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Clinical Investigations: TRANSPLANTS |

Effects of a Telephone-Based Psychosocial Intervention for Patients Awaiting Lung Transplantation* FREE TO VIEW

Melissa A. Napolitano, PhD; Michael A. Babyak, PhD; Scott Palmer, MD, FCCP; Victor Tapson, MD, FCCP; R. Duane Davis, MD, FCCP; James A. Blumenthal, PhD; for the INSPIRE Investigators
Author and Funding Information

Affiliations: *From the Departments of Psychiatry and Behavioral Sciences (Drs. Napolitano, Babyak, and Blumenthal), Medicine (Drs. Palmer and Tapson), and Surgery (Dr. Davis), Duke University Medical Center, Durham, NC.,  Currently at Brown University Center for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI.,  A complete list of the Investigational Study of Psychological Intervention in Recipients of Lung Transplant (INSPIRE) investigators is located in Appendix 1.

Correspondence to: James A. Blumenthal, PhD, Department of Psychiatry and Behavioral Sciences, Box 3119, Duke University Medical Center, Durham, NC 27710; e-mail: Blume003@mc.duke.edu


Affiliations: *From the Departments of Psychiatry and Behavioral Sciences (Drs. Napolitano, Babyak, and Blumenthal), Medicine (Drs. Palmer and Tapson), and Surgery (Dr. Davis), Duke University Medical Center, Durham, NC.,  Currently at Brown University Center for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI.,  A complete list of the Investigational Study of Psychological Intervention in Recipients of Lung Transplant (INSPIRE) investigators is located in Appendix 1.


Chest. 2002;122(4):1176-1184. doi:10.1378/chest.122.4.1176
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Study objectives: To test the efficacy of a tailored telephone-based intervention consisting of supportive counseling and cognitive behavioral techniques for individuals awaiting lung transplantation on measures of quality of life and general well-being.

Method: Patients were randomly assigned to either a telephone-based special intervention (SI; n = 36) for 8 weeks (average session length, 16.3 min) or a usual care (UC) control condition (n = 35) in which subjects received usual medical care but no special treatment or phone calls. At baseline, and immediately following the 8-week intervention, patients completed a psychometric test battery.

Setting: Duke University Medical Center, Pulmonary Transplantation Program.

Patients: Seventy-one patients with end-stage pulmonary disease listed for lung transplantation.

Primary outcome measures: Measures of health-related quality of life (both general and disease-specific), general psychological well-being, and social support.

Results: Multivariate analysis of covariance, adjusting for pretreatment baseline scores, age, gender, and time waiting on the transplant list, revealed that patients in the SI condition compared to the UC reported greater general well-being (p < 0.05), better general quality of life (p < 0.01), better disease-specific quality of life (p < 0.05), and higher levels of social support (p < 0.0001).

Conclusion: A brief, relatively inexpensive, telephone-based psychosocial intervention is an effective method for reducing distress and increasing health-related quality of life in patients awaiting lung transplantation.

Figures in this Article

Lung transplantation now represents a viable therapeutic option for many patients with advanced pulmonary parenchymal or pulmonary vascular diseases. Despite the relatively recent introduction of this procedure, successful short-term outcomes are reported at most centers,1 with 1-year survival rates approaching 80%. Long-term outcomes remain disappointing, however, with 5-year survival rates of only approximately 50%.16 Because of the limited long-term posttransplant survival rate, only patients with severe end-stage lung disease and a very limited life expectancy are considered for the operation. However, due to the severity of the disease, the prolonged waiting times until transplantation, and the high likelihood of death prior to receiving a transplant (eg, from July 1, 1999 to June 30, 2000, 883 patients underwent lung transplantation, while 553 patients died while waiting for a transplant),,1 lung transplant candidates often experience high levels of psychological distress.

Preliminary studies confirm high rates of anxiety and depression among patients with end-stage lung diseases such as COPD.79 Furthermore, psychological dysfunction and distress seem especially prevalent in those patients awaiting lung transplantation.10Prior studies have reported that pretransplant psychosocial factors, such as quality of life, depression, coping, and perceived social support, can adversely affect medical outcomes in a variety of chronic diseases,1115 including lung disease.1617 Little is known, however, regarding the impact of these factors on preoperative or postoperative lung transplantation outcomes. Moreover, there is little empirical research on the effects of modifying these psychosocial variables, particularly during the process of waiting for an organ.

