Longitudinal prospective measurement of the quality of life before and after liver transplantation among adults

Incidence and prevalence of depressive, anxiety, and insomnia symptoms among adult liver transplant recipients: A systematic review and meta-analysis

OBJECTIVE

Psychological morbidity among transplant recipients may negatively impact post-transplantation outcomes. Our objectives were to compute pooled incidence and prevalence estimates for depressive, anxiety, and insomnia symptoms among adults who underwent liver transplant.

METHODS

Electronic searches of MEDLINE, PubMed Central, CINAHL, and Google Scholar were carried out from inception to October 2022 to identify observational studies conducted among adult liver transplant recipients which measured depression, anxiety, and/or insomnia. We used the Joanna-Briggs tool for study quality appraisal.

RESULTS

Sixty-five studies (pooled N = 12,183) provided data for meta-analysis. The one-year pooled point prevalence rate for depressive symptoms was 25% (95% Confidence Intervals [CI]: 20% to 30%; I² = 94%; 37 studies; N = 6088) while that of anxiety and insomnia symptoms were 29% (95% CI: 21% to 38%; I² = 96%; 28 studies; N = 4016) and 28% (95% CI: 16% to 43%; I² = 98%; 14 studies; N = 1834), respectively. The findings remained robust across subgroup and sensitivity analyses. Most included studies had low or moderate risk of bias.

CONCLUSIONS

Depressive, anxiety, and insomnia symptoms are commonly prevalent following liver transplantation. Our findings, though limited by high heterogeneity across analyses, have important implications for screening, management, and prevention of psychological morbidity in this group.

SYSTEMATIC REVIEW REGISTRATION

This protocol was submitted for registration with the International Prospective Register of Systematic Reviews (PROSPERO) (CRD 42021276008).

Trajectories of Anxiety and Depression After Liver Transplantation as Related to Outcomes During 2-Year Follow-Up: A Prospective Cohort Study

OBJECTIVE

The aims of the study were to examine whether distinct trajectories of anxious and depressive symptoms are present among liver transplant recipients from before transplantation to 2 years afterward, to identify associated demographic, clinical, and individual characteristics, and to examine the influence of distinct trajectories on outcomes.

METHODS

A prospective, multicenter cohort study was performed among 153 liver transplant recipients. Data were retrieved using questionnaires administered before transplantation and at 3, 6, 12, and 24 months after transplantation. Clinical data were retrieved by medical record review. Latent class growth analysis was used to identify distinct trajectories. χ test, analyses of variance, and multinomial logistic regression were used to identify associated variables and the impact of the distinct trajectories on outcomes.

RESULTS

Three distinct trajectories for symptoms of anxiety (State-Trait Anxiety Inventory-short form) as well as depression (Center for Epidemiological Studies Depression Scale) were identified: "no symptoms," "resolved symptoms," and "persistent symptoms." The trajectories of persistent anxiety and depression comprised, respectively, 23% and 29% of the transplant recipients. Several clinical and individual variables were associated with the trajectories of persistent anxiety and/or depression: experiencing more adverse effects of the immunosuppressive medication, lower level of personal control, more use of emotion-focused coping, less disclosure about the transplant, and more stressful life events. The trajectories of persistent symptoms were associated with worse outcomes regarding medication adherence and health-related quality of life, but not with mortality.

CONCLUSIONS

A significant subset of transplant recipients showed persistent symptoms of anxiety and depression from before to 2 years after transplantation. These results emphasize the importance of psychosocial care in the transplant population.

Group Psychotherapy Could Improve Depression in Cirrhotic Patients on the Liver Transplant Waiting List

BACKGROUND

It is well-known that there is a high incidence of depression in patients on the liver transplant (LT) waiting list. However, there have been few studies of psychological intervention on these patients.

OBJECTIVES

To determine symptoms of depression in patients on the LT waiting list and the impact of group psychotherapy.

METHODS

Study population: patients on the LT waiting list who received group psychotherapy (n = 15).

CONTROL GROUP

patients who did not receive psychotherapy (n = 10). Measurement instrument: Beck's depression test, which was provided before psychotherapy was initiated and after it was completed (after 6 months). The control group was given the questionnaire at the same 2 points in time as the study group. The psychotherapeutic method consisted of discussing patients' feelings, which dealt with several matters related to transplantation. Different coping strategies were considered.

