Psychological Distress and Its Association With Quality of Life in Organ Transplant Recipients During COVID-19 Pandemic

Objectives: The coronavirus disease 2019 (COVID-19) pandemic may have an impact on the psychological distress of organ transplant recipients. We aimed to assess the status of psychological distress and its association with quality of life (QoL) in organ transplant recipients during the COVID-19 pandemic. Materials and Methods: A cross-sectional survey was carried out with 305 organ transplant recipients during March 30 and April 2, 2020, in Wuhan. Psychological distress comprised depression, anxiety, insomnia, and post-traumatic stress disorder (PTSD), which were assessed using the Patient Health Questionnaire-9, the seven-item Generalized Anxiety Disorder questionnaire, the Insomnia Severity Index, and Impact of event scale-revised. QoL was assessed using the Chinese version of the short Form 36-item health survey. Results: The prevalence of depression, anxiety, insomnia, and PTSD in organ transplant recipients was 13.4, 6.9, 11.8, and 30.5%, respectively. Organ transplant recipients with depression had significantly lower scores in all eight dimensions of QoL compared with participants without depression (all p < 0.05). Lower scores on the QoL dimensions of role physical, bodily pain, general health, vitality, role emotional, and mental health were found in organ transplant recipients with anxiety, insomnia, or PTSD compared with their counterparts without the respective disorder (all p < 0.05). Limitation: The cross-sectional study design limited us to make causal conclusion and the influence of potential confounders cannot be ruled out. Conclusions: Psychological distress was prevalent in organ transplant recipients during the COVID-19 pandemic, and those with depression, anxiety, insomnia, and PTSD had poorer QoL. Therefore, timely psychological counseling, COVID-19 related health education, and essential community medical services should be provided to organ transplant recipients to relieve their psychological distress, and to improve their QoL.


INTRODUCTION
The outbreak of coronavirus disease 2019 (COVID- 19), first reported in China (1), has become a pandemic. As of November 22, 2020, more than 57.8 million confirmed cases and 1.3 million deaths had been reported worldwide (2). During the COVID-19 pandemic, the psychological distress among the population can be prominent because of social isolation, uncertainty of the future, fear of being infected, and overwhelming negative news portrayal in mass media coverage (3,4). The mechanisms that people get into psychological distress are implicated, for instance, Serafini et al. found that extreme sensory processing patterns show a complex association with depression, and impulsivity, alexithymia, and hopelessness (5). Numerous studies have proven that both healthcare workers and the general public were associated high psychological burden during this crisis (6). It was suggested that psychological interventions targeting high-risk populations with heavy psychological distress are in urgent need, and the importance of protective factors including sufficient medical resources, up-to-date and accurate information, and precautionary measures should be stressed (6,7).
End-stage organ failure is a serious condition associated with an increased risk of mortality (8,9). Organ transplantation is often the only treatment for patients with end-stage organ failure. The number of patients undergoing organ transplantation is increasing (10), with more than 100,000 organ transplantations performed annually worldwide (11), and a post-transplant survival exceeding 85-90% in the first year and 70-75% at 5 years (12). Kidney transplantation is the most frequent, globally, followed by liver and heart transplantations. Patients with end-stage organ failure suffer from severe physical and psychological symptoms (13). QoL is a major index to the evaluate the efficacy of medical intervention among patients with end-stage organ failure. Organ transplantation has been demonstrated to be the best treatment both for quality of life (QoL) and cost effectiveness (14)(15)(16).
Organ transplant recipients are patients who have received organ transplantation. A large proportion of organ transplant recipients suffer psychological distress, including symptoms of depression (17), anxiety (18), and post-traumatic stress disorder (PTSD) (11). During the COVID-19 pandemic, moderate to severe depression and anxiety were demonstrated to be independently associated with increased risk of low QoL among healthcare workers (19). Affected by the COVID-19 pandemic, organ transplant recipients may suffer more apparent psychological distress than before, and as a result may endure worsen QoL. Nevertheless, the status of psychological distress during the COVID-19 pandemic and its association with QoL in organ transplant recipients is unknown. Therefore, this study involved a cross-sectional survey with organ transplant recipients to assess their level of psychological distress and QoL, and explore the association between the two, during the COVID-19 pandemic.

Study Participants
This cross-sectional study was conducted between March 30 and April 2, 2020. It was approved by the Clinical Research Ethics Committee of Renmin Hospital of Wuhan University (WDRY2020-K004). Organ transplant recipients were identified from the medical records of Renmin Hospital of Wuhan University. Individuals were included if they underwent kidney, heart, or liver transplantation from January 2015 to December 2019, and were excluded if they died, could not complete the questionnaires, or refused to sign the informed consent. 305 from 342 invited organ transplant recipients (with a response rate of 89.2%) agreed to participate in this study and signed the informed consent before their participation. In the informed consent forms, participants were encouraged to seek psychological assistance through a free online psychological support system, in which psychologist and psychiatrist could provide online psychological assistance (20).

