Morbidity and mortality following bone marrow transplantation: Predictive utility of pre-BMT affective functioning, compliance, and social support stability

It Takes a Team to Make It Through: The Role of Social Support for Survival and Self-Care After Allogeneic Hematopoietic Stem Cell Transplant

Background

Social support plays an important role for health outcomes. Support for those living with chronic conditions may be particularly important for their health, and even for their survival. The role of support for the survival of cancer patients after receiving an allogeneic hematopoietic cell transplant (alloHCT) is understudied. To better understand the link between survival and support, as well as different sources and functions of support, we conducted two studies in alloHCT patients. First, we examined whether social support is related to survival (Study 1). Second, we examined who provides which support and which specific support-related functions and tasks are fulfilled by lay caregivers and healthcare professionals (Study 2).

Methods

In Study 1, we conducted a retrospective chart review of alloHCT patients (N = 173, 42.8% female, age: M = 49.88) and registered availability of a dedicated lay caregiver and survival. In Study 2, we prospectively followed patients after alloHCT (N = 28, 46.4% female, age: M = 53.97, 46.4% ethnic minority) from the same hospital, partly overlapping from Study 1, who shared their experiences of support from lay caregivers and healthcare providers in semi-structured in-depth interviews 3 to 6 months after their first hospital discharge.

Results

Patients with a dedicated caregiver had a higher probability of surviving to 100 days (86.7%) than patients without a caregiver (69.6%), OR = 2.84, p = 0.042. Study 2 demonstrated the importance of post-transplant support due to patients’ emotional needs and complex self-care regimen. The role of lay caregivers extended to many areas of patients’ daily lives, including support for attending doctor’s appointments, managing medications and financial tasks, physical distancing, and maintaining strict dietary requirements. Healthcare providers mainly fulfilled medical needs and provided informational support, while lay caregivers were the main source of emotional and practical support.

Conclusion

The findings highlight the importance of studying support from lay caregivers as well as healthcare providers, to better understand how they work together to support patients’ adherence to recommended self-care and survival.

Interrupted Identities: Autologous Stem Cell Transplant in Patients With Multiple Myeloma

In the current study, we sought to examine whether patients incorporate the identity of a patient receiving autologous stem cell transplant (ASCT) for multiple myeloma (MM) into their daily lives. Multiple myeloma patients receive education before initiating the ASCT treatment process. In this ethnographic study using interpretative phenomenological analysis, we observed pretransplant education visits with 30 MM patients, followed by semistructured interviews in their hospital rooms during transplant. The experience of receiving ASCT for MM required effort by patients to not only maintain their past identity but also establish a new patient identity. Reconciling these 2 identities required deliberate and emotionally draining effort from the patient. Results were organized into 2 overarching themes of social relationships and aesthetics with subthemes for each. Understanding methods MM patients who are receiving ASCT use to negotiate normalcy during treatment may be helpful for developing interventions for alleviating distress during this difficult time.

The Transplant Evaluation Rating Scale predicts overall survival after allogeneic hematopoietic stem cell transplantation

To evaluate the impact of psychosocial risks on post-hematopoietic stem cell transplantation (HSCT) outcomes, we prospectively conducted psychosocial assessment of 556 consecutive allogeneic HSCT patients who received their first allogeneic transplant at our center between 2003 and 2017. The Transplant Evaluation Rating Scale (TERS) score was prospectively assessed by a psychologist before transplantation, and patients were categorized as low, intermediate, or high risk based on their TERS score. Patients in the high-risk TERS group had significantly longer hospital stays during the first 180 days and 1 year post-allogeneic HSCT compared with the low-risk group (16 vs 13 and 21 vs 16 days; P = .05 and .02, respectively). The survival estimates for low-, intermediate-, and high-risk TERS groups at 3 year were as follows: overall survival (OS), 73%, 60%, and 65%; disease-free survival (DFS), 63%, 55%, and 60%; nonrelapse mortality (NRM), 11%, 20%, and 17%; and relapse, 26%, 25%, and 23%, respectively. In a multivariable analysis, intermediate- and high-risk TERS scores predicted for inferior OS, similar DFS, and higher NRM compared with low-risk TERS score. In a subset analysis of patients with low/intermediate risk per Disease Risk Index, multivariable analysis showed that high- and intermediate-risk TERS scores predicted for significantly worse OS, worse DFS, higher NRM, and similar relapse rates compared with low-risk TERS score. Our findings show that psychosocial factors as measured by TERS score are strong predictors of morbidity and mortality after HSCT among patients with low/intermediate disease risk.

Patient eligibility for hematopoietic stem cell transplantation: a review of patient-associated variables

Assessing patient eligibility for hematopoietic stem cell transplantation (HSCT) remains a complex, multifaceted challenge. Among these challenges, the paucity of comprehensive clinical data to guide decision making remains problematic coupled with unclear trade-offs between patient, disease and local HSCT center factors. Moreover, it is unclear that the modification of poor patient characteristics will improve post-HSCT outcomes. However, the use of Comorbidity Indices and Comprehensive Geriatric Assessments helps meet this challenge, but may be limited by overlapping patient characteristics. The increasing consideration for pre-HSCT psychosocial assessments and interventions remains to be studied. Ultimately, the decision to proceed with a HSCT remains interdisciplinary while considering the available evidence discussed in this review.

