hochschule Hannover, Germany
Federal Association of German Hospital Pharmacists (Bundesverband Deutscher Krankenhausapotheker e. V., ADKA)	Prof. Dr. rer. nat. Irene Krämer Direktorin der Apotheke der Universitätsmedizin der Johannes-Gutenberg-Universität Mainz, Germany
	Prof. Dr. Frank Dörje (Deputy) Apothekenleiter Universitätsklinikum der Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany
German Society for Child and Adolescent Psychiatry and Psychotherapy (Deutsche Gesellschaft für Kinder- und Jugendpsychiatrie, Psychosomatik und -Psychotherapie e. V., DGKJP)	Dr. med. Özgür Albayrak Klinik für Psychosomatik und Psychotherapie, Medizinische Hochschule Hannover, Germany
Austrian Society for Psychosomatics and Psychotherapeutic Medicine (Österreichische Gesellschaft für Psychosomatik und Psychotherapeutische Medizin, ÖGPPM)	PD Dr. med. Christian Fazekas Universitätsklinik für Medizinische Psychologie und Psychotherapie, Medizinische Universität Graz, Austria
	Dr. med. Jolana Wagner-Skacel (Deputy) Universitätsklinik für Medizinische Psychologie und Psychotherapie, Medizinische Universität Graz, Austria
Austrian Association of Psychiatry, Psychotherapy and Psychosomatics (Österreichische Gesellschaft für Psychiatrie, Psychotherapie und Psychosomatik, ÖGPP)	Prof. Dr. med. univ. Benjamin Vyssoki Klinische Abteilung für Sozialpsychiatrie, Universitätsklinik für Psychiatrie und Psychotherapie, Medizinische Universität Wien, Austria
German Working Group for Nursing Care in Transplantation (Arbeitskreis Transplantationspflege e. V., AKTX Pflege)	Lara Marks, Pflegefachkraft für Transplantationspflege Klinik und Poliklinik für Allgemein-, Viszeral-, Tumor- und Transplantationschirurgie, Universitätsklinikum Köln, Germany
	Marei Pohl (Deputy) Pflegefachkraft für Transplantationspflege Rehaklinik, Klinik Fallingbostel, Germany
German Federal Association of Organ Transplant Recipients (Bundesverband der Organtransplantierten e. V., BDO)	Dipl. Soz.-Päd. Burkhard Tapp Bundesverband der Organtransplantierten e. V.
	Luisa Huwe (B. A.) (Deputy) Bundesverband der Organtransplantierten e. V., Hannover, Germany

eTable 2. Other individuals involved in the development of the guideline (from S3 GL).

Other participants	Function & scientific society/organization
Peter Fricke	BDO e. V., Mandate-holder representative
Dr. biol. hum. Marietta Lieb	Collaboration in the development of theguideline on adherence; regular attendance at meetings
Prof. Dr. Markus Burgmer	Collaboration in the development of theguideline on the topic of living donation; regular attendance at meetings
Prof. Dr. phil. Martin Kumnig	Collaboration in the guideline text on thetopic of living donation
Dr. Gertrud Greif-Higer	Collaboration in guideline development;attendance at meetings
PD Dr. Lena Schiffer	Assistance in drafting the text for theguideline on the topic of rehabilitation
Imke Huxoll (†)	Assistance in developing the guidelinetopic on the subject of relatives
Pia Kleemann	Assistance in developing the guidelinetopic on the subject of self-help
Thorsten Huwe	Assistance in developing the guidelinetopic on the subject of relatives

† Deceased; GL, guideline

A systematic search was conducted in at least two databases (Medline, Ovid, Cochrane Library, and CENTRAL). The literature search was carried out between August 2018 (key questions 1–3) and November 2019 (additional key questions). The results of the literature review for key questions 1–3 are presented by way of example in the eFigure. A non-systematic literature review was undertaken for this article.

The structured consensus development process took place in the period between 25.3.2019 and 24.03.2022 in a total of 12 in-person or web-based structured consensus conferences with neutral moderation by the AWMF. The proposals were discussed by the mandate holders, modified where appropriate, and adopted with a consistently strong consensus. In a final step, the guideline was adopted by the boards of the participating scientific societies in the period between 26.04.2022 and 14.08.2022.

