A Pilot Study of Posttraumatic Stress and Nonadherence in Pediatric Liver Transplant Recipients

Abstract

ABSTRACT. Background. Symptoms of posttraumatic stress disorder (PTSD) were described in survivors of life-threatening diseases, the trauma being the experiences associated with the disease or its treatment. Their prevalence in liver transplant recipients is unknown. Based on clinical observations, we hypothesize that a significant proportion of pediatric liver transplant recipients suffers from PTSD symptoms. We further hypothesize that nonadherence (noncompliance) to medical management may, in some cases, be associated with these symptoms. Traumatized patients, according to this hypothesis, will avoid taking their medications, because these serve as painful reminders of the disease.Objectives. To determine the prevalence of PTSD symptoms in a sample of pediatric liver transplant recipients. To determine whether symptoms of PTSD are associated with nonadherence in these patients. To describe the clinical presentation of PTSD and the management of severe nonadherence in patients who suffer from this disorder.Methods. Nineteen pediatric liver transplant recipients and their caretakers were interviewed, using the UCLA Post Traumatic Stress Disorder Reaction Index (PTSRI). Data were obtained on a few demographic parameters and perception of disease threat. Adherence was evaluated by 2 methods: 1) a clinician panel (taking into account the clinical sequelae of severe nonadherence); and 2) computation of the standard deviations (SDs) of consecutive determinations of blood levels of Tacrolimus (a higher SD means higher variability between individual measures and is therefore an indicator of nonadherence). As an illustration of the general phenomenon, we describe 3 cases of liver transplant recipients who were nonadherent and who suffered from PTSD.Results. Six of 19 patients had positive scores on all 3 components of the PTSRI (PTSD patients). Three of these, and none of the others, were considered significantly nonadherent by the panel. Therefore, nonadherence was significantly associated with the existence of symptoms from all 3 domains of PTSD (Fisher's exact test) in our sample. In particular, a high avoidance score on the PTSRI was highly correlated with panel-determined nonadherence. Further, SD of medication levels were significantly higher in PTSD patients, compared with the rest of our sample. No significant differences were found in perception of disease threat or demographic variables between PTSD patients and the rest of our sample. The 3 cases that we describe became adherent to their medications when symptoms of PTSD subsided during the course of therapy.Conclusions. Clinically significant nonadherence, determined by 2 different methods, was associated with the full spectrum of PTSD symptoms in this sample. It was especially associated with a high avoidance score, which suggests that avoidance of reminders of the disease (eg, medications) may be a mechanism of nonadherence. Screening for and management of these symptoms, therefore, may improve adherence. This novel concept may be applicable to other pati...

Brief report: Maternal posttraumatic stress symptoms are related to adherence to their child’s diabetes treatment regimen

“…The results add to the findings by Shemesh et al (2000), who reported that adherence problems in children who had received a liver transplant were significantly correlated with their PTSD symptoms and with avoidance symptoms in particular. However, they somewhat contradict the findings by Myers et al (2007) who reported that PTSD symptoms in adults with type I diabetes were not significantly related to glycemic control.…”

The Impact of Posttraumatic Stress Disorder on CPAP Adherence in Patients with Obstructive Sleep Apnea

“…32 In addition, prior reports have found an increased likelihood of missed appointments, underuse of medications, abuse of prescription psychoactive agents, and the propensity of self-adjust medical treatments among patients with PTSD. [33][34][35][36][37] OSA is more common among patients with underlying psychiatric disorders. In a sample of 118,105 military veterans, the prevalence of psychiatric disorders was significantly greater in patients with OSA than those without.…”

Comparison of Parent and Child Reports of Emotional Trauma Symptoms in Pediatric Outpatient Settings

“…3 Significant PTSD symptoms have been reported to be present in 6% to 30% of surveyed children in various settings in the United States. 4,5 It is important to recognize and treat these symptoms, because PTSD is associated with increased rates of health care utilization, 5 disability, 6 and medical and psychiatric adversity [6][7][8] in affected patients.…”

“…6 When a child is ill, the traumatic emotional experience that is associated with this illness is frequently shared by the parent, too. 5,6,12 When PTSD symptoms develop in patients who are medically ill, they are associated with poor health outcomes [6][7][8]17 ; therefore, it is important to recognize these symptoms. 6 Hence, medically ill children are a particularly interesting group of traumatized youths in which one would wish to examine discrepancies between child and parent reports of PTSD symptoms that are experienced by the child.…”