I Keep my Problems to Myself: Negative Social Network Orientation, Social Resources, and Health-Related Quality of Life in Cancer Survivors

BACKGROUND

Cancer survivors treated with hematopoietic stem cell transplant rely on their social network for successful recovery. However, some survivors have negative attitudes about using social resources (negative social network orientation) that are critical for their recovery.

PURPOSE

We examined the association between survivors' social network orientation and health-related quality of life (HRQoL) and whether it was mediated by social resources (network size, perceived support, and negative and positive support-related social exchanges).

METHODS

In a longitudinal study, 255 survivors completed validated measures of social network orientation, HRQoL, and social resources. Hypotheses were tested using path analysis.

RESULTS

More negative social network orientation predicted worse HRQoL (p < .001). This association was partially mediated by lower perceived support and more negative social exchanges.

CONCLUSIONS

Survivors with negative social network orientation may have poorer HRQoL in part due to deficits in several key social resources. Findings highlight a subgroup at risk for poor transplant outcomes and can guide intervention development.

Psychosocial factors predicting survival after allogeneic stem cell transplant

PURPOSE

A primary aim was to assess the relative contribution of psychological factors, such as anxiety, depression and mental adjustment to cancer, to overall survival outcomes at a median follow-up of 2 years following allogeneic haematopoietic stem cell transplant (HSCT). A secondary aim was to ascertain if demographic, medical and psychosocial factors assessed prior to transplantation were predictors of survival for patients after accounting for post-transplant events.

METHOD

Between 2005 and 2011, 130 allograft patients completed the Mental Adjustment to Cancer Scale and Brief Symptom Inventory-18 as part of routine psychological assessment before undergoing transplantation. Survival status data were obtained, and predictors of survival status assessed and analysed using Cox-regression models.

RESULTS

Thirteen percent experienced clinical levels of distress pre-transplant. None of the psychological factors predicted post-HSCT survival. In contrast, hierarchical multivariate analysis indicated that post-transplant factors (acute graft-versus-host disease and relapse post-transplant) predicted survival (Chi-square change, p < 0.001). The addition of a series of pre-transplant psychosocial and medical variables further improved the prediction of survival (Chi-square change, p = 0.01). In particular, relationship status (being single) (p = 0.04) and increased somatic symptoms (p = 0.02) pre-transplant were associated with shorter survival. Both variables were not associated with medical factors but were related to increased severity of anxiety and depressive symptoms as well as greater use of helpless-hopelessness and reduced fighting spirit adjustment response.

CONCLUSIONS

Despite the significant influence of acute post-transplant factors in predicting survival following allogeneic HSCT, multidisciplinary pre-transplant assessments are important in identifying patients who are likely to experience poorer survival outcomes.

Psychosocial factors associated with quality of life in allogeneic stem cell transplant patients prior to transplant

OBJECTIVES

The primary aim of this retrospective study was to determine levels of psychological distress and quality of life (QoL) immediately prior to allogeneic stem cell transplantation. The secondary aim was to examine the demographic, medical and psychosocial factors that were correlated with various QoL domains at this stage of treatment.

METHODS

A series of measures was completed by 122 allograft patients as part of routine psychological assessment at the treating hospital prior to undergoing the transplant. These included the Mental Adjustment to Cancer Scale, the Brief Symptom Inventory-18 and the World Health Organisation Quality of Life-BREF. Demographic and medical data were also extracted.

RESULTS

In this study, 12% and 14% of the sample experienced significant levels of depressive and anxiety symptoms, respectively. Half of the sample reported impaired physical QoL, whereas approximately 40% reported poor psychological and social QoL. Besides relationship status, the limited number of demographic (age and gender) and medical factors (disease status) tested did not contribute significantly to reported QoL. After controlling for medical and demographic factors, weaker Fighting Spirit and higher levels of depression (trend towards significance) were associated with poorer physical and social QoL.

CONCLUSIONS

The association among psychological distress, coping responses and QoL indicates that poor psychosocial functioning pre-transplant renders an increased likelihood of experiencing impaired QoL across various dimensions. It thus seems important that psychologically vulnerable patients are identified early in the treatment process. If psychosocial adjustment were improved, patients may experience better QoL pre-transplant with a potential subsequent influence on post-transplant outcomes.

The influence of social support on hematopoietic stem cell transplantation survival: a systematic review of literature

BACKGROUND

Hematopoietic Stem cell Transplantation (HSCT) can negatively impact the psychosocial well-being of the patient. Social support is a complex term that has been variably used to encompass perceived and objective support, including caregiver presence. Social support has been associated with superior psychosocial outcomes; however the influence of social support on HSCT survival remains unclear. We sought to summarize the literature on the influence of social support on HSCT survival.