Results

Nonadherence as a risk factor for prognosis after organ transplantation

Across all organ entities, nonadherence in adult patients in relation to immunosuppressant drug use, diet, physical activity, and other health measures ranges from 19 to 25 cases per 100 patients per year (PPY). This is the result of a meta-analysis of 147 studies (6). Nonadherence in relation to the use of immunosuppressant drugs was highest among patients following kidney transplantation (36 ± 2.3 cases per 100 PPY) compared to other organs (7–15 cases per 100 PPY). With regard to the implementation of dietary recommendations, a nonadherence prevalence across all organs of 25 (± 3.4) cases per 100 PPY was seen, while the nonadherence prevalence for physical activity was 19 (± 2.1) cases per 100 PPY. Post-heart transplant patients had a particularly high nonadherence rate for physical activity with 33.7 (± 4.5) cases per 100 PPY compared to other organ transplantations (9–22 cases per 100 PPY). Interestingly, studies in which adherence was measured using self-rating instruments showed the highest nonadherence in relation to the use of immunosuppressant drugs (39.2 cases per 100 PPY).

Especially nonadherence to immunsuppressant drug use is a relevant aspect in the treatment of organ transplant patients (6– 8, e1– e4). Nonadherence to the use of immunosuppressant drugs is associated with an increased risk for graft rejection and increased mortality (9– 11) and is one the commonest preventable causes of organ loss. The majority of available studies are on patients following kidney transplantation. Approximately 20% of late acute organ rejection episodes and 16% of cases of graft loss following renal transplantation can be attributed to nonadherence (38 studies) (12). Another review article of 36 studies concluded that a median of 36% (interquartile range 14–65%) of graft losses following renal transplantation were associated with nonadherence. The relative chance of graft loss in nonadherent patients was 7.1 times (95% confidence interval: [4.4; 11.7]) higher compared to adherent patients (13). Some studies demonstrated that even in the case of a rate of adherence to immunosuppressive medication of ≤ 98%, one must assume a worsening in clinical outcome (e5– e7).

The guideline group therefore recommends that pharmacological and non-pharmacological adherence (to diet, sun protection measures, physical activity, sexuality, hygiene, infection prevention, appointment-keeping, monitoring of own vital functions, and the performance of diagnostic tests) following organ transplantation should be measured at regular intervals. This can be carried out as part of transplantation-specific follow-up care, which is delivered at transplantation centers as well as by other outpatient and inpatient personnel. The frequency of this type of contact can vary significantly from person to person, explaining why no mention is made of a specific number of adherence measurements within a defined time period.

There are various different methods for assessing adherence. A simple way to measure adherence is by means of self-rating instruments. A number of validated questionnaires are available for this, either as self-(or third-party) rating instruments (diagnostic interview). To increase reliability, a combination of various measurement methods should be used (14, e8– e10) (table 1).

Table 1. Various methods for measuring adherence (adapted from Farmer [e27], [4]).

Method	Advantages	Disadvantages
Blood level of medication	(Only) very recent use can be investigated	Only statements about very recent use arepossible and may be affected by other biological factors, individual kinetics
Observed medication use	Use can be verified	Virtually unfeasible in the outpatient setting
Patient interview	Easy to implement, no high costs	Interviewer requires an open and non-judgmentalattitude, socially desirable response behavior cannot be excluded
Patient diary	Self-reporting instrument providing informationon dealing with medication	An overestimation of adherence cannot be excluded;patient must keep the diary and bring it to their visit
Questionnaire to assess adherence	Easy to use, validated instruments(e.g., BAASIS, MARS), can provide an explanation for patient behavior	Snapshot, no continuous data; accuracy depends onthe instrument used
Tablet counting	Easy to use, no high costs	No information on punctuality of use; patient could forget doses or provide incorrect information
Checking the prescriptions filledfor seamless prescribing	Noninvasive method; if data are available inelectronic form, more straightforward evaluations across larger patient groups are also possible. This is generally not the case in Germany	The required information must be available or viewable
Electronic medication boxes/doses	Precise data on punctuality and regularity ofremoval from box	High costs, difficulties in implementation/handlingare possible, technical malfunction cannot be excluded, use not guaranteed

Psychosocial interventions to improve adherence after organ transplantation

After reviewing the literature, the guideline group recommends with a high level of recommendation (A) and a high level of evidence (1) that, in the case of nonadherence, patients should be recommended an intervention, with multimodal interventions being the preferred approach (15– 18, e11– e17). The underlying rationale and suitable interventions are described below in more detail.