It has been demonstrated that psychosocial interventions can enhance coping skills and improve quality of life and well-being in patients with chronic medical conditions such as HIV/AIDS,1819 cancer,20and heart disease.2122 The use of telephone-based interventions has gained increased attention as a viable alternative to conventional counseling.2325 Because patients awaiting lung transplantation frequently live far from major medical centers and often do not have access to mental health services that are familiar with the unique issues facing transplant recipients, a telephone intervention provided by trained clinicians represents a practical and novel approach to improve well-being among patients listed for lung transplantation. The purpose of the present study, therefore, was to examine the efficacy of a telephone-based psychosocial intervention in reducing distress and improving health-related quality of life in patients awaiting lung transplantation.

Patient Population

Ninety-one lung transplant candidates who were listed for lung transplantation at Duke University Medical Center between October 1997 and April 1998 were initially contacted to be part of this study. Every patient who was listed for a transplant during that time period was approached to participate in the study. Of the 91 patients who were contacted, 81 (89%) initially agreed to be part of the study and provided written informed consent approved by the institutional review board at Duke University Medical Center. There were no differences with respect to age, gender, transplant status, time spent waiting on the transplant list, functional capacity, or disease severity between those who declined to participate and those who agreed. Of the 81 subjects initially recruited for the study, 2 subsequently were taken off the transplant list, 1 underwent transplantation prior to completing the baseline evaluation, 6 withdrew their consent, and 1 died, leaving a final sample of 71 participants. The most common diagnoses were COPD, primary pulmonary hypertension, and cystic fibrosis. Other medical diagnoses included α1-antitrypsin deficiency, pulmonary fibrosis, lymphangioleiomyomatosis, bronchiectasis, sarcoidosis, and Eisenmenger syndrome.

Procedure

Following contact by mail, each lung transplantation candidate was contacted individually by telephone to describe the study. Patients were contacted in the order that they were listed on the Duke University transplant list. Once patients agreed to participate in the study and completed the baseline psychosocial evaluation (described below), they were randomly assigned either to a special intervention (SI; n = 36) or to usual care (UC; n = 35) [Fig 1] .

Psychosocial Assessment:

A battery of psychometric instruments was administered individually, by mail, to each patient before and after the 8-week intervention. The measures included the following:

  1. Medical outcomes survey, short form-36 (SF-36).26The SF-36 is a questionnaire designed to measure global quality of life. The SF-36 has been used with patient populations including those with chronic lung disease (eg, COPD, bronchitis, emphysema, and asthma).28 There are eight subscales, as follows: (1) physical functioning (eg, Does your health now limit you in walking one block?); (2) social functioning (eg, During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups?); (3) role limitations due to physical problems (eg, During the past 4 weeks, have you accomplished less than you would like as a result of your physical health?); (4) role limitations due to emotional problems (eg, During the past 4 weeks, have you accomplished less than you would like as a result of emotional problems?); (5) pain (eg, How much bodily pain have you had during the past 4 weeks?); (6) mental health (eg, How much of the time during the past 4 weeks have you been a happy person?); (7) vitality (How much of the time during the past 4 weeks did you feel full of pep?); and (8) general health perception (eg, In general, would you say your health is excellent, very good, good, fair, or poor?). The validity of the SF-36 has been established using psychometric and clinical standards.29 Higher scores reflect better health-related quality of life.

  2. General health questionnaire (GHQ).3031 The GHQ is a 60-item scale that was developed to help primary care physicians screen for nonpsychotic psychiatric disorders. The four subscales of the GHQ are as follows: (1) somatic symptoms (eg, Have you been getting a feeling of tightness or pressure in your head?); (2) anxiety and insomnia (eg, Have you lost much sleep over worry?); (3) social dysfunction (eg, Have you been managing to keep yourself busy and occupied?); and (4) depression (eg, Have you felt that life is entirely hopeless?). The GHQ has been used to document the effectiveness of stress management interventions for cardiac patients,2122 and has been shown to be sensitive to changes in stress levels. Higher scores indicate more stress.