METHODS

MEDLINE, EMBASE, COCHRANE, CINAHL, AND PSYCINFO WERE SEARCHED USING THE FOLLOWING SEARCH CATEGORIES/CONCEPTS: 1) HSCT, 2) Social support, 3) Caregiver, 4) Survival, and 5) Treatment outcomes.

RESULTS

We identified 6 relevant studies: 4 publications, 1 dissertation, and 1 abstract. Three studies were retrospective and 3, prospective. Sample size ranged between 92-272 with a mean/median patient age between 30-55 yrs. The duration of follow-up ranged between 13.3-48 months. Social support was measured inconsistently: 2 by retrospective investigator assessment, 2 as patients' perceived support, 1 as caregiver presence, and 1 included caregiver presence and retrospective investigator assessment. The 4 published studies and 1 abstract demonstrate an association between better social support and survival. However, the unpublished dissertation, with the largest sample size found no association.

CONCLUSIONS

There is a paucity of evidence examining social support with HSCT survival. Available studies are older, with the most recent publication in 2005. A heterogeneous group of HSCT patients were studied with variable follow-up times. Further, covariates were variably considered in HSCT survival analyses and we suggest that there may be publication bias, given the negative unpublished study with the largest sample size. Prospective studies using validated scales are necessary to better assess the influence of social support on HSCT mortality. Given the potential for improved HSCT survival with better social support, HSCT centres should routinely provide HSCT recipients and their caregivers with enhanced psychosocial services.

Discharge needs of allogeneic transplantation recipients

Hematopoietic cell transplantation (HCT) recipients are one of the most complex patient populations to teach at the time of discharge. The purpose of this article is to discuss the qualitative themes that emerged at the time of discharge for 141 transplantation recipients who were enrolled in an advanced practice nurse (APN) intervention study. The APN intervention consisted of six teaching sessions, and the qualitative data for this article involved the first session at the time of discharge. Content analysis was conducted on the patient-initiated narrative content and structured into three groups: content scheduled to be covered at Session 1, content scheduled to be covered at a later session, and content that was not part of the scripted intervention. All topics were organized into the quality-of-life framework (physical, psychological, social, and spiritual or survivorship). Most of the patient-initiated topics, which were not part of the scripted intervention, were psychosocial in nature. Nurses need to be aware of the complex teaching needs that encompass not only physical issues but also psychosocial issues at discharge. That teaching awareness needs to be coupled with flexibility, competence, and comfort with challenging psychosocial issues.

Predictors of non-compliance in autologous hematopoietic SCT patients undergoing out-patient transplants

Non-compliance has received significant attention in medicine, yet few studies have examined its correlates in autologous hematopoietic SCT (AHSCT) patients. This study examined predictors of non-compliance in a sample of 151 AHSCT patients treated in an outpatient setting. Before AHSCT, participants completed a validated measure of mood and retrospective chart reviews were conducted to assess non-compliance during AHSCT, defined as refusal of oral hygiene, prescribed exercise programs, oral nutrition and/or prescribed medications. We found 121 patients (80%) were non-compliant with an aspect of the AHSCT regimen on 1 or more days; mean percentage of non-compliant days was 16.6 (s.d. 15.6). Men were more likely than women to be non-compliant (P<0.05); as were participants with an elevated depression score (P<0.05). Stepwise regression models identified significant predictors of non-compliance: gender, depression, global distress and nausea and vomiting severity (P-values all <0.01). Further analysis revealed that the interaction of the psychological variables with gender was a more robust predictor of non-compliance (P<0.001). For outpatient AHSCT, our findings suggest the need to broaden conceptualizations of risk factors for non-compliance and the importance of assessing patient barriers to compliance to ensure optimal treatment outcome.

Biobehavioral influences on cancer progression

This review focuses on the contributions of stress-related behavioral factors to cancer growth and metastasis and the biobehavioral mechanisms underlying these relationships. Behavioral factors that are important in modulation of the stress response and the pivotal role of neuroendocrine regulation in the downstream alteration of physiologic pathways relevant to cancer control, including the cellular immune response, inflammation, and tumor angiogenesis, invasion, and cell signaling pathways are described. Consequences for cancer progression and metastasis, as well as quality of life, are delineated. Behavioral and pharmacologic interventions with the potential to alter these biobehavioral pathways for patients with cancer are discussed.

Effectiveness of partner social support predicts enduring psychological distress after hematopoietic stem cell transplantation

OBJECTIVE

Hematopoietic stem cell transplant (HSCT) survivors who are 1 to 3 years posttransplant are challenged by the need to resume valued social roles and activities--a task that may be complicated by enduring transplant-related psychological distress common in this patient population. The present study investigated whether transplant survivors who receive adequate social support from their spouse or intimate partner experience lower distress.

