News from the Johns Hopkins Department of Psychiatry and Behavioral Sciences
Patients going through Hopkins’ transplant service for a new heart, lung, liver or kidney are, by definition, gravely ill. So it’s natural that many are demoralized by their physical weakness and shocked at the possibility of having to sit out life’s dance. There’s the anxiety of finding a donor or facing high-risk surgery or the uncertainties of life on mega-medication. Distress can shade into depression or anxiety disorders, especially in patients already cognitively compromised from low oxygen or other effects of their illnesses.
Helping patients with life adjustment problems and referring those with major depression or anxiety are clearly part of David Edwin’s work. As psychologist for Hopkins hospital’s transplant service, he also screens potential donors and recipients. “I’m not here to winnow people out so much as to make it safer to transplant them,” he says. But transplant’s no typical event, and the issues and pressures these patients face make what Edwin encounters far from predictable.
“Transplants don’t occur in a vacuum,” he says. “Life in all its variety encroaches.”
It’s only the discipline of what he calls “a psychological imagination” that helps him sift through layers of patient problems using the perspectives of his field. For example:
> The medical work-up stalled for a man awaiting a heart transplant when he couldn’t make clinic appointments. Earlier, he’d had a defibrillator implanted and its firings became terrifying. He found himself unable to undergo pre-transplant dental work because he feared the device would fire while he sat in the chair, and his anxiety generalized to the point that he rarely left home.
“The agoraphobia-like syndrome behind his “noncompliance” isn’t uncommon in defibrillator patients,” Edwin explains,“but, for him, it was life threatening.” Colleagues at Hopkins Community Psychiatry stepped in and he’s now in treatment with a psychiatrist and behavior therapist.
> A Chicago woman flew to Hopkins to be considered for an incompatible-donor transplant after her kidneys deteriorated from complications of lithium therapy. Her home psychiatrist had diagnosed bipolar disorder and the woman had a history of becoming psychotic on the prednisone normally given transplant patients.
“I didn’t see the patient at her evaluation visit,” says Edwin, but records suggested more than bipolar illness. The discharge notes I requested from her previous psychiatric hospitalization described a schizoaffective disorder, which makes her a more worrisome transplant candidate. But if she had appendicitis, we’d operate for that, wouldn’t we? The question is, Is a transplant doable for her? If we don’t advocate for mentally ill people, who will?
“The transplant team was concerned about steroid psychosis—many medications post-transplant aren’t benign in patients with mental illness. And while we knew we could address any acute post-op problems here, we found we also had to organize adequate psychiatric care for her at home. In this case, our patient has done well.”
> A man with alcoholic liver disease from years of abuse was dropped from the waiting list after a weekend binge brought him to the hospital. He went “clean” for the six months required to get relisted, but admitted that he still smoked marijuana.
“It’s not unusual for patients to dive off the transplant list because they can’t stay abstinent,” says Edwin. “Substance disorders are a chronic part of life on the service.” Relapsing post-transplant is difficult to predict, however, and a number of patients resume some level of drinking. But marijuana drastically increases relapse risk in recovering addicts, he explains,”so we’ve become active in testing for it. We look at this not as something to rule people out permanently but as part of planning their care.”