  3. Pulmonary-specific quality-of-life scale (PQLS).32This disease-specific quality-of-life measure (see “Appendix 2”) was developed specifically for use in the present study. Items were developed through focus groups and one-on-one interviews with pulmonary patients. Broad questions (eg, How has your pulmonary disease affected your life?) were asked first, followed by questions in seven specific areas (eg, mood, physical functioning, social activities, occupational functioning, activities of daily living, view of self, and relationships/sexuality). This information was compiled into two to four items relating to each of the seven areas. In addition, items from the Duke activity status index33 were modified to provide questions pertaining to activities of daily living and physical functioning. In this manner, the following seven subscales were created: (1) physical functioning (eg, I am able to walk up a flight of stairs without getting winded); (2) psychological/emotional status (eg, I have been feeling down, blue, or depressed); (3) functional status/activities of daily living (eg, Because of my lung disease, I have had to limit my household activities (eg, cooking, cleaning); (4) social activities (eg, Because of my lung disease, I have had to limit many of the activities that I enjoy); (5) intimacy/relationships/sexuality (eg, I have had the energy to engage in sexual relations); (6) occupational functioning (eg, Because of my lung disease, I have had to decrease the number of hours I work); and (7) view of self (eg, I have been self-conscious about my heavy breathing) with two to four items per subscale. The PQLS has good convergent validity (−0.74) with the SF-36 and has high internal consistency (0.87). Lower scores reflect better functioning.

  4. Perceived social support related to transplantation. This scale also was designed for the present study (Appendix 3) in order to assess the extent to which individuals feel supported by the people in their lives (ie, family, friends, and transplant team members). Items include “How supported do you feel by your pulmonologist?” and “How supported do you feel by your family?” Higher scores reflect greater perceived support.

  5. Perceived stress related to transplantation. This scale is based on research by Jalowiec and colleagues,34 which identified the primary stressors reported by patients waiting for a heart transplantation. Items are rated on a 4-point scale (0, not at all stressful; 3, very stressful). Sample items include the following: having end-stage lung disease; waiting for a donor to be found; and having one’s family take over responsibilities. Higher scores indicate greater distress.

Intervention:

Following completion of the battery of psychometric tests, participants were randomly assigned either to a special, telephone-based intervention (ie, SI) or to a usual care control group (ie, UC).

SI Condition:

The SI condition consisted of supportive counseling and cognitive behavioral techniques delivered over the telephone by an advanced graduate student in clinical psychology. The intervention was based on strategies employed in our previous work with cardiac patients who had transient myocardial ischemia.21 The intervention was conducted over the telephone because of the wide disbursement of patients throughout the southeastern region of the United States. The intervention consisted of eight weekly telephone calls. All patients received a standardized core intervention, which covered the following: (1) education about stress and health; (2) specific coping techniques (eg, relaxation training, problem-solving, and calming self-statements); and (3) relapse prevention, with some patients additionally receiving a tailored intervention based on self-reported concerns or distress.

UC Control Condition:

Participants in the UC control group received their UC through the transplant service at Duke University Medical Center. This UC included clinic visits with the pulmonologists and nurse coordinators, and regular contact with the nurse coordinators. Members of the transplant team were blinded to patient group assignments. Patients in the SI condition also received UC, so the SI intervention provided additional counseling over and above UC. Clinic visits are routinely scheduled every 3 to 6 months, as clinically indicated. There were no scheduled visits during the 8-week intervention period.

Statistical Analysis

The primary data analysis strategy was to conduct separate multivariate analysis of covariance (MANCOVA) models on the general well-being (ie, GHQ), health-related quality of life (ie, SF-36 and PQLS), perceived stress, and social support subscales. Each subscale was adjusted for the corresponding baseline level prior to the analysis. Models included treatment group as a between-subjects factor, and age, gender, and wait-list time as the covariates. The primary analyses were conducted following the intention-to-treat principle. If no observation was recorded at the end of treatment, the data were carried forward from the last observation (ie, the baseline value) to serve as the outcome value.