METHOD

Effects of receiving a greater quantity of partner support (a common approach to studying enacted support) were compared with effects of receiving more effective partner support (i.e., support that more closely matches their needs in terms of its quantity and quality). Men and women (N = 230) who were 1 to 3 years posttransplant completed measures of partner support quantity (Manne & Schnoll, 2001), partner social support effectiveness (Rini & Dunkel Schetter, 2010), and psychological distress (Brief Symptom Inventory; Derogatis & Spencer, 1982). Potential medical and sociodemographic confounds were controlled in analyses.

RESULTS

As hypothesized, survivors reported less distress when they received more effective partner support (p < .001). Quantity of partner support was not associated with distress (p = .23). An interaction revealed that when partner support was effective, the quantity of support survivors received was not associated with their distress (p = .90); however, when partner support was ineffective, receiving a greater quantity of partner support was associated with substantially elevated distress (p = .002).

CONCLUSIONS

Findings suggest that clinical approaches to addressing or preventing enduring distress after HSCT should target features of partner support related to its appraised effectiveness.

Spouse caregivers of kidney transplant patients: quality of life and psychosocial outcomes

CONTEXT

Most kidney transplant programs require patients to identify a primary caregiver who can assist them throughout the transplant process. Little is known about the quality of life, caregiving strain, and psychosocial functioning of these caregivers.

OBJECTIVES

To characterize the psychosocial functioning of spouse/partner caregivers.

DESIGN, SETTINGS, AND PARTICIPANTS

Cross-sectional survey administered to spouse/partner caregivers of patients before (n=33) and after (n=46) kidney transplantation at a transplant center in New England.

MAIN OUTCOME MEASURES

Quality of life, life satisfaction, caregiving strain and benefit, mood, and social intimacy.

RESULTS

Relative to normative samples and published data involving other transplant caregivers, caregivers of kidney transplant patients had favorable quality of life, life satisfaction, psychological, and social intimacy outcomes. Life satisfaction scores were significantly lower for caregivers before than after kidney transplantation, but otherwise the 2 cohorts did not differ significantly from each other. Most caregivers both before and after kidney transplantation reported clinically high levels of caregiving strain, as well as several caregiving benefits.

CONCLUSION

Our data are consistent with results of other studies in showing that spouses experience considerable caregiving strain both before and after transplantation. However, caregivers of kidney transplant patients overall have good quality of life, life satisfaction, mood, and social intimacy. More prospective research is necessary to characterize better how these outcomes change over time throughout the transplant process.

Patterns of social support among lymphoma patients considering stem cell transplantation

There is lack of literature addressing factors that influence the process of care for patients with hematological malignancies. We evaluated the forms of social support available for patients with relapsed lymphoma considering stem cell transplantation and examined the influence of support on treatment delay. Data were collected from 119 patients with relapsed lymphoma using a questionnaire to capture sociodemographic information and emotional, informational, and instrumental forms of social support. Sixty-four percent of the patients were married, 56% had children over 18 years of age, 43% were employed, and 72% had private health insurance. Family members formed a major source of emotional support (83%), while 47% of patients considered personal prayers to be important. While 79% of patients received clinical support from nurses, few received formal group support or formal peer support (6.7% and 1.7% respectively). Support from extended family and peer groups reduced the likelihood of treatment delays. The potential benefits of peer group support should be reinforced for patients considering transplantation given how infrequent this form of social support is utilized and its positive impact on the process of care. Future studies should test the impact of social support on health outcomes especially among the underserved population.

Spouse Caregivers of Kidney Transplant Patients: Quality of Life and Psychosocial Outcomes

Context

Most kidney transplant programs require patients to identify a primary caregiver who can assist them throughout the transplant process. Little is known about the quality of life, caregiving strain, and psychosocial functioning of these caregivers.

Objectives

To characterize the psychosocial functioning of spouse/partner caregivers.

Design, Settings, and Participants

Cross-sectional survey administered to spouse/partner caregivers of patients before (n = 33) and after (n= 46) kidney transplantation at a transplant center in New England.

Main Outcome Measures

Quality of life, life satisfaction, caregiving strain and benefit, mood, and social intimacy.

Results

Relative to normative samples and published data involving other transplant caregivers, caregivers of kidney transplant patients had favorable quality of life, life satisfaction, psychological, and social intimacy outcomes. Life satisfaction scores were significantly lower for caregivers before than after kidney transplantation, but otherwise the 2 cohorts did not differ significantly from each other. Most caregivers both before and after kidney transplantation reported clinically high levels of caregiving strain, as well as several caregiving benefits.

Conclusion

Our data are consistent with results of other studies in showing that spouses experience considerable caregiving strain both before and after transplantation. However, caregivers of kidney transplant patients overall have good quality of life, life satisfaction, mood, and social intimacy. More prospective research is necessary to characterize better how these outcomes change over time throughout the transplant process.

