Psychosocial assessments differ in content and application to candidate selection depending on the transplant program.  Psychosocial status before transplant does not consistently affect medical outcome after transplant.  Psychosocial status generally improves with transplant, although difficulties are prevalent in psychological adjustment and in compliance with medical regimens.  Psychiatric history can predict psychological outcomes after transplant but does not consistently predict compliance.  Social supports and coping strategies strengthen psychosocial outcomes. Post transplant psychosocial outcomes may predict physical morbidity and mortality.  Attention to adult patients' psychosocial status and well- being throughout the organ transplant experience is important for 2 very distinct reasons.  First, information about psychosocial history and current status is relevent to and frequently used for clinical decision making before transplantation. Second, information about patients' psychosocial status after transplant often provide important outcome information.

As part of any psychosocial assessment, a psychiatric evaluation should be performed tht covers both current and past mental health.  Other areas that must be evaluated are patients' compliance with past and current treatment regimens and patients' histories of substance use and abuse.  At the least, a brief assessment or screen for current health mental (cognitive) status should routinely be included in the psychosocial evaluation, because cognitive status will affect patients' ability to understand the transplant experience and provide informed consent, as well as comprehend what is required of them as transplant candidates and ultimately as recipients. The remaining elements of the psychosocial assessment focus on the patients' interpersonal and intrapersonal resources and liabilities.  Family members' own mental health history and social functioning are also relevent in understanding the psychosocial environment of the patient.  Serious mental health and/or social dysfunction in 1 or more family members can serve significant sources of stress for the patients, and may result in an absence of the support needed by the patient. The emphasis the transplant team places on evaluation findings will all vary depending upon the team's philosophy and beliefs about the role of their evaluation.  Identical views about the psychosocial assessment's role in the transplant process are not shared among transplant programs.

The greatest controversary and disagreement - moral and ethical issues arise when medical care -including transplantation -is offered or denied to individuals on the basis of their psychosocial history or current status.  America and Europe differ in whether they apply additional psychosocial criteria to select transplant candidates from patients who may be medically equivalent in terms of their needs for transplant.

General medical conditions impact on eligibility for transplantation: psychosocial problems that are unable to be resolved and have a high likelihood of impacting negatively on the patient's outcome, such as poorly controlled major psychoaffective disorder or inability to comply with complex medical regimen, are a relative contraindication. A documented history of noncompliance with medical care... even in the absence of documented psychiatric problems is a relative contraindication.

Heart transplant programs were more likely to see the psychosocial problem as an absolute contraindication, kidney programs were more likely to see the problem as irrelevant and liver programs held the middle ground. The kidney programs may be more leniant because loss of graft does not result in patient death and because of the potential of obtaining organs from family members.  Some programs take an active role in making recommendations and plans for psychosocial interventions, other programs view this as beyond their purview.  However, whether programs and services are offered to(or required to ) patients varies across transplant teams.  The psychosocial assessment has been seen as important by some teams because it allows them to develop individualized working relationships with the patient and family -- liaisons that can be critical for maintaining the patient's health before and after the transplant. In summary some programs, the evaluation is important for decisions about transplant candidacy; in other programs, information from the evaluation is considered helpful but not critical for such decisions.  Some programs use evaluation as an opportunity for healthcare personnel to identify and become actively involved in addressing patient needs for education and intervention.  In other programs, such interventions are viewed as beyond their responsibility of the program, although most have referral options in place so specific psychosocial difficulties may be addressed.

Impact of Pretransplant Psychosocial Evaluation on transplant outcomes - Published clinical case reports have sometimes described quite poor medical outcomes in patients with significant pretransplant histories of psychiatric and/or compliance problems.  Post transplant medical outcomes are determined by many factors, and psychosocial limitations do not automatically lead to poor outcomes. Post transplant compliance is not perfectly predicted by pretransplant compliance or byother pretransplant psychosocial characteristics. The simplest explanation is that the patient may actually change after transplant.  Also, the pretransplant evaluation and waiting period are characterized by high stress and uncertainty, and paitents may be at their worst emotionally and physically at this point. A second reason why pretransplant psychosocial assessments may not be perfect predictors of posttransplant problems is that the information collected may not accurately characterize the pretransplant status and history of the patient.

Psychological Outcomes in Transplant Recipients - While the prevalence of mood and anxiety disorders is considerably elevated over rates in generallly healthy, community- based samples, the rates in transplant population are within the range of rates for those with other chronic disease groups.  Observed rates of mood and anxiety disorders during the first several years after transplant range from 10-58% for depressive disorders(primarily major depression and dysthymia) and from 3-33% for anxiety disorders ( eg. generalized anixiety disorders, panic disorder and post traumatic stress disorder related to the transplant experience).

Heart vs. Lung Transplant - The prevalence of major depressive disorder (MDD) for heart and lung recipients shows that heart transplant, 19% of the candidates have a lifetime history of MDD.  At the time of transplant evaluation, a median of 6% of individuals are currently in an episode of MDD.  After the transplant, the cumulative rate of new episodes of MDD rises, more steeply during the first 12 months and more gradually thereafter. About 25% of heart recipients experience MDD during the first three years after transplant.  Very few studies have been conducted to date, about the prevalence of MDD in lung transplant.  It appears that the median lifetie prevalence rate prior to transplant, in contrast to the pattern for MDD, is considerably more elevated in lung recipients than heart recipients.  One might hypothesize that anxiety disorders would  continue to be more pravelent after a lung transplant, especially to the extent that lung disease may have a etiologic relationship to certain type of distress ( ex. panic disorder.)