Depression, social support, and clinical outcomes following lung transplantation: a single-center cohort study

Abstract

Depressive symptoms are common among lung transplant candidates and have been associated with poorer clinical outcomes in some studies. Previous studies have been plagued by methodologic problems, including small sample sizes, few clinical events, and uncontrolled confounders, particularly perioperative complications. In addition, few studies have examined social support as a potential protective factor. We therefore examined the association between pretransplant depressive symptoms, social support, and mortality in a large sample of lung transplant recipients. As a secondary aim, we also examined the associations between psychosocial factors, perioperative outcomes [indexed by hospital length of stay (LOS)], and mortality. We hypothesized that depression would be associated with longer LOS and that the association between depression, social support, and mortality would be moderated by LOS. Participants included lung transplant recipients, transplanted at Duke University Medical Center from January 2009 to December 2014. Depressive symptoms were evaluated using the Beck Depression Inventory (BDI-II) and social support using the Perceived Social Support Scale (PSSS). Medical risk factors included forced vital capacity (FVC), partial pressure of carbon dioxide (PCO ), donor age, acute rejection, and transplant type. Functional status was assessed using six-minute walk distance (6MWD). We also controlled for demographic factors, including age, gender, and native disease. Transplant hospitalization LOS was examined as a marker of perioperative clinical outcomes. Participants included 273 lung recipients (174 restrictive, 67 obstructive, 26 cystic fibrosis, and six "other"). Pretransplant depressive symptoms were common, with 56 participants (21%) exhibiting clinically elevated levels (BDI-II ≥ 14). Greater depressive symptoms were associated with longer LOS [adjusted b = 0.20 (2 days per 7-point higher BDI-II score), P < 0.01]. LOS moderated the associations between depressive symptoms (P = 0.019), social support (P < 0.001), and mortality, such that greater depressive symptoms and lower social support were associated with greater mortality only among individuals with longer LOS. For individuals with LOS ≥ 1 month, clinically elevated depressive symptoms (BDI-II ≥ 14) were associated with a threefold increased risk of mortality (HR = 2.97). Greater pretransplant depressive symptoms and lower social support may be associated with greater mortality among a subset of individuals with worse perioperative outcomes.

Palliative care in lung transplantation

“…The majority of palliative care consults occurring within the first year after transplantation belies the distress that many transplant recipients experience immediately after transplantation, including from side effects related to immunosuppression, pain, postoperative cognitive dysfunction, depression and post-traumatic stress disorder. This, as well as the distress associated with adjusting to the challenges of post-transplant life, has been seen in many recent studies (23,35,38,39).…”

“…In addition, psychological co-morbidities of post traumatic stress disorder, depression, and anxiety are common in this patient population, and depression in particular is worrisome as it is associated with worse outcomes, including survival. Smith et al have shown that survival is linked to psychosocial well-being in lung transplant patients (35), and this pattern can be seen in other transplant patients: importantly, bone marrow transplant recipients for AML follow a similar pattern of declining quality of life and increasing psychological and symptom burden (36,37). One recent randomized controlled trial of integrated palliative care for bone marrow transplant recipients demonstrated reduced decline in quality of life and improvement in psychological burden both in the immediate perioperative period, and the benefits of palliative care were still seen 6 months later (36,37).…”

Incorporating patient and caregiver feedback into lung transplant referral guidelines for individuals with cystic fibrosis—Preliminary findings from a novel paradigm

“…Understanding potential psychosocial barriers to optimal referral for lung transplant evaluation is particularly important as a high number of CF patients do not appear to be appropriately referred, 4 although the specific psychosocial barriers to referral are not adequately understood 23 . Indeed, a growing body of data suggest the psychosocial factors, including coping strategies, 20,24 depression, 25‐28 and social support, 26 are important predictors of lung transplant outcomes even after accounting for traditional prognostic factors, 22 such as background characteristics, 26,27 post‐transplant pulmonary function, 28 and primary graft dysfunction 25 . More specifically, individuals who exhibit avoidant or passive coping strategies, 29 a low sense of control over their health care, 30 or denial regarding their health, demonstrate an array of maladaptive behaviors, experience worse QoL before and after transplant, 19,24 and are at increased risk for adverse clinical outcomes 31 …”

Psychosocial considerations in the assessment of hand transplant candidates: A single‐center experience and brief literature review

“…The BDI-II is a 21-item self-report measure assessing the presence and severity of depressive symptoms, including cognitive, somatic, and affective symptomatology. 50 Beck anxiety inventory…”