Psychological effects of hematopoietic SCT on pediatric patients, siblings and parents: a review

Although hematopoietic SCT (HSCT) has become standard therapy for many life-threatening disorders of childhood, there is little research on the psychosocial ramifications of HSCT on patients, siblings and parents. Pediatric patients experience numerous psychological reactions throughout hospitalization, the procedure and recovery process: anxiety, depression, behavioral and social problems, and post-traumatic stress reactions. Similarly, sibling donors are at risk of developing emotional disturbances such as post-traumatic stress reactions, anxiety and low self-esteem. Parental distress, anxiety and depression levels are often increased as a result of their child undergoing the HSCT process. The distress and anxiety may be even greater for parents whose healthy child also becomes part of the HSCT process through donating their marrow. Thus, it is critical to develop interventions for pediatric patients and their families. There is, however, minimal research of interventions aimed at decreasing distress and improving emotional and psychosocial functioning for children undergoing HSCT, siblings and parents. Cognitive-behavioral interventions are the most researched treatment approaches for children with cancer and chronic illness and these are promising in improving emotional distress, compliance with treatment and behavioral problems associated with HSCT. Appropriate arenas in which pediatric patient interventions may focus include social skills and emotional well-being. Familial interventions that aim to enhance protective factors, improve communication, and decrease parental anxiety and depression are crucial, and cancer-specific interventions may serve as a template for the development of HSCT-specific interventions.

Social support and cancer progression: a systematic review

OBJECTIVE

The variability in the conceptualization and categorization of social support has resulted in mixed findings regarding its role in cancer progression. This systematic review identifies and summarizes the evidence for the significance of two important indices of social support in progression of different cancers.

METHOD

We used systematic and replicable methods to search, select, and evaluate findings.

RESULTS

Thirty-one longitudinal prospective findings (in 26 papers) which were selected for inclusion categorized social support into structural and functional support. The types of cancer included in these studies fell into three major categories: breast cancer (16), other cancer (10), and mixed cancers (5). Results suggest that the evidence for the relationship between social support and cancer progression is sufficiently strong for breast cancer as shown by five out of seven methodologically sound studies but consistently unconvincing for other types of cancer or in studies which combined different types of cancer. Structural support indices were found to be more frequently associated with disease progression than the indices of functional support in breast cancer. Disease-related variables such as severity, treatment, nodal status, and site of metastasis were found to be significant predictors of cancer progression, and it is suggested that these variables must be considered when conducting studies on the role of psychosocial factors in cancer-related outcomes including progression.

CONCLUSION

Methodological limitations of the studies and counterintuitive findings are discussed, and further conclusive research, particularly randomized controlled trials of social support interventions, is warranted to support the findings of this systematic review.

Do coping and social support predict depression and anxiety in patients undergoing hematopoietic stem cell transplantation?

This study examined whether different types of coping and social support predict anxiety and depression in 212 hematopoietic stem cell transplant (HSCT) recipients. Data were collected prior to and 6 months after HSCT. Coping, social support, and gender predicted 26% of the variance in pre-HSCT anxiety and 24% of the variance in pre-HSCT depression. Coping and social support did not explain significant post-HSCT anxiety or depression when controlling for pretransplant anxiety or depression. High use of acceptance/ resignation coping, cognitive avoidance coping, lower tangible support, and lower belonging support were related to increased pre-HSCT anxiety and depression. Approach coping was not related to pre-HSCT anxiety. Patients who use acceptance/resignation coping and report low levels of two types of social support prior to HSCT may require additional intervention before HSCT, as they are at higher risk for depression and anxiety.

Psychological issues of stem cell transplant

OBJECTIVES

To address the psychological impact of transplant on quality of life, including physical, psychological, social, and spiritual, for the patient and caregiver, and to discuss the nurse's "emotional labor of caring" and "compassion fatigue" for such an intense vulnerable population.

DATA SOURCES

Psychological transplant studies, peer review journals, and textbooks.

CONCLUSION

The psychological impact after the experience of transplant can leave an indelible impression on the patient, caregiver, and nurse.

IMPLICATIONS FOR NURSING PRACTICE

Suggestions are made for assessment and management of various potential psychological issues for the three mentioned populations. With these issues being better understood, nurses can actively lessen psychological morbidity.

Predictors of psychological morbidity in liver transplant assessment candidates: is alcohol abuse or dependence a factor?

Orthotopic liver transplantation candidates with depressive and other symptoms report poorer perceived quality of life when compared with nondepressed patients, and are also significantly more likely to die while awaiting transplantation. Alcohol abuse and dependence have been associated with increased levels of psychological co-morbidity. This article presents data about psychological morbidity from a prospective study of patients being assessed for liver transplantation in Birmingham, UK, and explores whether those with a diagnosis of alcohol abuse or dependence are at increased risk of psychological symptoms. Of 399 consecutive patients assessed for liver transplantation between July 2004 and July 2005, a sample of 155 was included in the study. Eighty-three (53.5%) patients were identified as having general psychological distress that merited referral for specialist assessment using the Symptom Checklist-90-Revised instrument. The alcohol-dependent group achieved the highest overall 'caseness' rates, with 72% (n = 26) compared with 52% (n = 12) of the alcohol-abuse group and 47% (n = 45) of those with no alcohol-related diagnosis. However, alcohol abuse or dependence was not the significant predictor of psychological symptoms in the final regression model. Higher rates of psychological distress were associated with greater severity of liver disease, being unemployed, and being a tobacco smoker. Possible reasons for these findings and potential future management strategies are discussed.

