Transplant psychiatry

The number of transplant procedures undertaken in the UK is increasing steadily, although the number of potential recipients is rising at a faster rate. Psychiatrists in substance misuse, alcohol, and general adult services are increasingly likely to encounter patients who await or possess a solid organ transplant, often for reasons causally related to their mental disorder, such as alcoholic liver disease. They therefore need to understand the roles of the small number of highly specialized transplant psychiatrists who work alongside transplant teams. Transplant psychiatrists are often required to help select among recipients, guided in part by protocols that set out absolute and relative psychosocial contraindications to transplant listing, such as continuing substance dependence. Mental disorders are considered contraindications to the extent that they predict excess mortality, morbidity, or non-compliance leading to graft failure. Guideline development is hampered by a lack of studies linking mental disorders to post-operative outcome. Some factors, such as obesity and continued smoking, are more clearly linked to adverse outcome, and transplant psychiatrists may be asked to give opinions and offer management in these areas. Increasingly, transplant psychiatrists are also required to help in assessing potential live donors. In the case of non-directed donors, such assessment is mandated by UK law. Post-operative management has close parallels to the work of liaison psychiatry after any major surgery, particularly as regards delirium, post-traumatic stress disorder, and adjustment disorders, but when mental disorder threatens graft survival, specialist work alongside transplant teams is again required.