Since the literature search for the guideline, further meta-analyses across all organs have been published on the efficiency of interventions to improve adherence to immunosuppressant drug use following organ transplantation. These studies confirm the recommendation and are cited here.

Shi et al. (19) evaluated 27 articles up to December 2019 and Mellon et al. (20) evaluated 40 studies up to October 2021. Two studies were conducted in children and adolescents, 80% relating to patients following renal transplantation. The study interventions are heterogeneous, with the duration of interventions ranging between 2 and 12 months and the duration of follow-up history between 3 and 120 months. In overlapping studies, the evaluations of risk of bias differ significantly between the two meta-analyses. A variety of adherence outcomes are investigated:

• Overall adherence (depending on the main outcome of the study)

• Proportion of correctly taken medication doses (taking adherence)

• Proportion of days on which medication dose is taken correctly (dosing adherence)

• Proportion of medication doses taken at the correct time (timing adherence).

For overall adherence, the relative risk for a better outcome in the intervention group was 1.17 [1.07; 1.28] (19). Taking adherence did not differ significantly between treatment groups in either of the two meta-analyses, but days on which the drug dose was correctly taken certainly did (RR 1.21 [1.08; 1.29] [19] and RR 1.14 [1.03; 1.26] [20]). The positive effect of the intervention on taking the drug dose at the appropriate time was significant with low heterogeneity in Shi et al. (19) (RR 1.16 [1.03; 1.29], I²= 35%), whereas it did not differ significantly in Mellon et al. (20) (RR 1.10, [0.98; 1.23]). Subgroup analyses revealed that overall adherence could be improved both in renal transplant recipients (RR 1.23 [1.08; 1.41] and in patients receiving other organ transplants (RR 1.10 [1.0; 1.22], and that multidisciplinary interventions showed higher efficiency (RR 1.45 [1.25; 1.67], I²= 28%) compared to interventions by only one professional group (19). Another meta-analysis found no difference between eHealth interventions to improve adherence and treatment-as-usual (RR 1.10 [0.85; 1.41], seven studies) (21).

As a guide, the interventions can be classified into three categories (17, 18). Multicomponent interventions that are generally offered in a multidisciplinary setting and combine individual strategies from one or more of the following categories:

• Cognitive/educational: imparting information and health-related knowledge

• Behavioral: aimed at making concrete behavioral changes through measures such as planning, behavioral contracts, reminders, adherence monitoring, and feedback, etc.

• Psychological/affective: focusing on emotional and social aspects, such as supportive treatment for affective stressors such as anxiety, depression, inclusion of the social environment, stress management, etc.

Overall, the heterogeneity of the study interventions, the outcomes, and their measurement, as well as the risk of bias of the individual studies, are high. Although some studies showed an improvement in adherence as a result of various interventions, a positive effect on prognosis in terms of event-free survival, 12-month mortality, or hospital admissions and their duration, has not yet been demonstrated in the available studies. On the other hand, neither was any harm as a result of the psychosocial interventions reported. Further research is needed here. Numerous other randomized studies aimed at improving adherence are currently underway (20).

Psychosocial risk factors for a poor prognosis after transplantation

Psychological comorbidity

Depressive disorders, anxiety disorders, adjustment disorders, acute stress reactions, and posttraumatic stress disorders are common among transplant patients, independent of the affected organ (2, 22, 23, e18– e20): Depressive disorders develop in, on average, 12–60% of patients prior to transplantation, independent of the affected organ. Following transplantation, prevalence rates of 13–40% are reported. Anxiety disorders are observed in, on average, 8–58% of patients before and in 17–60% after transplantation.

The presence of depression in transplantation patients is associated with higher overall mortality. In their meta-analysis, Dew et al. (2) conclude that, across all organs, the presence of depression increases the relative risk of mortality after transplantation by 65% (RR 1.65 [1.34; 2.05], 20 studies). The presence of an anxiety disorder did not significantly increase this risk (RR 1.39 [0.85; 2.27], six studies). The association is more pronounced in depression after compared to depression before transplantation (2, 12, 24– 26, e21).