RESULTS

More than half of those surveyed initially had depressive symptoms. When the second survey was administered to the study population, all the patients improved in their psychopathological assessment. When the survey was administered to the control group, a worse psychopathological assessment was obtained in all cases.

CONCLUSIONS

Our data suggest an improvement in depressive symptoms in patients on the LT waiting list after receiving group psychotherapy.

Trajectories of anxiety and depression in liver transplant candidates during the waiting-list period

OBJECTIVES

To explore whether distinct trajectories of anxiety and depression exist among liver transplant candidates, and to gain insight into demographic, clinical, and individual characteristics related with these trajectories.

DESIGN

A multicentre, prospective cohort study among 216 liver transplant candidates. Respondents filled out a questionnaire at study entrance and subsequently every 6 months until transplantation or removal from the waiting list.

METHODS

Anxiety (STAI6), depression (CES-D), demographic, and individual variables were assessed by questionnaire. Clinical variables were retrieved by medical record review. The SAS PROC TRAJ procedure was used to identify distinct trajectories. Univariate and multiple ordinal logistic regression analyses were used to explore related variables.

RESULTS

Regarding anxiety, three stable trajectories were identified as follows: below clinical level (51%), slightly above clinical level (34%), and high above clinical level (15%). Regarding depression, four stable trajectories were identified as follows: below clinical level (23%), slightly below clinical level (34%), slightly above clinical level (28%), and high above clinical level (6%). For anxiety as well as for depression, experiencing more liver disease symptoms, a lower level of personal control, making more use of emotional coping, and making less use of task-oriented coping increased the likelihood of membership in those trajectories with higher symptom levels.

CONCLUSION

Distinct, but stable, trajectories of anxiety and depression were present in liver transplant candidates. The trajectories with symptom levels above clinical relevant levels for anxiety or depression comprised, respectively, 49% and 34% of the respondents. Therefore, psychological screening and subsequently providing appropriate interventions are warranted early in the transplant process. Statement of contribution What is already known on this subject For transplant candidates, the waiting-list period is a period of uncertainty and unpredictability. Psychological problems, such as anxiety and depression, are common among liver transplant candidates. Several demographic, clinical, and individual characteristics are associated with anxiety and depression, but these results remain inconclusive. What does this study add Distinct trajectories of symptoms of anxiety and depression are present among liver transplant candidates. Given the stability of the trajectories over time, the symptom level at baseline is indicative of the symptom level during the waiting-list period. Experiencing more liver disease symptoms, low mastery, more use of emotional coping, and less use of task-oriented coping are associated with trajectories of high symptom levels.

Utility of pretransplant psychological measures to predict posttransplant outcomes in liver transplant patients: a systematic review

OBJECTIVE

Evaluation of liver transplant (LT) candidacy involves psychosocial evaluation to ensure appropriate organ allocation. However, the utility of pre-LT psychiatric and neuropsychological factors in predicting posttransplant outcomes remains uncertain. We reviewed current evidence on the prognostic value of pre-LT psychological factors for outcomes after LT.

METHOD

We conducted a systematic review of studies with adult LT recipients that investigate the relationship between pre-LT psychiatric and neuropsychological variables and posttransplant outcomes. We searched Ovid, MEDLINE, PsycINFO, EMBASE/Scopus, Cochrane Controlled trials register and Web of Science (January 1975 to May 2015) for longitudinal, peer-reviewed studies of at least 20 subjects and written in English.

RESULTS

The 19 studies included in this review are heterogeneous in population, prognosis and duration of follow-up (from 20days to more than 3 years). Findings on the prognostic value of pre-LT depression or anxiety on post-LT outcomes are mixed, though depression appears to predict lower quality of life (QOL). Pre-LT suicidal thoughts in particular are associated with post-LT depression. High submissiveness may predict rejection within 20days of LT, and low conscientiousness is associated with greater nonadherence. Whereas pre-LT cognitive performance has not been shown to predict survival, poorer performance may predict poorer QOL after LT.

CONCLUSION

Further studies are needed to examine this important element of LT candidacy evaluation. Studies should evaluate psychiatric factors in large samples, include systematic evaluations by mental health clinicians and explore broader neuropsychological domains in predicting posttransplant outcomes.

