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(Chest. 2005;127:166-170.)
© 2005 American College of Chest Physicians

Psychosocial Situation and Physical Health in 50 Patients > 1 Year After Lung Transplantation*

Lutz Goetzmann, MD; Eberhard Scheuer, PhD; Rahel Naef, RN; Esther Vetsch, PhD; Claus Buddeberg, MD; Erich W. Russi, MD, FCCP and Annette Boehler, MD, FCCP

* From the Department of Psychosocial Medicine (Drs. Goetzmann, Scheuer, Vetsch, and Buddeberg) and Division of Pulmonary Medicine (Drs. Russi and Boehler, and Ms. Naef), Lung Transplant Program, University Hospital Zurich, Zurich, Switzerland.

Correspondence to: Lutz Goetzmann, MD, University Hospital Zurich, Psychosocial Medicine, Haldenbachstrasse 18, 8091 Zurich, Switzerland; e-mail: lutz.goetzmann{at}usz.ch


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 Conclusions
 References
 
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.

Key Words: anxiety • depression • lung transplantation • psychosocial situation • state of health


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 Conclusions
 References
 
Lung transplantation is not only a lifesaving procedure but it can also improve quality of life and emotional health.123456789 This may be explained by a significant improvement in the overall state of health; however, persisting health problems after transplantation may appear to be less burdensome compared to the threat of the underlying lung disease before transplantation.9 After transplantation, patients are confronted with various health problems, such as pulmonary (acute and chronic allograft rejection, and pulmonary infections) as well as nonpulmonary complications, and severe side effects of the immunosuppressive drugs. There are two important considerations in the psychosocial care of patients after lung transplantation: (1) the interrelation of the physical state of health and psychological well-being after lung transplantation, and (2) which physical problems may have an impact on psychological conditions.

In the present study, patients who had undergone lung transplantation > 1 year previously were investigated. In a cross-sectional design, psychosocial parameters (anxiety, depression, self-esteem, social support), physical parameters (FEV1, pulmonary and nonpulmonary complications), and the judgement of physical and psychological health estimated by the patients as well as the treating physicians were assessed. The aims of the study were as follows: (1) to record the psychosocial state of the overall patient sample and to compare it with the corresponding standard samples in the average population, and (2) to search for correlations between psychosocial and physical parameters.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 Conclusions
 References
 
Sample and Procedure
Between 1992 and 2002, 125 patients underwent lung transplantation at University Hospital Zurich. The inclusion criteria of the present study required that the patients undergo transplantation > 1 year before the assessment, be regularly followed up at the outpatient clinic, and have sufficient knowledge of the German or Italian languages. These criteria were fulfilled in 53 patients. Forty-five of the 125 patients were deceased, and the other patients were ≤ 1 year after transplantation (n = 18), had incomplete medical data (n = 5), or were French speaking (n = 4). After approval by the ethics committee of University Hospital Zurich, the study was announced and explained in the patient teaching classes; the questionnaire was then delivered by mail, and informed consent was obtained. The treating physicians of the Lung Transplant Program completed a medical questionnaire for each patient.

Instruments
The patient questionnaire recorded general sociodemographic information (age, gender, partnership status, children, employment status). Self-assessment of current physical and psychological state of health was requested on a scale featuring the comments of excellent (score 1), very good (score 2), good (score 3), less good (score 4), and poor (score 5).

The Hospital Anxiety Depression Scale (HADS) measures anxiety and depression in physically ill patients.1011 The HADS consists of seven items, each scale with a 4-point Likert-type scale. A total score > 10 on each scale is regarded as indicative for a clinical diagnosis of anxiety or depression, a total score in the range of 8 to 10 is borderline, and values < 8 are interpreted as clinically insignificant or normal. The German-language version of the HADS is validated.11

The Rosenberg Self-esteem Scale (RSES) measures the individual’s feeling of self-esteem; the original English version of the questionnaire has a well-examined validity and reliability,12 confirmed for the German-language version.13 The German version of the RSES has been used in several clinical populations, eg, patients with cancer, and also in healthy persons.13 The RSES consists of 10 items with a 4-point Likert-type scale. Higher scores reflect better self-esteem.