Baseline Characteristics

The sample consisted of 22 men (31%) and 49 women (69%) with end-stage pulmonary disease. The mean age of the subjects was 45.4 years, and the average waiting time on the transplant list was almost 1 year. Other baseline characteristics included the following: 61 patients (86%) had greater than a high school education; 42 patients (59%) were married; and only 7 patients (9.9%) were employed full time. There were no differences with regard to age, gender, disease severity, or time spent waiting on the transplant list between SI and UC control patients (Table 1 ). There also were no baseline differences between the SI and UC groups on any of the primary outcome variables (see Tables 234 ).

Dropout and Compliance

Among the 35 patients who entered the UC condition with compete baseline assessments, 3 were unable to complete the follow-up assessments (1 patient was rehospitalized and was too sick to complete the posttreatment measures, 1 patient moved from her original address and did not provide an updated address or telephone number, and 1 patient did not return materials). All of the 36 patients who were entered the SI condition with compete baseline assessment data received the full eight sessions, but 2 patients received a transplant before they could complete the follow-up assessment (Fig 1).

Treatment Group Differences
GHQ:

A MANCOVA on the GHQ subscales revealed a significant treatment-group effect multivariate (F [4,66] = 3.36; p < 0.05). Table 2 presents group GHQ means and SDs before and after treatment, with higher scores reflecting better functioning. Univariate analyses of covariance (ANCOVAs) revealed that, compared to individuals in the UC group, those in the SI group reported less general distress, anxiety, social dysfunction, depression, and fewer somatic symptoms.

Health-Related Quality of Life:

Separate MANCOVAs were conducted for the general measures of health-related quality of life (ie, SF-36) and disease-specific measures of health-related quality of life (ie, PQLS). Significant multivariate treatment group main effects were observed for the SF-36 (F [9,61] = 3.09; p < 0.01) and for the PQLS (F [7,57] = 2.44; p < 0.05). Means and SDs for the SF-36 are reported in Table 3, with higher scores indicating better function. Data from the PQLS are reported in Table 4, with lower scores indicating better function. Follow-up univariate ANCOVAs for the SF-36-derived scales revealed that, compared to control subjects, individuals in the treatment group reported a better overall quality of life, better mental health, fewer role limitations due to emotional functioning, greater vitality, and tendencies for greater social functioning and fewer role limitations due to physical functioning (Table 3).

Patients in the treatment group also displayed improved disease-specific quality of life (ie, PQLS) when compared to control subjects. Univariate ANCOVAs revealed that compared to the UC control group, individuals in the SI group reported better psychological/emotional functioning, physical functioning, and overall functioning (Table 4).

Social Support:

After controlling for pretreatment social support, age, gender, and time spent waiting on the transplant list, the ANCOVA revealed a significant treatment group effect for the general social support scale (F [1,70] = 6.88; p < 0.01). Although there were no treatment group differences in perceived social support at baseline, participants in the SI condition perceived more support from the people in their lives when compared with individuals in the control group at the end of the 8-week program. Patients in the SI condition increased their perceived support, while patients in the UC condition exhibited a slight decline in perceived support (Fig 2 ).

Perceived Stress:

Patients in both the SI and UC groups exhibited declines in perceived stress over the 8-week intervention. The SI and UC groups had comparable mean (± SD) levels of perceived stress at baseline (SI, 22.7 ± 8.5; UC, 24.2 ± 10.3; not significant). After controlling for pretreatment social support, age, gender, and time spent waiting on the transplant list, the intervention and control groups did not differ after treatment on levels of perceived stress (SI, 20.5 ± 11.1; UC, 23.3 ± 10.2; not significant).

In this randomized study of a telephone-based psychosocial intervention consisting of supportive counseling and cognitive behavioral techniques, we have demonstrated significant improvements in global well-being and reductions in anxiety, depression, somatic complaints, and social dysfunction in patients awaiting lung transplant who received a special counseling program. In contrast, the UC control group reported only slight changes in each of these areas, exhibiting either small improvements or actual declines in psychosocial functioning. For example, patients receiving UC reported less social support, increased anxiety, greater role limitations, and lower overall mental health and general quality of life. These data demonstrate that a psychosocial intervention, delivered over the telephone, can effectively improve psychosocial functioning and can reduce the increases in anxiety and declines in health-related quality of life observed in patients awaiting lung transplantation.