Employment after liver transplantation: a review

BACKGROUND

Return to productive employment is often an important milestone in the recovery and rehabilitation process after liver transplantation (OLT). This literature review identifies factors associated with employment in patients who underwent OLT.

METHODS

We searched PubMed for articles that addressed the various factors affecting employment after OLT.

RESULTS

The studies demonstrated improvement in the quality of life and examined factors that predicted whether patients would return to work after OLT. Demographic variable associated with posttransplant employment included young age, male sex, college degree, Caucasian race, and pretransplant employment. Patients with alcohol-related liver disease had a significantly lower rate of employment than did those with other etiologies of liver disease. Recipients who were employed after transplantation had a significantly better posttransplant functional status than did those who were not employed.

CONCLUSION

Economic pressures are increasing the expectation that patients who undergo successful OLT will return to work. Thus, transplant teams need to have a better understanding of posttransplant work outcomes for this vulnerable population, and greater attention must be paid to the full social rehabilitation of transplant recipients. Specific interventions for OLT recipients should be designed to evaluate and change their health perceptions and encourage their return to work.

Prevalence of psychological problems and associated transplant-related variables at different time periods after liver transplantation

After liver transplantation, recipients often experience psychological problems that are influenced by demographic, personal, and transplant-related variables. However, because previous studies have mostly reported on psychological problems and their influencing factors in the first years after transplantation, less is known about their prevalence and influence in the long run. The aims of this study were to examine point-prevalence rates of symptoms of anxiety, depression, and posttraumatic stress (PTS) at different time periods after transplantation and to examine the transplant-related variables associated with these problems. A cross-sectional survey was performed among 373 liver transplant recipients who received transplants between 1979 and 2009 at our center. Five clinically relevant time periods were identified: 0.5 to <2 years, 2 to <5 years, 5 to <10 years, 10 to <15 years, and ≥15 years after transplantation. The response rate was 75% (n=281). Overall, 33.4% of the respondents experienced clinically relevant symptom levels of anxiety (28.7%), depression (16.5%), or PTS (10.0%). Symptoms of anxiety and depression were more prevalent in the first 2 years and in the long term after transplantation. PTS symptoms were more prevalent in the first 5 years after transplantation. However, the prevalence rates did not differ significantly between time periods. Viral hepatitis and the number of side effects of the immunosuppressive (IS) medication were found to be associated with all psychological problems. Alcoholic liver disease was associated with anxiety and depression in the short term after transplantation. In conclusion, a significant subset of transplant recipients experience psychological problems, both shortly after transplantation and in the long run. These problems are often associated with side effects from the IS medication. Therefore, the monitoring of psychological problems, the offering of psychological counseling, and the management of the medication's side effects should be part of the routine care of transplant recipients.

Mental health affects the quality of life and recovery after liver transplantation

There has been little research examining the effects of mental health before liver transplantation on quality of life (QOL) and recovery after transplantation. Therefore, the purpose of the current study was to examine how pretransplant depression and anxiety affect mental health, QOL, and recovery after transplantation. Eighty-two transplant recipients provided data when they were listed for transplantation and 6 months after transplantation. Pretransplant anxiety predicted posttransplant anxiety (P < 0.001), and there was a trend in predicting posttransplant depression (P = 0.06). Pretransplant depression predicted posttransplant depression (P = 0.03), and there was a trend in predicting posttransplant anxiety (P = 0.06). Additionally, pretransplant anxiety predicted posttransplant QOL for several domains, including Body Pain, Role Limitations Due to Emotional Problems, and Mental Health, as well as the Mental Health Composite Score (P < 0.05). However, in comparison with anxiety, pretransplant depression independently predicted outcomes for more QOL domains, which included Physical Functioning, Role Limitations Due to Physical Problems, General Health, Vitality, and Social Functioning, as well as the Physical Composite Score (P < 0.05). Patients with depression at the baseline were more likely to report incomplete recovery 6 months after transplantation (P < 0.001). With respect to baseline anxiety, there was a trend suggesting that these patients were also more likely to report incomplete recovery (P = 0.09). These findings highlight the importance of evaluating transplant candidates both before and after transplantation for anxiety and depressive symptoms. Once patients with these symptoms are identified, they can be referred for treatment, which may lead to better posttransplant outcomes for mental health, QOL, and recovery.