The Social Support Questionnaire (F-SoZu) consists in its short form of 14 items with a 5-point Likert-type scale. The questionnaire measures perceived and anticipated social support, validated in the German-language version.14 All of the instruments were used in a validated German-language version; to assess our seven Italian-speaking patients, the instruments were translated into the Italian language (in a nonvalidated version).

The medical questionnaire included the diagnosis of the underlying disease leading to the lung transplant, the date of the lung transplant, current FEV1 value, number of pulmonary/nonpulmonary complications in the last 6 months (with the option of listing these in abbreviated form), and presence of acute rejection or chronic rejection. In addition, the physicians were asked to evaluate the current physical and psychological health of the patients. Reply options corresponded to those of the patients’ questionnaire, with excellent (score 1), very good (score 2), good (score 3), less good (score 4), and poor (score 5).

Spirometry was performed with a mass flowmeter (66200 Autobox; SensorMedics; Yorba Linda, CA). Criteria for acceptability and reproducibility and predicted normal values were according to the European Community of Coal and Steel.15 The term chronic rejection was used to describe the condition of bronchiolitis obliterans syndrome according to the criteria defined by the International Society of Heart and Lung Transplantation.16

Descriptive statistics data were expressed in absolute numbers, percentage, and mean and SD. To identify differences between groups, the t test for independent samples was used. The correlations between variables were calculated by the Pearson correlation. The statistical evaluation was carried out using software (SPSS 11.0; SPSS; Chicago, IL).


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 Conclusions
 References
 
Patient Sample
Fifty of the 53 patients who were asked participated in this survey. The response rate was thus 94%. Forty-eight of the 50 medical questionnaires filled out by the treating doctors were sent back completed (96%).

The sample included 23 women (46%) and 27 men (54%) with a mean age of 42.9 years (SD, 13.6). Forty-one patients (82%) lived with a partner, and 24 patients (48%) had one or more children. Forty-four patients (88%) were from Switzerland, 5 patients (10%) were of Italian origin living in Switzerland, and 1 patient (2%) was from Germany. Seven patients were Italian speaking (14%), and 43 patients were German speaking (86%). At the time of the survey, five patients (10%) were working > 50% of the time or full-time; the majority worked ≤ 50% of the time.

Forty-nine patients (98%) had undergone bilateral lung transplantation, and 1 patient (2%) had undergone unilateral lung transplantation. On average, the lung transplantation was performed 4.2 years previously (SD, 2.2; minimum, 1.6 years; maximum, 9.1 years). The largest diagnostic group consisted of patients with cystic fibrosis, followed by patients with COPD (Table 1 ).


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  		Table 1.. Underlying Lung Diseases Prior to Transplantation (n = 50)

 
Patient’s Self-Assessment of Physical and Psychological Health
The mean value of the self-assessment of physical health was 2.54 (SD, 0.93), and the mean value of the self-assessment of psychological health was 2.44 (SD, 0.95). Hence, the mean values on the 5-point Likert-type scale ranged between very good (score 2) and good (score 3). No patient assessed his/her current physical or emotional health as poor.

Psychosocial Parameters
The mean values for anxiety (5.76; SD, 3.69) and depression (3.27; SD, 3.31) on the HADS were comparable within a standard sample in the normal population (anxiety, 5.8; depression, 3.4).10 Clinically significant or borderline anxiety was present in 14 patients (28%); 5 patients (10%) had clinically significant or borderline depression.

The mean value for social support (as measured by the F-SoZu) was 4.3 (SD, 0.63). Unfortunately, to date no standard values have been published for the 14-item version of the F-SoZu.

Self-esteem in our patient population was similar to a comparison sample with healthy persons as measured by the RSES, with 2.46 (SD, 0.51) and 2.29 (SD, 0.44), respectively. The mean value in a German clinical comparison sample with cancer patients was 2.31 (SD, 0.40).13

Medical Parameters
At the time of the survey, the mean FEV1 percentage of predicted was 93% (SD, 24.9; range, 25 to 148%). Five patients (10%) had chronic allograft rejection, which was diagnosed in all of them > 6 months before the current study took place. Within the past 6 months of the survey, 16 patients (32%) had a pulmonary complication, which consisted of a respiratory tract infection in all cases (there was no episode of acute rejection during that time period).

