A pilot study of posttraumatic stress and nonadherence in pediatric liver transplant recipients
A pilot study of posttraumatic stress and nonadherence in pediatric liver transplant recipients
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DOI：
10.1542/peds.105.2.e29
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发表时间：
2000-02-01
期刊：
影响因子：
8
通讯作者：
Shneider, BL
中科院分区：
文献类型：
--
作者：
Shemesh, E;Lurie, S;Shneider, BL
背景资料。创伤后应激障碍(PTSD)的症状被描述为危及生命的疾病的幸存者，创伤是与疾病或其治疗相关的经历。它们在肝移植受者中的患病率尚不清楚。根据临床观察，我们假设相当大比例的儿科肝移植受者患有创伤后应激障碍症状。我们进一步假设，在某些情况下，不坚持(不遵守)医疗管理可能与这些症状有关。根据这一假设，受到创伤的患者会避免服药，因为这些药物会痛苦地提醒人们这种疾病。目的：确定儿童肝移植受者创伤后应激障碍症状的患病率。以确定PTSD的症状是否与这些患者的不依从性有关。描述创伤后应激障碍的临床表现和严重违纪的处理方法。使用加州大学洛杉矶分校创伤后应激障碍反应指数(PTSRI)对19名儿童肝移植受者和他们的照顾者进行了访谈。获得了关于一些人口统计参数和对疾病威胁的看法的数据。依从性通过两种方法进行评估：1)临床专家小组(考虑严重不依从性的临床后遗症)；2)计算连续测定他克莫司血药浓度的标准差(SD越高，单项测量之间的变异性越大，因此是不依从性的指标)。作为对这一普遍现象的说明，我们描述了3例肝移植受者的无粘连和PTSD。19例患者中有6例PTSRI(创伤后应激障碍患者)的3个组成部分均为阳性。其中有三项，其他任何一项都被专家小组认为严重不遵守。因此，在我们的样本中，不坚持与PTSD(费舍尔准确测试)的所有三个领域的症状的存在显著相关。特别是，PTSRI上的高回避分数与小组确定的不依从性高度相关。此外，与我们样本的其余部分相比，创伤后应激障碍患者的用药水平标准差显著更高。创伤后应激障碍患者和我们样本中的其他患者在疾病威胁或人口统计学变量的感知上没有发现显著差异。我们描述的3例患者在治疗过程中创伤后应激障碍症状缓解后开始依从性用药。通过两种不同的方法确定的临床上有意义的不坚持与本样本中PTSD症状的全部谱相关联。它尤其与高回避分数有关，这表明避免提醒疾病(例如，药物治疗)可能是一种不坚持的机制。因此，对这些症状的筛查和处理可能会提高依从性。这一新概念可能也适用于其他患者群体。然而，在得出任何明确的结论之前，还需要更多的数据。
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 patient populations. However, more data are needed before any definite conclusions can be drawn.