Transplant and ICU psychiatry

Meet the patient

Two referrals land on the same ward round. First, a 46-year-old with heart failure referred "for psychiatry to clear him for transplant" — he has a remote drinking problem, a thin support network, and missed his last two cardiology appointments. Second, the ICU team pages you about a ventilated 70-year-old who is "quiet and flat" and "probably depressed".[1][9][11]

These are the two halves of this topic, and the registrar will treat them with the same reflex — "psychosocial contraindication" for one, "start an antidepressant" for the other. Both reflexes are wrong. The transplant patient needs optimisation, not a veto; the ICU patient needs a delirium assessment, not an SSRI. Everything below is how you answer both at consultant depth.[1][8][11]

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1. [1]Dew MA, DiMartini AF, Dobbels F, et al. The 2018 ISHLT/APM/AST/ICCAC/STSW Recommendations for the Psychosocial Evaluation of Adult Cardiothoracic Transplant Candidates and Candidates for Long-term Mechanical Circulatory Support Psychosomatics, 2018.PMID 30197247
2. [2]Dew MA, DiMartini AF, Dobbels F, et al. The 2018 ISHLT/APM/AST/ICCAC/STSW recommendations for the psychosocial evaluation of adult cardiothoracic transplant candidates and candidates for long-term mechanical circulatory support J Heart Lung Transplant, 2018.PMID 29709440
3. [3]Maldonado JR, Dubois HC, David EE, et al. The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT): a new tool for the psychosocial evaluation of pre-transplant candidates Psychosomatics, 2012.PMID 22424160
4. [4]Maldonado JR, Sher Y, Lolak S, et al. The Stanford Integrated Psychosocial Assessment for Transplantation: A Prospective Study of Medical and Psychosocial Outcomes Psychosom Med, 2015.PMID 26517474
5. [5]Dew MA, DiMartini AF, De Vito Dabbs A, et al. Rates and risk factors for nonadherence to the medical regimen after adult solid organ transplantation Transplantation, 2007.PMID 17460556
6. [6]Dew MA, Rosenberger EM, Myaskovsky L, et al. Depression and Anxiety as Risk Factors for Morbidity and Mortality After Organ Transplantation: A Systematic Review and Meta-Analysis Transplantation, 2015.PMID 26492128
7. [7]Dew MA, DiMartini AF, Steel J, et al. Meta-analysis of risk for relapse to substance use after transplantation of the liver or other solid organs Liver Transpl, 2008.PMID 18236389
8. [8]Rosenberger EM, Dew MA, Crone C, et al. Psychiatric disorders as risk factors for adverse medical outcomes after solid organ transplantation Curr Opin Organ Transplant, 2012.PMID 22277955
9. [9]Ely EW, Inouye SK, Bernard GR, et al. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU) JAMA, 2001.PMID 11730446
10. [10]Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients Am J Respir Crit Care Med, 2002.PMID 12421743
11. [11]Devlin JW, Skrobik Y, Gélinas C, et al. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU Crit Care Med, 2018.PMID 30113379
12. [12]Pandharipande PP, Girard TD, Jackson JC, et al. Long-term cognitive impairment after critical illness N Engl J Med, 2013.PMID 24088092
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15. [15]Davidson JE, Jones C, Bienvenu OJ Family response to critical illness: postintensive care syndrome-family Crit Care Med, 2012.PMID 22080636
16. [16]Jones C, Bäckman C, Capuzzo M, et al. Intensive care diaries reduce new onset post traumatic stress disorder following critical illness: a randomised, controlled trial Crit Care, 2010.PMID 20843344
17. [17]Appelbaum PS Clinical practice. Assessment of patients' competence to consent to treatment N Engl J Med, 2007.PMID 17978292
18. [18]Appelbaum PS, Grisso T Assessing patients' capacities to consent to treatment N Engl J Med, 1988.PMID 3200278
19. [19]Raymont V, Bingley W, Buchanan A, et al. Prevalence of mental incapacity in medical inpatients and associated risk factors: cross-sectional study Lancet, 2004.PMID 15488217
20. [20]Wijdicks EF Neurotoxicity of immunosuppressive drugs Liver Transpl, 2001.PMID 11699028