Twenty patients (40%) had nonpulmonary complications: condylomata accuminata, excision of lipoma, basal cell carcinoma, excision of neurinoma, cervical papilloma, excision of ovarian cyst, rectal hemorrhage, surgery of inguinal hernia, symptomatic osteoporosis, acute severe sinusitis, atrial fibrillation, bladder dysfunction, prostate hyperplasia, multiple acral necrosis, bilateral cataract (n = 1), migraine (n = 2), and various osteoporotic fractures (n = 3).

Correlations Between Psychosocial Variables, Lung Function, and Time After Transplantation
Table 2 shows the correlations between the psychosocial variables of self-esteem, anxiety, depression, social support, self-assessment of current physical and psychological health, lung function (FEV1), and time since transplantation. There was a significant positive correlation between the patient’s self-esteem and social support; in contrast, there were significant negative correlations between self-esteem and anxiety and depression. Social support also correlated significantly negatively with anxiety and depression. A significantly positive correlation was found between the patient’s psychological and the physical health assessment.


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  		Table 2.. Correlations (r) Between Psychosocial Variables, Lung Function, and Time After Transplantation (n = 50)

 
There was a significantly negative correlation between FEV1 and time since transplantation. There was no significant correlation between FEV1 or the time since transplantation and psychosocial variables.

Patients with pulmonary complications (ie, pulmonary infections) in the last 6 months (n = 16) reported significantly higher anxiety values (t = – 3.57, p < 0.01) and tended to assess their current psychological health as poorer than did patients without pulmonary infections (n = 34). The groups did not differ statistically with respect to self-esteem, depression, self-assessment of physical health, social support, and FEV1. In contrast, although patients experiencing nonpulmonary complications in the last 6 months (n = 20) assessed their physical health as significantly poorer than did patients without complications (n = 30), the two groups did not differ statistically with respect to anxiety, depression, self-esteem, assessment of psychological health, social support, and FEV1. The patient group with chronic rejection (n = 5) was too small to be compared to the patient group without chronic rejection. Patients with chronic rejection, however, reported higher anxiety values (mean, 8.75 vs 5.59, respectively) and assessed their psychological health as poorer (mean, 3.20 vs 2.38, respectively) than did patients without chronic rejection.

A comparison between women (n = 23) and men (n = 27) revealed that men were significantly more depressed than women (mean, 4.44 and 1.82, respectively; p < 0.01). For all other psychosocial variables, FEV1, and the experience of chronic rejection, there was no significant difference between men and women. Interestingly, women experienced significantly more pulmonary infections (p < 0.05) and more nonpulmonary complications (p < 0.05) than men; nevertheless, women still were significantly less depressed.

Patients with cystic fibrosis (n = 15) differed significantly from patients with other underlying pulmonary diseases (n = 35) only in terms of mean age (cystic fibrosis, 34 years; pulmonary diseases, 48 years; p < 0.01). Otherwise, there was no statistically relevant difference between the two groups. No correlations between the psychosocial parameters (anxiety, depression, self-esteem, social support) and actual age were found in our sample.

Physician’s Assessment of Physical and Psychological Health and Comparison of Self-Assessments and Outside Assessments
The average medical assessment of physical health was 1.55 (SD, 0.80), ie, between excellent (score 1) and very good (score 2), whereas the average assessment of psychological health was 2.06 (SD, 1.11), ie, between very good (score 2) and good (score 3). There was a significantly positive correlation between the assessment of physical health (r = 0.38, p < 0.01) by the physician and by the patient; the same was true for the assessment of psychological health (r = 0.55, p < 0.001).


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
Conclusions
 References
 
In the present study, we investigated the psychosocial situation of patients after lung transplantation and its relation to their physical health. Although the study has a cross-sectional design and the questionnaire of the Italian-speaking patients (n = 7) had to be translated into an Italian nonvalidated version, the results point to interesting aspects after lung transplantation.

