The Role of Psychosocial Screening Tools in the Evaluation of Transplantation Patients With Alcohol‐Related Liver Disease

Psychosocial assessment is a wellrecognized component in addition to the medical and surgical aspects of a comprehensive transplant candidate evaluation. The role of a transplant psychosocial evaluation is to assess a candidate’s social, behavioral, psychiatric, and cognitive functioning with the intent of identifying areas that may represent potential risks to optimal transplant outcomes. If areas of deficiency are identified through the psychosocial evaluation, many transplant programs allow potential candidates an opportunity to be reassessed once they begin to address or remediate these problem areas. Thus, a key aspect of the psychosocial assessment is to assist in the development and implementation of a psychosocial treatment plan to mitigate risk and minimize preventable problems with the goal of optimizing posttransplant psychiatric and medical outcomes. Standardized transplantspecific assessment tools are used by some transplant psychosocial assessors in addition to a clinical interview to maintain consistency and to ensure that all relevant areas are covered. One such assessment tool is the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT). The SIPAT developers recognized a lack of standardization in the psychosocial selection criteria as well as the actual psychosocial assessment at their own institution and within the published literature. (1) They reasoned that such a tool could standardize the evaluation, ensuring that all content domains were assessed and accurately summarized in addition to improving equity for all transplant candidates. Notably they envisioned the SIPAT as a tool to identify potential candidates at risk for lessthanoptimal outcomes after transplant to focus the assessors on areas needing improvement and to develop interventions directed at increasing a patient’s likelihood of being accepted and placed on the waiting list. (1) The authors did not consider the SIPAT a standalone assessment and recommended a psychosocial assessor use collateral sources of information to supplement and verify the information obtained from the patient interview. Moreover, given the limited information on the validity of such metrics,(2) the use of the SIPAT or other psychosocial tools to generate a score or rating of a patient’s suitability for transplant is not recommended by the SIPAT creators(1) or transplant society guidelines. (2) Rather, the SIPAT developers recommended using the SIPAT to complement the psychosocial evaluation process and not be used as the sole determinant of eligibility for transplantation. (1) In the article by Daniel et al.(3), SIPAT scores were used to examine differences between liver transplantation (LT) candidates with alcoholrelated liver disease (ALD) compared with candidates without ALD. Not unexpectedly, based on their alcohol and/or substance use histories, LT candidates with ALD had higher SIPAT scores, which is indicative of greater psychosocial risk. The authors found that compared with the nonALD cohort, patients with ALD had higher scores on all subscales of the SIPAT, including substance and alcohol use, other mental health disorders, social support, and psychosocial stability. Individuals with alcohol use disorders have higher rates of comorbid substance use, depression, anxiety, and other mental health disorders,(4) which could explain the difference Abbreviations: ALD, alcoholrelated liver disease; LT, liver transplantation; SIPAT, Stanford Integrated Psychosocial Assessment for Transplantation.