Since this meta-analysis, other longitudinal individual studies, some with large patient groups, have been published. Lentine et al. (27) found that 1-year mortality was 39% higher (12.6% of a total of n = 72,054) (adjusted hazard ratio, aHR 1.39 [1.18; 1.64]) in patients that had used antidepressant medications before kidney transplantation. The use of antidepressants in the first year after transplantation was associated with a two-fold increase in mortality in the second year (aHR 1.94, [1.60; 2.35]). Smith et al. (28) reported that higher levels of depression were associated with higher mortality at 5 years post-lung transplantation (aHR 1.31, [1.06; 1.61], n = 132). Likewise, Rosenberger et al. (29) showed that there was a significantly higher risk of mortality in lung transplant patients diagnosed with depression (HR 1.65 [1.01; 2.71]. De la Rosa et al. (26) reported that patients with depression after heart transplantation had a significantly higher risk of 5-year-mortality (30% versus 9.5%, HR 3.57 [1.4; 9.3], n = 114).

The evidence on an increased risk of mortality after transplantation in the presence of depression is highly consistent and clinically relevant. Therefore, the likelihood of the presence of a mental health disorder should be assessed by means of screening questions in the patient history interview or standardized questionnaires at all stages of transplantation treatment. Depression should be treated according to the guidelines. To date, there are only sparse studies on the effect of treatment for depression on mortality following transplantation.

The two-question test is a suitable instrument to screen for the presence of current depression (30, e22):

• During the past month, have you often been bothered by feeling down, depressed, or hopeless?

• During the past month, have you often been bothered by little interest or pleasure in doing things?

Alcohol use

In a comparative approach, a number of meta-analyses have included patients following different organ transplants, with the number of studies after liver transplantation clearly predominating here (31, 32). Across all organs, the rate of alcohol use was calculated to be 23.6%, with 15.1% of transplant patients having at-risk drinking (32).

Alcoholic cirrhosis is one of the commonest indications for inclusion on the waiting list for a liver transplant (German Foundation for Organ Transplantation [Deutsche Stiftung Organtransplantation, DSO], Eurotransplant). Two recent meta-analyses described relapse rates for this group of between 22% (33) and 26.3% (34) following transplantation. In addition, Kodali et al. report annual relapse rates of 4.7% for any alcohol use and 2.9% for heavy alcohol use (34).

In the case of liver transplant patients with ethyl toxic cirrhosis, relapses following liver transplantation are associated with an increased risk of mortality. The relative chance of dying within 10 years of transplantation is 3.67 times [1.4; 9.5] higher compared to abstinent patients, with 19% of fatalities being attributable to continued alcohol use (34). Therefore, throughout the transplantation process, any alcohol use should be assessed, documented, and treated according to the guidelines in the case of high-risk, harmful, or dependent alcohol use (31– 34, e23– e25). To identify alcohol use, the Alcohol Use Disorder Identification Test (AUDIT) or the short version thereof, (AUDIT-C), are recommended. In patients with alcohol-related liver disease, the documentation of alcohol abstinence should be complemented by appropriate direct and indirect status markers (for example, ethyl glucuronide in urine, serum, or hair, phosphatidylethanol) (35).

Psychosocial evaluation

Due to the frequency and impact of nonadherence and mental health comorbidity, the guideline group recommends that all patients on the waiting list for organ transplantation should undergo a psychosocial evaluation carried out by an MHP. Ideally, it would be obligatory for an MHP to participate in the interdisciplinary transplantation conference for all organ groups. In the current guidelines of the German Medical Association (Bundesärztekammer) on waiting list management for liver and lung transplantation, provision is already made for an MHP as a mandatory participant with voting rights in the transplant conference.

The psychosocial evaluation should provide information in particular on previous and current mental health disorders and psychosocial stressors, use of psychoactive substances, as well as the patient’s individual and social resources (36– 38). The psychosocial evaluation should be carried out in a systematic manner in the form of a clinical diagnostic (semistructured [e26]) interview. Possible critical results are listed in Table 2.

