Original Articles
Early post-transplant medical compliance and mental health predict physical morbidity and mortality one to three years after heart transplantation

These data were presented at the annual meeting of the International Society for Heart and Lung Transplantation, Chicago, IL, April, 1998.
https://doi.org/10.1016/S1053-2498(98)00044-8Get rights and content

Abstract

Background

Poor medical compliance has been held responsible for a large proportion of deaths occurring subsequent to initial postoperative recovery. However, beyond clinical reports, there has been little empirical examination of this issue, or of the extent to which major psychiatric disorder and failure to adjust to the transplant predict long-term physical morbidity and mortality. We prospectively examined whether a full range of compliance behaviors and psychiatric outcomes during the first year post-transplant predicted subsequent mortality and physical morbidity through 3 years post-transplant.

Methods

A total of 145 heart recipients who had received detailed compliance and mental health assessments during the first year post-transplant were followed up at 3 years post-transplant. Interview data and corroborative information from family members were used to determine compliance in multiple domains, psychiatric diagnoses, and psychiatric symptomatology during the first year post-surgery. Medical record reviews were performed to abstract data on acute graft rejection episodes, incident cardiac allograft disease (CAD) and mortality from 1 to 3 years post-transplant.

Results

After controlling for known transplant-related predictors of outcome, multivariate analyses yielded the following significant (p < 0.05) results: (a) risk of acute graft rejection was 4.17 times greater among recipients who were not compliant with medications; (b) risk of incident CAD was elevated by persistent depression (Odds Ratio, OR = 4.67), persistent anger-hostility (OR = 8.00), medication noncompliance (OR = 6.91), and obesity (OR = 9.92); and (c) risk of mortality was increased if recipients met criteria for Post-Traumatic Stress Disorder related to the transplant (OR = 13.74).

Conclusions

The findings, plus data we have previously reported that showed which patients are most likely to have compliance and psychiatric problems early post-transplant, suggest that interventions focused on maximizing patients’ psychosocial status in these areas may further improve long-term physical health outcomes in this population.

Section snippets

Respondents

A total of 166 adult (aged 18+) heart transplant patients from the Cardiothoracic Transplantation Program, University of Pittsburgh Medical Center, were enrolled in a longitudinal evaluation of health status during the first year following heart transplantation.6, 29 All adults surviving beyond the initial post-transplant recovery period (defined as the first 6 weeks following surgery) were eligible for the study (N = 174) and were initially contacted at that time; the refusal rate for the

Morbidity and mortality during followup period

During the period from 1 to 3 years post-transplant, 20.7% of the recipients experienced at least 1 episode of acute graft rejection (n = 28 of the 135 recipients with available biopsy data). Among these 28 persons, 19 (68%) had also had acute graft rejection episodes graded 3A or higher during the first year post-transplant, averaging 1.95 episodes each (SD = 0.85), with an average grade of 3A. Of the remaining 107 persons with no documented episodes during the period 1 to 3 years

Discussion

Although noncompliance with the post-transplant medical regimen and serious psychiatric distress post-transplant have been anecdotally noted to bode for a poorer post-transplant physical health course, the empirical documentation of such effects has been rare to nonexistent. There are no large-scale cohort studies of the role of these factors in mortality post-transplant. In the only quantitative analysis to date of their role vis-à-vis morbidity, Paris et al.2 examined the correlation of such

References (85)

  • A.F Brennan et al.

    Predictors of quality of life following cardiac transplantation

    Psychosomatics

    (1987)
  • O.S Surman

    Psychiatric aspects of liver transplantation

    Psychosomatics

    (1994)
  • M.G Goldstein et al.

    Psychological factors affecting physical conditioncardiovascular disease literature review

    Psychosomatics

    (1992)
  • P.A Shapiro

    Psychiatric aspects of cardiovascular disease

    Psychiatric Clinics North America

    (1996)
  • D.K.C Cooper et al.

    Noncompliance in heart transplant recipientsthe Cape Town experience

    Heart Transplant

    (1984)
  • W Paris et al.

    Study of the relative incidences of psychosocial factors before and after heart transplantation and the influence of posttransplantation psychosocial factors on heart transplantation outcomes

    J Heart Lung Transplant

    (1994)
  • D.E Tolman et al.

    Clinical complications of heart transplantationpresent and future trends

  • M.A Dew et al.

    Medical compliance and its predictors in the first year after heart transplantation

    J Heart Lung Transplant

    (1996)
  • P.A Shapiro et al.

    Psychosocial evaluation and prediction of compliance problems and morbidity after heart transplantation

    Transplantation

    (1995)
  • L.J Baumann et al.

    Living with a heart transplantlong-term adjustment

    Transplant Int

    (1992)
  • De Geest S. Subclinical noncompliance with immunosuppressive therapy in heart transplant recipients. Doctoral...
  • R.A.M Erdman et al.

    Compliance with the medical regimen and partner’s quality of life after heart transplantation

    Qual Life Res

    (1993)
  • K.L Grady et al.

    Patient compliance at one year and two years after heart transplantation

    J Heart Lung Transplant

    (1998)
  • R.M House et al.

    Psychiatric aspects of organ transplantation

    JAMA

    (1988)
  • R.T Schweizer et al.

    Noncompliance in organ transplant recipients

    Transplantation

    (1990)
  • S Sisson et al.

    Medication noncompliance and its relationship to financial factors after heart transplantation

    J Heart Lung Transplant

    (1994)
  • G Parry et al.

    Cigarette smoking after cardiac transplantation [Abstract]

    J Heart Lung Transplant

    (1994)
  • A.J Christensen et al.

    Family support, physical impairment, and adherence in hemodialysisan investigation of main and buffering effects

    J Behav Med

    (1992)
  • J.A Cramer et al.

    How often is medication taken as prescribed? A novel assessment technique

    JAMA

    (1989)
  • S De Geest et al.

    Incidence, determinants, and consequences of subclinical noncompliance with immunosuppressive therapy in renal transplant recipients

    Transplantation

    (1995)
  • T.S Inui et al.

    Variations in patient compliance with common long-term drugs

    Med Care

    (1980)
  • D.J Kiley et al.

    A study of treatment compliance following kidney transplantation

    Transplantation

    (1993)
  • D Meichenbaum et al.

    Facilitating treatment adherencea practitioner’s guide book

    (1987)
  • A Rodriguez et al.

    Psychosocial profile of noncompliant transplant patients

    Transplant Proc

    (1991)
  • S.E Taylor et al.

    Coping with chronic illness

  • P Bohachick et al.

    Psychosocial outcome six months after heart transplant surgerya preliminary report

    Res Nurs Health

    (1992)
  • M.A Dew et al.

    Prevalence and predictors of depression and anxiety-related disorders during the year after heart transplantation

    Gen Hosp Psychiatry

    (1996)
  • M.A Dew et al.

    Psychosocial predictors of vulnerability to distress in the year following heart transplantation

    Psychol Med

    (1994)
  • D.C Fisher et al.

    Changes in health-related quality of life and depression in heart transplant recipients

    J Heart Lung Transplant

    (1995)
  • A.M Freeman et al.

    Cardiac transplantationclinical correlates of psychiatric outcome

    Psychosomatics

    (1988)
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    This research was funded by grants MH45020 and MH30915 from the National Institute of Mental Health, and HL54326 from the National Heart, Lung and Blood Institute, Rockville, MD.

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