Assessment of QoL
QoL was evaluated using the Chinese version of the Short Form 36-Item Health Survey (SF-36) (29). The SF-36 comprises 36 items that cover eight dimensions: physical functioning (PF), role physical (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role emotional (RE), and mental health (MH). The score for each dimension ranges from 0 to 100, with higher values indicating better functioning and fewer limitations.
Wilcoxon rank sum test where appropriate. The significance level was set as α = 0.05.  Table 2 presents the status of psychological distress in organ transplant recipients during the COVID-19 pandemic. The estimated prevalence of depression, anxiety, insomnia, and PTSD was 13.4, 6.9, 11.8, and 30.5%, respectively. Older organ transplant recipients had a higher prevalence of insomnia than younger ones. Participants with comorbidities had a higher prevalence of insomnia than those without. A higher prevalence of PTSD was observed in those of older age, married, having an education level lower than undergraduate, and being worried about infection compared to their respective counterparts. Table 3  Males had higher PF scores compared with females. Younger participants had higher PF and SF scores than older ones. Unmarried participants had higher PF scores and lower VT scores than their counterparts. Those worried about infection had lower scores on PF, RP, GH, SF, and RE than those who were not worried. Participants who had undergone organ transplantation within 1 year had lower scores on PF and RP compared with those who had undergone transplantation more than 1 year before. Lower GH, VT, and RE scores were observed in participants with comorbidities compared with those without. Table 4 shows the results regarding the association of psychological distress with QoL in organ transplant recipients during the COVID-19 pandemic. Organ transplant recipients with depression had significantly lower scores in all eight dimensions of QoL compared with those without depression (all p < 0.05). Lower scores on RP, BP, GH, VT, RE, and MH were found in organ transplant recipients with anxiety, insomnia, or PTSD compared with those without the respective disorder (all p < 0.05).

DISCUSSION
In this study, the estimated prevalence of depression, anxiety, insomnia, and PTSD in organ transplant recipients was 13.4, 6.9, and 11.8, and 30.5%, respectively. Overall, during the COVID-19 pandemic, organ transplant recipients with psychological distress had poorer QoL than those without psychological distress. More specifically, organ transplant recipients with depression experienced poorer QoL in all the eight dimensions of SF-36 than those without depression, and organ transplant recipients with anxiety, insomnia, and PTSD showed reduced performance in six dimensions of SF-36, namely RP, BP, GH, VT, RE, and MH, relative to their counterparts without the respective disorder. The prevalence of depression and anxiety in organ transplant  recipients was in consistent with previous studies, which reported a prevalence of depression ranging from 13 to 37% (17), and a prevalence of anxiety ranging from 3 to 18% (18,30). The prevalence of PTSD in organ transplant recipients seemed to be higher than that in a prospective cohort study, which found that the prevalence of PTSD in liver transplant recipients before transplantation and at 1-year post-transplantation was 10.5 and 6.3%, respectively (31). It has been suggested that more organ transplant recipients suffered from PTSD during the COVID-19 pandemic compared with normal conditions (31). However, the difference in PTSD prevalence might be partially attributed to variations in study populations, assessment tools, and the time of assessment. When compared with general population, organ transplant recipients had higher prevalence of depression and insomnia, lower prevalence of anxiety, and similar prevalence of PTSD, during the same stage of COVID-19 pandemic in China (32,33).
Organ transplant recipients have been found to exhibit various forms of psychological distress such as depression, anxiety, and stress associated with physical and psychosocial stress factors such as life-threatening illness, transplant surgery, pain, and intensive care unit stays with mechanical ventilation and possible delirium (11). Although psychological problems may decrease after transplantation as patient outcomes and QoL improve (34), one-third of heart transplant recipients experienced high levels of psychological distress in the year following transplantation (35,36). Notably, being a public health emergency, the COVID-19 pandemic has had a significant psychological impact on both the general population and healthcare workers. Prior to this study, the status of psychological distress in transplant recipients during the COVID-19 pandemic was unknown. Since this study found that psychological distress is prevalent in organ transplant recipients, we therefore suggest that more attention be paid to the mental health status of this patient population and social support be provided for them during the COVID-19 pandemic.
QoL in organ transplant recipients could be improved posttransportation. Based on a review, in all included studies that used the SF 36 to assess QoL, the PF scores of elderly transplant recipients were significantly higher compared to their ageadjusted norms, while the BP, GH, VT, SF, RE, and MH scores did not differ significantly (37). This has brought hope for organ transplant recipients to reach an acceptable level of QoL after transplantation. However, the QoL in organ transplant recipients could be affected by several factors, such as age, educational level, employment status, family support, and negative emotional states (38). In this study, we provided evidence that symptoms of depression, anxiety, insomnia, and PTSD were associated with poorer QoL in organ transplant recipients. Our findings highlight the importance of implementing essential measures to relieve organ transplant recipients' psychological distress and improve their QoL.
To the best of our knowledge, this is the first study to assess the status of psychological distress and its association with QoL in organ transplant recipients during the COVID-19 pandemic. However, our study had several limitations. We analyzed cross-sectional data from a limited number of participants, and all the variables were self-reported; thus, there is a possibility of recall and misclassification bias, which may lead to misleading results. In addition, our study was conducted during the COVID-19 pandemic, and there was no baseline data that obtained before the outbreak of COVID-19; therefore, we could not assess whether or not the status of psychological distress in organ transplant recipients was more severe during the COVID-19 pandemic. Moreover, the prevalence of psychological distress may decline over time after transplantation; therefore, the present findings should be further confirmed using longitudinal data.

CONCLUSIONS
In conclusion, the current study indicated that psychological distress was prevalent in organ transplant recipients during the COVID-19 pandemic. Moreover, organ transplant recipients with depression, anxiety, insomnia, and PTSD had poorer QoL than their counterparts without the respective disorder. Timely psychological counseling, COVID-19 related health education, and essential community medical services should thus be provided to organ transplant recipients to relieve their psychological distress, and improve their QoL.

DATA AVAILABILITY STATEMENT
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

ETHICS STATEMENT
The studies involving human participants were reviewed and approved by Clinical Research Ethics Committee of Renmin Hospital of Wuhan University. The patients/participants provided their written informed consent to participate in this study.