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Background: Neurobehavioral functioning is widely recognized as being an important consideration in lung transplant candidates, but little is known about whether these factors are related to clinical outcomes. The present study examined the relationship of neurobehavioral functioning, including measures of executive function and memory, depression, and anxiety, to long-term survival among lung transplant recipients., Methods: The sample was drawn from 201 patients who underwent transplantation at Duke University and Washington University who participated in a dual-site clinical trial investigating medical and psychosocial outcomes in transplant candidates with end-stage lung disease. All patients completed the Beck Depression Inventory-II (BDI-II) and Spielberger State-Trait Anxiety Inventory at baseline and again after 12 weeks, while a subset of 86 patients from Duke University also completed neurocognitive testing. Patients were followed for survival up to 12 years after completing baseline assessments., Results: One hundred eleven patients died over a mean follow-up of 10.8 years (SD=0.8). Baseline depression, anxiety, and neurocognitive function were examined as predictors of posttransplant survival, controlling for age, 6-min walk distance, FEV, and native disease; education and cardiovascular risk factors were also included in the model for neurocognition. Lower executive function (hazard ratio [HR]=1.09, P=.012) and memory performance (HR=1.11, P=.030) were independently associated with greater mortality following lung transplant. Although pretransplant depression and anxiety were not predictive of mortality, patients who scored>13 on the BDI-II at baseline and after 3 months pretransplant had greater mortality (HR=1.85 [95% CI, 1.04, 3.28], P=.036)., Conclusions: Neurobehavioral functioning, including persistently elevated depressive symptoms and lower neurocognitive performance, was associated with reduced survival after lung transplantation., Trial Registry: ClinicalTrials.gov; No.: NCT00113139; URL: www.clinicaltrials.gov.

This review examines psychosocial issues among lung transplant patients from the time of assessment through the posttransplant period. Although psychological factors are recognized as being important in the transplant evaluation, no standard approach to psychological assessment currently exists. Lung transplant candidates often experience high levels of psychological distress while awaiting transplant, and both pretransplant and posttransplant psychological functioning have been found to predict posttransplant quality of life, adherence to treatment, and, in some cases, medical outcomes. Given the limited long-term survival following transplantation, improving psychosocial functioning is essential for enhancing outcomes among lung transplant recipients. This review summarizes the extant literature on the psychosocial factors in lung transplantation and highlights several innovative efforts to improve psychological outcomes in this challenging patient population.

Background: Lung transplants have been performed worldwide since the early 1980s. While numerous studies have been published on somatic aspects after lung transplantation, there is considerably less information available on psychosocial aspects and on the correlation between the physical and the psychosocial state of health after transplantation., Methods: Between 1992 and 2002, 125 patients underwent lung transplantation at University Hospital Zurich. To be included into the study, patients had to have received a lung transplant > 12 months previously and to have good knowledge of the German or Italian languages. With the aid of standardized questionnaires, psychosocial variables such as levels of anxiety and depression, self-esteem, and social support were determined. In addition, self-assessments of physical and psychological health were obtained. The medical data included information on FEV1, complications such as pulmonary infections, acute or chronic allograft rejection, and assessment of the patient's physical and psychological health by the treating doctors., Results: The overall degree of anxiety and depression of the lung transplant recipients was comparable to standard samples of an average population. However, male lung transplant recipients were significantly more depressed than female recipients. Self-esteem was higher than in clinical comparison samples. Preceding pulmonary complications had long-lasting effects on the level of anxiety, whereas nonpulmonary complications did not have such an effect., Conclusions: Overall, the psychological well-being of patients after lung transplantation is similar to the normal population. Subgroups of patients with increased psychological distress have been identified.

