Heart transplantation (txp) exemplifies a high-technology biomedical intervention that is extremely costly in terms of economic and health care resources, yet provides highly-valued outcomes: it yields a dramatic extension of duration of life, and marked improvement in quality of life. Like many other major life-extending interventions, however, heart txp brings its own consequent stressors and morbidities. Most critically, it gives patients only a limited extension in life expectancy, usually far less than that based on chronological age. As the population of heart recipients grows, an expanding number of individuals will enter the late years of txp survivorship and face the inevitable physical deterioration that comes during these years. The psychological consequences of late term survivorship are unknown. In this application, we provide the economic, conceptual, and public health rationales for the need to consider these consequences at this time and in this population. There are no data on the nature or course of psychiatric morbidity that may accompany physical health declines, despite the potential impact of such psychiatric morbidity on txp recipients' quality of life and survival time. There are no data on whether the mental health of the patient's primary family caregiver is affected by late-term txp-related health changes. These data, plus identification of factors that create vulnerability or increase psychological resilience in the face of growing physical challenges for the patient will provide the critical knowledge base for the design of mental health interventions for both patients and caregivers during these years. We previously enrolled and followed the only cohort of heart recipients (n=250) ever to have received repeated, extensive psychiatric, behavioral, and psychosocial assessments across the early to middle (0-4) years posttxp. Their family caregiver's mental health and psycho-social status was also assessed. We plan to reassess all cohort survivors (n=132) and their caregivers. At study inception, the bulk of patients will be 9-13 years post-txp. We will collect 3 new waves of data separated by 1 year each in order to address a series of clinical epidemiologic questions pertaining to: (a) the prevalence of depressive and anxiety-related disorders during the late years post-txp, (b) the degree to which patients' and caregivers' risk for psychiatric morbidity in the face of late post-txp physical health stressors is moderated by key psychosocial characteristics, and (c) whether both parties' mental health, in turn, influences patients' continued medical compliance and subsequent physical morbidity. Data collection will involve semi-structured interviews, Txp Program staff evaluations, and medical record reviews.
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