Posttraumatic stress disorder after liver transplantation

BACKGROUND

Liver transplantation can lead to the development of posttraumatic stress disorder (PTSD), but the risk factors associated with this progression are not well understood. To study this syndrome in adult liver transplant recipients, a cross-sectional investigation of 296 recipients at our hospital was carried out between January and June 2010.

METHODS

Study participants completed two questionnaires [a PTSD self-rating scale (PTSD-SS) and a validated Chinese version of the Medical Outcomes Study Short Form-36 (SF-36)]. Clinical and demographic data were collected from the records of the Chinese Liver Transplant Registry and via questionnaires.

RESULTS

The prevalence of full PTSD and partial PTSD (that met the criteria for 2 of the 3 symptom clusters) was 3.7% and 5.4%, respectively, for all transplant recipients. Significant differences between the recipients with no PTSD, partial PTSD, and full PTSD were found in all SF-36 domains except for physical functioning (P=0.466). In general, domain scores were the highest in the recipients who did not meet the criteria for PTSD and the lowest in the recipients who met the criteria for full PTSD. Greater severity of posttraumatic stress symptoms was correlated with poorer quality of life, especially in the bodily pain (P=0.004), social functioning (P=0.001), role-emotional (P=0.048), and mental health (P<0.001) domains. The model for end-stage liver disease (MELD) scores, complications, and educational status were identified by multiple regression analysis as risk factors for developing PTSD.

CONCLUSIONS

PTSD occurred after liver transplantation and was significantly associated with decreased quality of life. Higher MELD scores and complications after transplantation were risk factors that contributed to PTSD, and higher education was a protective factor.

Quality of life and psychologic distress of recipients after adult living-donor liver transplantation (LDLT)-A study from mainland China

This cross-sectional study investigated potential factors impacting quality of life in 125 recipients after living-donor liver transplantation (LDLT). Health-related quality of life (HRQoL) was measured by using the Chinese version of Medical Outcomes Study Short Form-36 (SF-36), and psychologic symptoms by using the Symptom Checklist-90-Revised (SCL-90-R). Clinical and demographic data were collected from the records of the Chinese Liver Transplant Registry and via questionnaire. A total of 102 recipients (81.6%) completed the questionnaires. All SF-36 domain scores (except the mental health score) were lower in the study than in the general population of Sichuan. The mental quality of life was significantly lower in female than in male subjects (P = .000). Regarding the role-physical (P = .016), social functioning (P = .000), and role-emotional (P = .004) domains, recipients >1 year after transplantation scored higher than those <1 year. Bodily pain scores were lower in recipients with prior acute liver failure than those with hepatic carcinoma or hepatic cirrhosis (P = .032). Social functioning was poorer in recipients with than in those without complications (P = .039). Mental component summary scale (MCS) scores and some of physical component summary scale (PCS) significantly correlated with symptom dimension scores of the SCL-90-R (P < .05). In conclusion, gender, time since transplant, etiology of disease, complications, occupation, and some psychologic symptoms were possible factors influencing postoperative HRQoL of LDLT recipients.

Quality of life in simultaneous pancreas-kidney transplant recipients

BACKGROUND

Simultaneous pancreas-kidney transplantation (SPK Tx) allows dialysis and insulin therapy to be discontinued and improves the complications of diabetes mellitus type 1 (DM1). This study measure quality of life (QoL) in SPK transplant recipients and determine if there are differences in QoL between these patients and those with DM1 in renal replacement therapy (RRT).

METHODS

Short Form Health Survey 36-Item (SF-36) was administered to 69 SPK transplant recipients and 34 patients with DM1 under RRT. A descriptive analysis, multiple linear regression, ANOVA, and ordinal regression (PLUM) models were constructed.

RESULTS

QoL was higher in SPK transplant recipients than in patients receiving RRT. The best results were in the recently transplanted patients. Respect to Spanish population the men with SPK transplants scored higher on vitality and lower on general health, role limitations-physical and role limitations-emotional. Women with SPK transplants scored lower on general health. Among patients under RRT, men scored lower on the general health, physical functioning, vitality, and bodily pain while women scored lower on all dimensions. In both groups, greater age was associated with better mental health.

CONCLUSION

Positive predictive factors of QoL are SPK Tx and age while negative predictive factors are female sex and RRT.

Importance of Depression and Active Coping in Liver Transplant Candidates' Quality of Life

Objective

To investigate the importance of psychiatric and psychological factors such as depression, anxiety, personality traits, and coping strategies in liver transplant candidates' quality of life.