Study Objective: To examine the relationship between psychiatric comorbidity and quality of life in patients awaiting lung transplantation., Setting: Duke University Medical Center/Lung Transplantation Program., Participants: One hundred patients with end-stage pulmonary disease listed for lung transplantation., Measurements and Results: Twenty-five percent (n = 25) of the sample met diagnostic criteria for at least one current mood or anxiety disorder. Controlling for age, gender, ethnicity, percentage of predicted FEV, and lung disease diagnosis, patients with a current psychiatric diagnosis reported poorer general quality of life (p < 0.0001), poorer disease-specific quality of life (p < 0.0001), greater shortness of breath (p = 0.01), more symptoms of psychological distress (p < 0.0001), lower levels of social support (p < 0.0001), and fewer positive health habits (p < 0.04) than their counterparts without a psychiatric diagnosis., Conclusions: Psychiatric comorbidity affects a significant portion of patients awaiting lung transplantation and is associated with decreased health-related quality of life.

Study Objectives: To test the efficacy of a tailored telephone-based intervention consisting of supportive counseling and cognitive behavioral techniques for individuals awaiting lung transplantation on measures of quality of life and general well-being., Method: Patients were randomly assigned to either a telephone-based special intervention (SI; n = 36) for 8 weeks (average session length, 16.3 min) or a usual care (UC) control condition (n = 35) in which subjects received usual medical care but no special treatment or phone calls. At baseline, and immediately following the 8-week intervention, patients completed a psychometric test battery., Setting: Duke University Medical Center, Pulmonary Transplantation Program., Patients: Seventy-one patients with end-stage pulmonary disease listed for lung transplantation., Primary Outcome Measures: Measures of health-related quality of life (both general and disease-specific), general psychological well-being, and social support., Results: Multivariate analysis of covariance, adjusting for pretreatment baseline scores, age, gender, and time waiting on the transplant list, revealed that patients in the SI condition compared to the UC reported greater general well-being (p < 0.05), better general quality of life (p < 0.01), better disease-specific quality of life (p < 0.05), and higher levels of social support (p < 0.0001)., Conclusion: A brief, relatively inexpensive, telephone-based psychosocial intervention is an effective method for reducing distress and increasing health-related quality of life in patients awaiting lung transplantation.

Study Objectives: End-stage lung disease is associated with poor quality of life and increased risk for psychological distress. Despite the significant number of individuals with end-stage lung diseases, the emotional health of these patients, as compared with those with other chronic organ diseases, is not well-known. The purpose of this article is to elucidate personality styles and the presence of psychopathology in a clinical sample of patients with end-stage lung disease presenting for possible lung transplantation., Design: Cross-sectional survey., Setting: Two academic medical center transplant programs., Participants: Two hundred forty-three consecutively referred transplant candidates., Results: Cluster analysis of the Minnesota Multiphasic Personality Inventory (MMPI)-2 indicated five different personality styles. The majority of patients evidenced mild somatic and depressive symptoms. Approximately one fourth of the sample exhibited marked anxiety and mood disturbances. A small cluster also evidenced features consistent with an antisocial personality style., Conclusions: Separate and distinct personality styles that could affect quality of life, the need for adjunct treatments, and medical compliance emerged from this sample of individuals with end-stage lung disease. Results are discussed in light of prior research on other end-stage organ conditions and in relation to personality and coping theories.

Objective: The purpose of this study was to examine the psychological functioning and quality of life (QOL) of lung transplant candidates and recipients., Methods: The following measures were completed by 36 lung transplant candidates (the pretransplant group [PRE]) and 73 recipients (the posttransplant group [POST]): the Rand-36 Item Health Survey 1.0 (RAND-36), visual analog scale of overall QOL (OQOL), Brief Symptoms Inventory (BSI), Derogatis Sexual Functioning Inventory (DSFI), Hospital Anxiety and Depression Scale (HAD), Rosenberg Self-Esteem Scale (RSES), and Body Cathexis Scale (BC)., Results: Compared to the PRE, POST patients had significantly better scores on the following measures: RAND-36 total, physical health, role limitations due to physical health, general health, vitality, and social functioning subscales (all p < 0.0001); visual analog scale of OQOL (p < 0.0001); BSI (p < 0.05); BC (p < 0.05); HAD anxiety (p < 0.05) and depression (p < 0.0001); and RSES (p < 0.05). Despite better scores, some areas did not differ between the PRE and the POST, and many patients continued to experience impairments in psychological functioning. Specifically, the RAND-36 emotional health and role limitations due to emotional health subscale scores did not differ between the PRE and the POST and they remained lower than published norms. A significant proportion of patients in both groups (44% of PRE patients and 28% of POST patients) had borderline or clinical levels of anxiety (ie, the HAD). Finally, PRE and POST mean scores were significantly lower than published norms on the RSES (p < 0.05) and the body image scale of the DSFI (p < 0.05)., Conclusions: Although lung transplant recipients have better general, physical, and psychological health than their pretransplant counterparts, the present research suggests that both groups experience impairment in several areas of psychological functioning. Future research into the QOL of the lung transplant population should be aimed at recognizing, intervening, and improving patients' psychological and emotional well-being.