Critical results from the psychosocial evaluation, such as the presence of a manifest mental health disorder, should not as a matter of course be seen as a criterion for exclusion from the transplantation waiting list. Instead, in such cases, the indication for a psychosocial intervention needs to be assessed. The aim of the intervention should be to sufficiently stabilize the individual for placement on the list and for the transplantation process. This is successful in many cases. It is not possible to make a universally valid recommendation regarding the exclusion of a patient from the transplantation list due to a mental health disorder. Rather, a decision of this kind needs to be very carefully considered on a case-by-case basis.

Table 2. Assessment criteria of a psychosocial evaluation prior to transplantation (AWMF homepage [4]).

Criteria of a psychosocial evaluation	Critical assessment
Social history, including family and living situation,social network, social support	Unstable/problematic relationships, lack of social support
Occupational, educational, and financial situation	Severe occupational/educational/financial problems,unrealistic occupational goals
Psychosocial stressors	High level of psychosocial burden
Current and previous coping behavior, includingcoping with disease	Dysfunctional coping behavior, dysfunctionalcoping with disease
Current symptoms of anxiety and depression	High level of burden through anxiety and depression
Preoperative anxiety	High level of preoperative anxiety
Subjective theory of disease	Lack of disease acceptance/insight, incorrect attributionof the cause of disease, low self-efficacy expectations
Knowledge regarding disease and transplantation	Lack of knowledge
Risk assessment regarding transplantation	Inadequate risk assessment, in particular, trivializing ordismissing risks
Decision-making regarding transplantation	Impulsive/unreflected decision, external pressure,predominantly extrinsic motivation
Expectations regarding outcome	Unrealistic expectations
Health behavior (exercise, weight control, sleep)(substance use, see below)	Adverse health behavior
Criteria of particular relevance
Motivation for transplantation	Lack of motivation/consent
Current and previous adherence to medical treatments,medication use, etc.	Currently nonadherent
Substance use (alcohol, tobacco, other addictive substances),including taking an addiction (treatment) history	Current substance dependence/abuse(evidence-based evaluation of relevance, according to organ-specific guidelines where appropriate)
Current and previous mental health disordersand their treatment	Unstable mental health disorder(s), especially persistentdelusional disorders, severe personality disorders, especially involving impulsivity, severe depressive disorders, eating disorders, severe anxiety disorders, posttraumatic stress disorders
Current and previous suicidal tendencies and suicide attempts	Acute suicidal tendencies
Cognitive status including ability to give consent	Irreversible absence of cognitive prerequisites foradherence/giving consent (e.g., dementia, severe/profound intellectual disability) without sufficient support

eBOX. Qualification of psychosocial practitioners (AWMF homepage [4]).

• The Mental Health Professional should possess one of the following qualifications:

  • Psychological psychotherapist

  • Specialist in psychosomatic medicine and psychotherapy

  • Specialist in psychiatry and psychotherapy

  • Physician in advanced training in the abovementioned specialties under the supervision of a practitioner holding one of the three aforementioned qualifications and possessing the necessary specialist expertise defined below

  • Medical psychotherapist without further specialist training in the fields of psychosomatics or psychiatry (additional qualification in “specialist psychotherapy”) if they have been active predominantly in the field of transplant medicine for at least 3 years

  • Psychologist, without a license to practice psychotherapy, under the supervision of a practitioner who fulfills one of the first three requirements

  • Diploma or Master of Science in Psychology with a focus on clinical psychology, if they have been active predominantly in the field of transplant medicine for at least 3 years

• For the psychosocial counseling and treatment of children and adolescents and their families/relatives, professionals should have the following qualifications:

  • Specialist in child and adolescent psychiatry and psychotherapy

  • License to practice as a child and adolescent psychotherapist

  • Physician in advanced training in child and adolescent psychiatry and psychotherapy under the supervision of a specialist or practitioner licensed to practice as a child and adolescent psychotherapist possessing the expertise defined below

  • Child and adolescent therapist in training under the supervision of a specialist or practitioner licensed to practice as a child and adolescent psychotherapist possessing the expertise defined below

The Mental Health Professional (MHP) should possess sufficient theoretical knowledge and clinical experience of psychological/psychosomatic/psychiatric issues and problem areas in transplantation medicine.

The definitions for an MHP refer exclusively to the professional group designations in medicine and psychology in the German health care system. The professional group designations used here are not valid for the Austrian or other health care systems and need to be newly defined for other health care systems.

eFigure.

Flow chart on key questions 1–3 (4)