Patients at risk: addressing addiction in patients undergoing hematopoietic SCT

Addictive disorders are common and underdiagnosed in the general medical population. While it is well recognized that alcohol consumption is linked to cancers of the head and neck as well as the large bowel, its association with cancers for which hematopoietic SCT (HSCT) is a modality of treatment is not as clear. Further, the complications of alcohol or other drug addiction in patients undergoing HSCT has not been well studied. However, patients with comorbid substance use disorders (SUDs) are at higher risk for morbidity and mortality while undergoing HSCT due to medical sequelae of SUDs and issues of social support, adherence to treatment plans, and impairment of judgment and decision-making. Behavioral patterns of patients with SUDs are clearly relevant factors to consider in patient selection, management and outcome. We offer a review of the existing literature and recommendations for assessment and management of this patient population.

Psychologische Intervention im Rahmen einer allogenen Knochenmarktransplantation

Zusammenfassung. Allogene Knochenmarktransplantationen (KMT) haben sich in den letzten Jahren zu einem anerkannten Verfahren zur Behandlung von Krebserkrankungen entwickelt. Obwohl der Einfluss psychologischer Faktoren auf Erleben und Überleben einer KMT immer stärker Beachtung findet, existiert zum jetzigen Zeitpunkt keine Arbeit, die systematisch die Wirkung standardisierter psychologischer Betreuung in diesem Zusammenhang untersucht. Anhand von 20 Patienten überprüft die vorliegende Studie in einem randomisierten kontrollierten Versuchsdesign die Eignung eines psychologischen Interventionsprogramms zur Senkung der subjektiven Wahrnehmung körperlicher Beschwerden im Rahmen einer KMT. Die Ergebnisse sprechen für die Wirksamkeit des Interventionsprogramms: Patienten in der Interventionsgruppe berichteten weniger körperliche Beschwerden als Patienten in der Kontrollbedingung, wobei die Effektstärken als klein bis mittel einzuordnen sind. Die Ergebnisse werden hinsichtlich des möglichen zukünftigen Einsatzes des Interventionsprogramms diskutiert.

Social Support and Depression among Bone Marrow Transplant Patients

This study considered the role of social support in mitigating depression among bone marrow transplant (BMT) patients. Eighty-six BMT patients completed the Medical Outcomes Study Social Support Scale (MOS-SSS) and the Centers for Epidemiological Studies of Depression Scale (CES-D) before transplant and again at one year posttransplant. Results showed moderate levels of depressive symptoms in BMT patients, with 29.1 percent and 27.6 percent meeting the suggested criterion for clinical depression at pre-BMT and one year post-BMT, respectively. Overall, patients experienced a reduced level of depression post-BMT, although females reported more depression than males. Social support pre-BMT predicted depression levels post-BMT controlling for initial levels of depression. Clinical implications for health care providers working with cancer patients and their families are discussed.

Depression After Lung Transplantation: Causes and Treatment

During the postoperative course of lung transplantation, patients may experience depressive symptoms that negatively influence their ability to cope with the new organ, their adherence to rehabilitation and pharmacologic therapy, and their overall quality of life (QoL). To date, no review has explored the causes of depression following transplantation or the efficacy and safety of therapeutic interventions in this patient group. We conducted a comprehensive 1966-2006 MEDLINE, EMBASE, and PsycINFO search for studies of the causes and treatments of depression in lung transplant recipients. We identified 25 studies of variable methodologic quality. Depression rates are high among candidates for lung transplantation. In the short term, after surgery depressive symptoms remain low with an improvement in QoL, whereas in the long term (>3 years), the decline of functional status is associated with a dramatic increase in such symptomatology. Personality disorders, coping strategies, stressful life events, physical complications, corticosteroid medications, age, gender, and psychosocial support all play a central role in causing depressive states in lung transplant recipients. Serotonin reuptake inhibitors (SSRIs) and new-generation antidepressants (mirtazapine) represent the best therapeutic choices for this group of patients. The risk of serious drug-drug interactions should be carefully monitored by experienced clinicians. Complementary therapies and psychoeducational intervention also help recipients to strengthen their coping strategies, offering further advantages after transplantation. Additional well-conducted randomized controlled trials are needed to clarify the epidemiologic course of depression following lung transplantation and to tailor effective pharmacologic or psychological interventions accordingly.

