Original articlePsychosocial vulnerability predicts psychosocial outcome after an organ transplant: Results of a prospective study with lung, liver, and bone-marrow patients☆
Introduction
The vulnerability model represents a well-accepted conceptual framework for explaining the development and outcome of psychiatric and psychosomatic disorders. It is successfully being used today in the psychology of human development (Petermann et al. [1], pp. 203–227) and in research on schizophrenic [2], [3], affective [4], or addictive [5], [6] disorders. The basic assumption of this model is that vulnerable people exposed to stressors tend to have poor psychosocial adjustment [2]. Based on so-called vulnerability markers, future nonadjustment can be predicted. In transplantation medicine, risk assessment concerning posttransplant psychosocial adjustment plays a major role.
The identification of at-risk patients is a main task of pretransplant psychosocial assessment. Previous studies [7], [8], [9], [10], [11], [12], [13], [14] have shown that psychosocial variables assessed before transplant are able to predict both psychosocial and physical outcomes after the transplant. To quote an example, pretransplant psychiatric disorders are significant predictors of lack of psychosocial adjustment after a transplant [7], [8], [9], [10]. High pretransplant anxiety or neuroticism values predict low posttransplant quality of life [9], [10]. Some studies suggest that patients with pretransplant psychiatric disorders show higher allograft rejection rates [11], as well as an increase in posttransplant mortality [7], [8], [12], [13], [14]. Other studies, however, have not been able to demonstrate the prognostic validity of psychosocial variables in terms of physical posttransplant outcome [15], [16]. To our knowledge, no study has investigated patterns or features of psychosocial variables predicting posttransplant outcome. Other studies tested mostly the prognostic validity of just a few isolated psychosocial symptoms or variables in terms of posttransplant psychosocial or physical outcome, without providing an appropriate psychological framework. So far, elements of vulnerability have been looked at previously, but not within a multidimensional vulnerability model.
The goal of the present study is to apply the vulnerability model to transplant patients and to test the model for prognostic validity vis-à-vis psychosocial and physical outcomes after surgery or allogeneic bone-marrow transplantation. In general, psychosocial vulnerability is known as a congenital or acquired disposition towards psychosocial nonadjustment. Vulnerability is a psychosocial multidimensional pattern that consists of cognitive, affective, and social components, called vulnerability markers. Stable personality traits (e.g., dysfunctional cognitive beliefs), situational symptoms (e.g., anxiety and depression), or external resources (e.g., poor social support) [17], [18], [19], [20] represent the most current vulnerability markers. Typical stressors are crucial life events [2]. Cognitive appraisals form the reaction to a stressor by experiencing it as a challenge, threat, or loss [21], [22], [23].
In this prospective study, psychosocial variables are defined as pretransplant vulnerability markers in three dimensions, assessed by self-rating measures: Dimension 1—stable personality-related traits (cognitive beliefs: sense of coherence and optimism); Dimension 2—situational symptoms (affect: anxiety and depression); and Dimension 3—external resources (social network: perceived social support). Additionally, psychosocial functioning was judged by professionals in terms of psychiatric disorders, health behavior, social support, coping, affect, and mental status. Twelve months after transplant, psychosocial outcome was measured by self-rated quality of life (mental), life satisfaction, and need for counseling, as judged by professionals. Physical outcome variables consisted of the self-rated quality of life (physical) and survival rate. The transplantation procedure was seen as a repetitive stressor that challenged the patient's psychological adaptability with numerous demands. Fig. 1) shows the vulnerability model in transplantation patients.
The study deals with the following question: Do vulnerability markers (i.e., indicators of a patient's psychosocial vulnerability) predict psychosocial and physical outcomes 12 months after a lung, liver, or bone-marrow transplant?
Section snippets
Study design and course of investigation
The first assessment of the prospective study took place between September 2000 and August 2003 at the University Hospital of Zurich. At this time, 161 German-speaking lung, liver, and bone-marrow transplant candidates were included in the study. All patients were informed verbally and in writing about the trial, and they signed a written informed consent. The study was approved by the responsible ethical committee of the University of Zurich.
The pretransplant survey (T0) of lung and liver
Sociodemographic and medical data
Patients' sociodemographic data are shown in Table 1), while diagnoses of underlying diseases are given in Table 2).
Psychosocial predictors of psychosocial and physical outcome after lung, liver, or bone-marrow transplantation
Table 3 shows interrelationships between the pretransplant predictors (T0) sense of coherence, optimism, anxiety, depression, social support, and psychosocial functioning.
Between predictors, there are partly significant correlations (e.g., between sense of coherence, anxiety, and optimism, and between anxiety and depression).
The results of multiple regression analyses are given in
Discussion
In this study, a specific assessment of vulnerability markers was used to investigate the prognostic validity of psychosocial vulnerability for posttransplant psychosocial and physical outcomes. In our model (see Fig. 1), pretransplant psychosocial variables (cognitive beliefs, affect, and social network) represent essential markers of psychosocial vulnerability. We consider this model as a framework of both psychological and social aspects that are usually noticed by clinical observations.
Conclusions
Patients with high pretransplant psychosocial vulnerability should receive ongoing counseling by a psychologist/psychiatrist throughout the transplant process. Experts in this field should be available in transplant centers. Furthermore, pretransplant psychosocial evaluation should consist of a face-to-face interview, to which psychometric test instruments are added to objectify the individual degree of psychosocial vulnerability.
Acknowledgments
We wish to thank U. Schäfer, M. Struker, N. Bodrie, and M. Blum (transplantation coordinators at the University Hospital Zurich), as well as M. Schleuniger and M. Stamm (psychologists in the Department of Psychosocial Medicine), for their excellent collaboration; furthermore, we thank our colleagues E. Lambreva, K. Schwegler, and B. Buddeberg-Fischer for their valuable clinical and conceptual advice.
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This work was supported by the Swiss National Science Foundation (project no. 4046-05661).