Methods

A total of 131 consecutive liver transplant candidates attending outpatient clinics at a liver transplantation central unit were assessed by means of the Medical Outcomes Study Short Form quality-of-life questionnaire, psychiatric diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, a personality inventory (NEO Five-Factor Inventory), the Hospital Anxiety and Depression Scale, and the Brief COPE scale.

Results and Conclusions

Both physical and mental components of quality of life are far more correlated with depression and active coping strategy than with clinical and sociodemographic factors. Neuroticism was also strongly correlated with the mental component of quality of life, and employment was correlated with the physical component of quality of life.

What is the biopsychosocial role of human immunodeficiency virus positivity in patients with end-stage liver disease who undergo orthotopic liver transplantation?

INTRODUCTION

Since 2003 the National Research Program for Solid Organ Transplantation in patients with human immunodeficiency virus (HIV) is active at our liver transplantation center. Patients with HIV who enter this protocol are assessed by the Consultation Liaison Psychiatry Service. The aim of the present study was to evaluate their psychiatric comorbidity.

METHODS

An observational prospective study was conducted comparing end-stage liver disease (ESLD) patients with and without HIV. After the assessment, the psychiatrist compiled the Transplant Evaluation Rating Scale (TERS) and the Montgomery Asberg Depression Rating Scale (MADRS). Baseline evaluation was made before inclusion on the OLT waiting list and the follow-up evaluation was made 12 months later.

RESULTS

From January 2003 to December 2006 we assessed 553 patients: 39 (6%) with HIV and 361 (94%) without HIV. The 2 groups were homogeneous for gender (75% of male patients; P=not significant [NS]) but not for age (46+/-5 vs 56+/-9; P=NS). Psychiatric history was negative in 176 (49%) patients without HIV and in 6 (15%) patients with HIV (P< .001). At baseline psychiatric comorbidity was present in 33 HIV patients (85%) and in 148 non-HIV patients (41%; P< .001). At follow-up MADRS highlighted an improvement in all of the items for HIV patients. In the non-HIV group, the variation was as follows: baseline, 7.10; follow-up, 8.15. In the HIV group, the variation was as follows: baseline, 10.20; follow-up, 4.09 (P< .001). The average score at TERS was higher among patients with HIV (43+/-9 vs 35+/-9; P=NS).

CONCLUSIONS

At baseline HIV patients with ESLD showed a higher rate of psychopathology, but they improved at follow-up; the contrary happened in the non-HIV group.

Quality of life after liver transplantation. A systematic review

BACKGROUND/AIMS

Although many studies have reported significant improvements in quality of life (QOL) after liver transplantation (LT), consistent data on areas of improvement are lacking. To perform a systematic review on medical literature of QOL after LT paying particular attention to studies that utilized the most commonly adopted study instrument, Short Form-36 (SF-36).

METHODS

To collect studies focused on QOL in adult LT recipients, from 1963 to 2007, cited in Pub Med, Embase or Cochrane databases. From an initial identification of 613 articles, we selected 44 longitudinal studies with pre- and post-LT data that we assessed using a sign test, and 19 used SF-36, which we analyzed separately.

RESULTS

Longitudinal data showed remarkable improvement of common domains of QOL comparing pre- and post-transplant items. However, analysis of 16 SF-36 cross-sectional studies comparing post-LT patient domains with control population showed significantly higher ratings for controls in six while no differences were found in two.

CONCLUSIONS

This review suggests that whereas general QOL improves after LT, when compared with healthy controls, LT recipients have significant deficits in QOL. Consequently, the previously reported QOL benefits after LT may have been overstated.

Waiting for a liver transplant

The waiting period for liver transplantation is a difficult time fraught with uncertainty and associated with a high rate of morbidity and mortality. To understand better what it means for a transplant patient to wait, the authors explore in this phenomenological study the meaning that people with liver failure ascribe to the experience of waiting for a transplant. They conducted 9 interviews using phenomenological methods of inquiry as a guide for analysis. Eight core themes emerged from 146 significant statements and corresponding meaning units. The experience of waiting includes transformations, doctors, teams and trust, elation to despair, loss, questioning the process, searching, coping, and the paradox of time. The essence of the experience is discussed in light of the theory of chronic illness as a disruption of biographical narrative. The authors highlight implications for the transplant teams and other health care providers.