Social Support, Optimism, and Self-Efficacy Predict Physical and Emotional Well-Being After Bone Marrow Transplantation

This study examined whether three psychosocial variables (social support, self-efficacy, and optimism) assessed prior to bone marrow transplantation (BMT) predicted physical and emotional wellbeing one year post-BMT. Data were gathered on 87 participants enrolled in a multicenter, randomized trial examining the impact of ex-vivo T-cell depletion on disease-free survival in leukemia patients receiving allogeneic BMT. Social support, optimism, and self-efficacy significantly predicted emotional and physical well-being one year post-BMT, controlling for age, gender, maximum grade of acute GVHD, and treatment arm. Attention to psychosocial factors prior to BMT and during recovery appears critical for physical and mental well-being, especially considering the influence of psychosocial variables independent of medical risk factors.

[Psychosocial need for counselling before and after a lung, liver or allogenic bone marrow transplant--results of a prospective study]

OBJECTIVES

Transplant patients are exposed to many different types of mental and social stress. The study investigates these patients' need for psychosocial counselling.

METHODS

At 6 months and again at 12 months following either a lung, liver or bone-marrow transplantation, 76 patients were questioned about their need for psychosocial counselling. The measuring instruments employed were: SF-36 (quality of life), FLZ (life satisfaction), HADS-D (anxiety/depression), and F-SoZu K-14 (social support).

RESULTS

The need for psychosocial counselling in all three patient groups was at its greatest before transplantation. It amounted to 42.9 % (lung transplantation patients), 50.0 % (liver transplantation patients) and 26.7 % (bone marrow transplantation patients). Six months after transplantation, the need for counselling in all patient groups had quite clearly decreased. Among liver transplant patients, however, it increased again between the sixth and twelfth months. The need for counselling in all patient groups correlated significantly with anxiety. Moreover, at one-year follow-up, significantly negative correlations with mental health, life satisfaction and social support were observed.

DISCUSSION

Especially during the evaluation phase prior to organ transplantation, transplantation patients demonstrate a considerable need for counselling. Psychosocial counselling should be an obligatory part of therapy before and after organ transplantation.

Psychosocial vulnerability predicts psychosocial outcome after an organ transplant: results of a prospective study with lung, liver, and bone-marrow patients

OBJECTIVE

The pretransplant medical evaluation of transplantation candidates includes an assessment of psychosocial data. This study investigates psychosocial vulnerability as a predictor of posttransplant outcome.

METHODS

Seventy-six patients were assessed prior to lung, liver, or bone-marrow transplant. Pretransplant vulnerability markers were cognitive beliefs (sense of coherence and optimism), affect (anxiety and depression), and external resources (social support). In addition, psychosocial functioning was assessed by professionals. Quality of life, general life satisfaction, need for counseling, and survival rate were assessed 12 months after transplant.

RESULTS

Pretransplant variables explain 21-40% of the variance in posttransplant psychosocial outcome variables. Cognitive beliefs predict mental quality of life; affect (depression) and social support predict life satisfaction; and expert-rated psychosocial functioning predicts life satisfaction and need for counseling.

CONCLUSION

The multidimensional vulnerability model is suitable for predicting posttransplant psychosocial outcome. Patients with high pretransplant vulnerability should receive ongoing psychosocial counseling.

Do negative or positive emotions differentially impact mortality after adult stem cell transplant?

Multiple diverse biomedical variables have been shown to affect outcome after hematopoietic stem cell transplantation (HSCT). Whether psychosocial variables should be added to the list is controversial. Some empirical reports have fueled skepticism about the relationship between behavioral variables and HSCT survival. Most of these reports have methodological shortcomings. Their samples were small in size and included heterogeneous patient populations with different malignant disease and disease stages. Most data analyses did not control adequately for biomedical factors using multivariate analyses. The pre-transplant evaluations differed from study to study, making cross-study generalizations difficult. Nevertheless, a few recently published studies challenge this skepticism, and provide evidence for deleterious effects of depressive symptomatology on HSCT outcome. This mini review integrates the new data with previously reviewed data, focusing on the differential impact of negative and positive emotional profiles on survival. Pre-transplant negative emotional profiles are associated with worse survival in the long term, whereas pre-transplant optimism about transplant appears to affect survival in the short term. These data have practical implications for transplant teams. Pre-transplant psychological evaluation should assess for specific adverse behavioral risk factors, particularly higher levels of depression and lower levels of optimistic expectations about transplant. Transplant centers should develop collaborative studies to further test the effects of these adverse behavioral risk factors, and run multicenter hypothesis-driven clinical trials of psychological intervention protocols. Such studies should aim to better define pragmatics of assessment and intervention (timing, assessment tools, personnel), and evaluate their contribution to improving outcome after transplant.

Coping and survival in patients with leukemia undergoing allogeneic bone marrow transplantation--long-term follow-up of a prospective study

OBJECTIVE

The exploratory study examined the relationship between coping and survival in patients undergoing bone marrow transplantation (BMT).