Study Objective: Few studies have examined predictors of quality of life and adjustment after lung transplantation. This study determined whether pretransplant psychological measures predicted physical health, quality of life, and overall adjustment posttransplant. Cross-sectional analyses also examined differences in adjustment and quality of life for lung transplant candidates and recipients., Design and Participants: Seventeen transplant candidates and 60 transplant recipients completed questionnaires measuring adjustment and quality of life. In addition, we examined archival data on 107 transplant candidates who had received pretransplant psychological assessments, and posttransplant physical health status data were collected on these patients. Of the 107 patients who provided a pretransplant psychological assessment, 32 completed the questionnaires measuring posttransplant adjustment and quality of life., Setting: University medical center transplant service., Results: Cross-sectional analyses indicated significantly better adjustment and quality of life posttransplant. Pretransplant psychological variables were not associated with measures of posttransplant physical health. Hierarchical multiple regression analyses found that pretransplant anxiety and psychopathology predicted posttransplant adjustment (beta's ranging from 0.32 to 0.68) and greater pretransplant anxiety also predicted worse posttransplant quality of life (beta's ranging from 0.29 to 0.62). Subjective sleep disturbances were associated with poorer adjustment and quality of life (beta's ranging from 0.36 to 0.75), and were found to mediate the relationship between presurgical anxiety and posttransplant adjustment and quality of life., Conclusions: This study found that psychological status pretransplant predicted adjustment and quality of life posttransplant. Moreover, increased anxiety levels pretransplant predicted subsequent subjective sleep disturbances, which were, in turn, associated with poorer adjustment and quality of life. The benefits of pretransplant stress management interventions are discussed.

Study Objectives: To assess the change in health-related quality of life (HRQL) among Dutch lung transplant patients before and after transplantation., Design: Prospective longitudinal study on HRQL among 24 Dutch lung transplant patients who participated first as transplant candidates, and later as recipients in the study. This study design provides an accurate estimate of the change in HRQL as a result of lung transplantation because there is no confounding between change due to differences in composition between groups of patients at the different points of follow-up and the true change as a result of the transplantation. Patients completed self-administered questionnaires before transplantation, and at 1, 4, 7, 13, and 19 months after transplantation. The main HRQL measures were: the Nottingham health profile (NHP), the State-trait Anxiety Inventory, the Self-rating Depression Scale-Zung, the Karnofsky Performance Index, the index of well-being, and activities of daily living (ADL)., Setting: University Hospital Groningen, the Netherlands., Results: Before transplantation, patients report major restrictions on the dimensions mobility and energy of the NHP, a low level of experienced well-being, and depressive symptoms. In addition, patients experience difficulties in performing ADL and report a low ability to take care of themselves. About 4 months after transplantation, mobility, energy, sleep, ADL dependency level, and dyspnea were particularly positively affected by the lung transplantation. These improvements were maintained in the following 15 months., Conclusions: Lung transplantation contributes positively to the HRQL of surviving patients over time.