Employment and health insurance in long-term liver transplant recipients

This study was conducted to examine factors affecting health insurance and employment status in long-term liver transplant (OLT) recipients. All adult primary OLT recipients surviving at least 1 year were surveyed using existing questionnaires. Out of 217 eligible recipients, 186 (86%) responded. The median age of respondents was 55 years with a median survival after OLT of 3.4 years. The majority (98%) of respondents had health insurance coverage. Thirty-four (18%) reported having lost and/or having been denied health insurance since OLT, and 63 (34%) switched health insurance since OLT. Of the 179 that reported employment status, 98 (55%) were employed, including homemakers and students, while 39 (22%) were retired and 42 (24%) unemployed. The majority (76%) of those unemployed cited poor health as the reason for unemployment, followed by 5 (12%) who feared loss of disability or Medicaid benefits. Fourteen reported to have been denied or terminated from employment because of their transplant. In the regression analysis, employment prior to transplantation (odds ratio (OR)=5.1), age less than 57 (OR=5.1), physical function score>52.4 (OR=3.6) and general health score>33.3 (OR=7.6) were significantly associated with employment. These data may help identify high-risk pre-OLT patients for intervention measures such as work rehabilitation.

Psychosocial adjustment to orthotopic liver transplantation in 266 recipients

Although the survival rate of patients undergoing orthotopic liver transplantation (OLT) is highly satisfactory, one of the most important objectives for liver transplantation teams at the present time is to achieve the best possible quality of life and psychosocial functioning for these patients after transplantation. We present the preliminary results of a study designed to determine which domains of psychosocial functioning are most affected in liver transplant recipients, and to examine the factors associated with poorer adjustment after OLT, using a utility-based standardized measure. Patients who had undergone liver transplant more than 12 months previously were eligible. They were administered the Psychosocial Adjustment to Illness Scale (PAIS), and they provided the answers themselves. Multivariate regression models showed that attitudes toward health care were poorer in women (beta = 0.916, P <.001), in patients who were employed at the moment of transplantation (beta = 0.530, P =.032), and in patients of lower social class (beta = 0.722, P =.026) than in men, unemployed patients, and patients of higher social class. Sexual functioning was worse in women (beta = 0.907, P =.001) and older patients (beta = 0.999, P <.001) than in men or younger patients. Psychological distress was higher in women (beta = 0.981, P =.001) than in men, and lower in currently employed patients (beta = -0.937, P =.001) than in the unemployed. Only gender remained significantly associated with the total PAIS score (beta = 0.969, P <.001), with women showing a poorer overall psychosocial adjustment to OLT. In conclusion, there seems to be no doubt that liver transplantation improves quality of life, but special attention should be paid to female recipients, who seem to have more difficulty than their male counterparts in adjusting to the psychosocial consequences of the procedure.

Predictors of psychiatric disorders in liver transplantation candidates: logistic regression models

This study has two goals. The first goal is to assess the prevalence of psychiatric disorders in orthotopic liver transplantation (OLT) candidates by means of standardized procedures because there has been little research concerning psychiatric problems of potential OLT candidates using standardized instruments. The second goal focuses on identifying predictors of these psychiatric disorders. One hundred sixty-five elective OLT candidates were assessed by our unit. Psychiatric diagnoses were based on the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Patients also were assessed using the Hamilton Depression Rating Scale (HDRS) and the Spielberger Anxiety Index, State and Trait forms (STAI-X1 and STAI-X2). Severity of cirrhosis was assessed by applying Child-Pugh score criteria. Chi-squared and general linear model analysis of variance were used to test the univariate association between patient characteristics and both clinical psychiatric diagnoses and severity of psychiatric diseases. Variables with P less than.10 in univariate analyses were included in multiple regression models. Forty-three percent of patients presented at least one psychiatric diagnosis. Child-Pugh score and previous psychiatric diagnoses were independent significant predictors of depressive disorders. Severity of psychiatric symptoms measured by psychometric scales (HDRS, STAI-X1, and STAI-X2) was associated with Child-Pugh score in the multiple regression model. Our data suggest a high rate of psychiatric disorders, particularly adjustment disorders, in our sample of OLT candidates. Severity of liver disease emerges as the most important variable in predicting severity of psychiatric disorders in these patients.