METHODS

Patients scheduled for BMT were recruited from 1990 until 1995 at the University Hospital of Ulm, Germany. They were interviewed before transplantation, and the corresponding records were checked in December 2002. Seventy-two audiotaped interviews could be analyzed for 34 coping strategies as defined in the Ulm Coping Manual (UCM). Main outcome measure was survival time post-BMT.

RESULTS

On average, the patients were 35 years old, 65% were male, and 56% diagnosed acute leukemia (AL). Four coping strategies were found to show a clear trend towards an association with survival time: emotional support, acceptance, taking control, and compensation. The last strategy was associated with shorter, the others with longer survival.

CONCLUSION

We found further evidence for an association between coping and survival. Because of the possible wide-reaching consequences for clinical management, replication of the data is essential.

Psychosocial influences on 305 adults' survival after bone marrow transplantation; depression, smoking, and behavioral self-regulation

OBJECTIVE

The role of psychological factors in adult survival after bone marrow transplant (BMT) has not been adequately established. BMT survival rates have been shown to depend largely on disease and demographic variables. With sample sizes no larger than 123, the majority of psychosocial studies found little definitive statistical evidence that mood, marital/cohabiting status, coping styles, or smoking affect survival. The purpose of this study was to comprehensively examine the relative contribution of psychological variables to survival after BMT in a unified model, controlling for medical and demographic variables.

METHODS

Pre-BMT, 305 consecutive patients were psychologically assessed with interview and Minnesota Multiphasic Personality Inventory (MMPI). Transplant Evaluation Rating Scale (TERS) ratings were assigned retrospectively by two raters (interrater reliability r=.89). We employed a fully parametric, accelerated failure time regression model (Weibull), which provides richer extrapolation and interpretation than the semiparametric Cox proportional hazards regression model.

RESULTS

Overall our results indicate that for a given medical condition, the type of BMT patient likely to survive longest was a young, married, educated, European-American, nonsmoker who was more defiant, better adjusted, and less depressed. Moreover, the longer a patient survived, the smaller the probability of dying in the short run.

CONCLUSIONS

This study, the first large-scale statistical analysis using a fully parametric model (Weibull), provides evidence that select psychosocial variables can affect BMT survival. Future investigations could explore possible mediating variables, and whether identifying high-risk individuals pretreatment could enhance resource allocation, psychological intervention, and possibly even survival itself.

Psychological factors and cancer development: Evidence after 30 years of research

The question whether psychological factors affect cancer development has intrigued both researchers and patients. This review critically summarizes the findings of studies that have tried to answer this question in the past 30 years. Earlier reviews, including meta-analyses, covered only a limited number of studies, and included studies with a questionable design (group-comparison, cross-sectional or semiprospective design). This review comprises only longitudinal, truly prospective studies (N=70). It was concluded that there is not any psychological factor for which an influence on cancer development has been convincingly demonstrated in a series of studies. Only in terms of 'an influence that cannot be totally dismissed,' some factors emerged as 'most promising': helplessness and repression seemed to contribute to an unfavorable prognosis, while denial/minimizing seemed to be associated with a favorable prognosis. Some, but even less convincing evidence, was found that having experienced loss events, a low level of social support, and chronic depression predict an unfavorable prognosis. The influences of life events (other than loss events), negative emotional states, fighting spirit, stoic acceptance/fatalism, active coping, personality factors, and locus of control are minor or absent. A methodological shortcoming is not to have investigated the interactive effect of psychological factors, demographic, and biomedical risk factors.

A systematic review of psychosocial factors affecting survival after bone marrow transplantation

An electronic database search identified 15 studies of psychosocial factors affecting survival after bone marrow transplantation. The studies were assessed for methodological quality by two reviewers using the procedures of Bland and colleagues. Although some studies found that psychological variables affect survival after bone marrow transplantation, the reviewers' analysis of the methodologically sound studies suggested that survival after bone marrow transplantation is not substantively affected by depressed mood or other psychopathology in adults or by social support in adults or children. Longer survival may be related to lower "anxious preoccupation," higher "fighting spirit," and better quality of life ratings before and soon after transplant in adults. Overall, however, the literature is insufficiently developed to provide definitive evidence for a relationship between psychological variables and survival after bone marrow transplantation. Future primary studies in this area should be designed to maximize replicability and generalizability.

Psychological assessment and care of organ transplant patients

Organ transplant has been developed in animal models over the past 100 years. The major limiting factor in transplant medicine is the shortage of donor organs. This shortage creates pressure for fair and efficient allocation of organs, with expectations that those involved in transplantation will strive to achieve optimal outcomes and ensure just access. This article reviews the major types of transplants and the illnesses and behavioral comorbidities that lead to these procedures, the psychological assessment of transplant candidates, the adaptive tasks required of the transplant recipient at various stages of the transplant process, and relevant psychological interventions. Liaison with others on the transplant team and ethical issues of concern to psychologists who work with transplant patients, including living organ donors, are also discussed. Finally, new developments in transplant and suggestions for future psychological research in organ transplant are presented.