Study Objectives: To calculate cost-effectiveness of scenarios concerning lung transplantation in The Netherlands., Design: Microsimulation model predicting survival, quality of life, and costs with and without transplantation program, based on data of the Dutch lung transplantation program of 1990 to 1995., Setting: Netherlands, University Hospital Groningen., Patients: Included were 425 patients referred for lung transplantation, of whom 57 underwent transplantation., Intervention: Lung transplantation., Results: For the baseline scenario, the costs per life-year gained are G 194,000 (G=Netherlands guilders) and the costs per quality-adjusted life-year (QALY) gained are G 167,000. Restricting patient inflow ("policy scenario") lowers the costs per life-year gained: G 172,000 (costs per QALY gained: G 144,000). The supply of more donor lungs could reduce the costs per life-year gained to G 159,000 (G 135,000 per QALY gained; G1 =US $0.6, based on exchange rate at the time of the study)., Conclusions: Lung transplantation is an expensive but effective intervention: survival and quality of life improve substantially after transplantation. The costs per life-year gained are relatively high, compared with other interventions and other types of transplantation. Restricting the patient inflow and/or raising donor supply improves cost-effectiveness to some degree. Limiting the extent of inpatient screening or lower future costs of immunosuppressives may slightly improve the cost-effectiveness of the program.

Objective: Quality of life (QOL) studies of lung transplant recipients indicate that there are improvements following transplantation. More recently, there has been some suggestion that certain QOL issues are different for men and women. The purpose of the present study was to examine changes in QOL, body satisfaction, and sexual functioning in women lung transplant recipients., Study Population: Seven prelung transplant (PRE) and 34 postlung transplant (POST) women., Main Outcome Measures: The RAND-36 Health Survey, Body Cathexis Scale, Derogatis Sexual Functioning Inventory, Hospital Depression and Anxiety Scale, Rosenberg Self-Esteem Scale, and an open-ended questionnaire., Results: Higher scores were found in the POST group with respect to general health and role limitations due to physical health. We were unable to detect significant differences between the groups with respect to emotional well-being, role limitations due to emotional health, and social functioning. There were significant differences between the PRE and the POST body satisfaction scores. Although there was no significant difference in overall sexual functioning, recipients in the PRE group reported higher sex drive. Eleven of the POST recipients (52%) scored below the 10th percentile in overall sexual functioning., Conclusions: Overall QOL improves following lung transplantation; however, the lack of differences in many domains of QOL raises the concern that women lung transplant recipients may continue to have significant impairments, including those regarding sexuality and body satisfaction.

Lung transplantation is an important topic today in healthcare policy because the technique is new and costly. One of the important issues in the evaluation of lung transplantation is quality of life. The quality of life after lung transplantation must be relatively high compared with other forms of medical care to legitimize the high costs of transplantation. Quantifying the quality of life after lung transplantation and other medical therapies is possible with general measurements of quality of life. In a pilot study of six patients with cystic fibrosis, the quality of life, both before and after lung transplantation, was measured by the following five instruments: (1) standard gamble, (2) time trade-off, (3) the Karnofsky performance status, (4) the EuroQol visual analog scale, and (5) the Nottingham health profile. This pilot study demonstrates that the introduced methodology is feasible. The preliminary results suggest that the improvement in quality of life for patients with cystic fibrosis after bilateral lung transplantation is comparable to the improvement in quality of life after heart transplantation.

The quality of well-being scale (QWB) has been used to measure overall life quality in a number of different clinical conditions, including cystic fibrosis and chronic obstructive pulmonary disease. Evidence supports its validity and reliability in both cross-sectional and longitudinal studies. One of the strengths of the QWB is that it is not organ-specific, so that it can take into account the broad impact of a disease and/or intervention, including unanticipated effects. The well-year of life is a concept that includes both morbidity and mortality: if a disease reduces quality of life by one-half, over a period of two years, that person can be said to have lost one full well-year. As we examine the impact of diseases such as cystic fibrosis, and of interventions such as lung transplantation, it is important to consider changes in overall well-being over time to help individual patients and families make difficult therapeutic choices and to help formulate health policy.