Psychological state of health and quality of life improve considerably after lung transplantation.123456789 Accordingly, the results of this study show that in lung transplant recipients, the psychological status (anxiety, depression) does not differ from the standard samples of the average population. Self-esteem in our patient population as measured by the RSES (mean, 2.46; SD, 0.51) was not only higher compared to a German clinical comparison sample of cancer patients (mean, 2.31; SD, 0.40), but also higher compared to a sample of healthy persons (mean, 2.29; SD, 0.44).13 Overall, our cohort patients felt well supported socially, had good self-esteem, and were neither more depressed nor more anxious than the general population. These results are in agreement with the results of Limbos et al8 from Toronto, who recorded similar values for anxiety, depression, and self-esteem in their 73 lung transplant recipients.

However, an important finding in this study is the gender-specific difference in psychosocial well-being after transplantation. In our sample, men were significantly more depressed than women, although women had experienced more pulmonary infections and nonpulmonary complications in the last 6 months. The reason for this difference is not clear. One reason might be that men are differently affected in their job performance when health limitations occur.

The second new finding was that in lung transplant recipients, preceding pulmonary health problems had long-lasting effects on the level of anxiety, whereas nonpulmonary complications did not have such an effect. The significantly positive correlation between either anxiety or a negative self-assessment of psychological health and a pulmonary infection within the last 6 months is interesting. In the present sample, patients with pulmonary infections did not differ from patients without pulmonary infections with regard to lung function (FEV1). Maybe it is the awareness of susceptibility to infection that is primarily responsible for the observed anxiety. In some patients, this anxiety may be supported by bad memories of previous severe infections in their native lung before lung transplantation.

There was no significant correlation between psychosocial parameters and lung function (FEV1). Although FEV1 correlated negatively with time since transplantation, decreased lung function did not correlate with greater anxiety or depression, or reduced self-esteem. Likewise, the self-assessment of physical health did not correlate significantly with FEV1. This supports the observation that posttransplant lung function must be substantially reduced until it is recognized by the patients and affects their well-being. However, data on psychosocial well-being and self-assessment of physical health do not allow the drawing of conclusions concerning actual lung function. The lack of a significant correlation between time since transplantation and current psychosocial findings in our patients points out that psychosocial well-being can be present shortly after surgery or even years away from transplantation.

In the self-assessment questionnaire about psychological and physical health, our study population judged both current physical and psychological health as good to very good. In this context, it is of importance that social support correlated with psychological well-being: the greater the social support, the lower the values for depression and anxiety.

The significant correlations between anxiety, depression, and self-esteem and the self-assessment of physical health also indicate that patients with a tendency toward anxiety and depression rate their physical state of health rather negatively. This result shows that subjective perceptions of health are not entirely explained by objective findings.

The assessments of the patients and the assessments of their treating physicians correlated significantly. Interestingly, the agreement was moderate with regard to physical health (r = 0.38, p = <0.01), whereas both parties’ appraisal of psychological health agreed to a larger extent (r = 0.55, p = <0.001). We assume that after an organ transplantation, patients tended to be rather restrained about raising physical complaints (eg, changes in body image, side effects of medications) as an issue. In contrast, the intense exposure of patients and doctors within the framework of a lung transplant program might well result in similar ratings of psychological well-being.


   Conclusions
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusions
References
 
Overall, the psychological well-being of patients after lung transplantation is similar to the normal population. However, subgroups of patients with increased psychological distress have been identified. Future studies have to address whether awareness and psychological support may improve psychological well-being in these patients.


   Footnotes
 
Abbreviations: F-SoZu = Social Support Questionnaire; HADS = Hospital Anxiety Depression Scale; RSES = Rosenberg Self-esteem Scale

Dr. Boehler holds a Swiss National Science Professorship position.

This work is supported by a grant of the Swiss National Science Foundation (project No. 4046–05661).

Received for publication April 24, 2003. Accepted for publication September 7, 2004.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusions
 References
 

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