The present findings may have important clinical implications for the care of patients awaiting lung transplantation. Because high levels of psychosocial distress may be associated with adverse health outcomes,1112,14,1617 posttransplant noncompliance3537 and poor posttransplant psychological adjustment,3839 reducing anxiety and improving psychosocial well-being before the patient undergoes transplantation, may improve clinical outcomes. The effect sizes ranged from 0.31 to 1.25, with a median of 0.41, suggesting that the treatment group on average scored about 0.4 SD higher than the control group on the outcome measures. This is typically considered to be a moderate effect size in the behavioral sciences and certainly would be clinically significant. We are currently examining the impact of a more extensive telephone-based intervention on psychosocial functioning and clinical end points such as compliance, rehospitalization, and survival in pretransplant candidates.

Mechanisms by which the SI may have led to improved quality of life and psychological well-being were by providing support and by teaching concrete coping strategies (eg, problem solving and relaxation techniques). Although similar interventions have been shown to lead to improvement in psychological function in other nontransplant populations,1822 much of the transplantation literature has focused on improved quality of life and well-being as a result of the transplant.3539 The present study demonstrates that a psychosocial intervention during the transplantation waiting period also can serve to improve well-being and psychosocial functioning.

Individuals completing the psychosocial intervention reported increases in their level of perceived social support. Hirth and Stewart40 found that patients’ perceptions of social support decreased following waiting periods > 3 months. The present sample had an average waiting time of 364 days, thus, for the majority of patients, this intervention was timely and may have interceded at a critical time to prevent declines in perceived social support. The SI group exhibited increased support, while the UC group exhibited small declines in perceived support. Low levels of social support have been shown to be related to posttransplant survival,14 noncompliance with medical regimens posttransplantation,3637 and poor posttransplant psychological adjustment.3839 Therefore, the improved perceived social support observed among those in the SI group may positively affect posttransplant survival, compliance, and psychological distress.

This study is limited by the small, self-selected sample, which may limit its generalizability. In addition, the sample included transplantation candidates who had different lung diseases. Although lung transplantation candidates share a condition with many common features (eg, all have severe lung disease and have a life expectancy of < 2 years), there may be distinct psychosocial issues facing patients with different lung diseases (ie, cystic fibrosis and COPD). These different pulmonary conditions may be associated with differences in quality of life and may present different psychological challenges, which may require distinct therapeutic approaches to be maximally effective. Another limitation was that the assessors were not blinded to treatment group. Although the psychological measures were self-administered and objectively scored, it is possible that patients in the treatment group may have biased their responses in a deliberate effort to present themselves as improved or perhaps more subtly to “please” the assessors. It also would have been more desirable for the control group to have received telephone calls to control for “attention” without teaching coping skills to those group members. Finally, because this study did not include any follow-up, it also is not clear whether patients were able to maintain the benefits they achieved with treatment. Future studies should provide follow-up assessments and should measure medical outcomes as well as quality of life and compliance after transplantation.

In summary, patients awaiting lung transplantation who were randomized to a psychosocial intervention delivered over the telephone reported significant improvements in global well-being, quality of life, and social support. The intervention was associated with improvements in important areas of psychosocial functioning and also prevented the declines in quality of life that were seen in patients receiving UC. Because these psychosocial factors have been linked to posttransplant psychological distress, noncompliance, and survival, these improvements could favorably impact posttransplantation outcomes. A larger, appropriately powered, randomized study is currently underway to test this hypothesis and to determine whether a telephone-based psychosocial intervention can significantly reduce pretransplant anxiety and distress, and improve postoperative survival in lung transplant recipients.

The following are the INSPIRE investigators: James A. Blumenthal, PhD (Director, Behavioral Medicine); Robert Carney, PhD (Co-director, Behavioral Medicine); R. Duane Davis, MD (Surgical Director); Scott M. Palmer, MD (Medical Director); Michael Babyak, PhD; Francis Keefe, PhD; Kenneth Freedland, PhD; Elizabeth Gullette, PhD; Joel Hughes, PhD; Kari Merrill, PhD; Melissa Napolitano, PhD; Jennifer Norten, PhD; Priti Parekh, PhD; Victor Tapson, MD; and Elbert Trulock, MD.

PQLS

Responses are rated on a 5-point Likert-type scale, as follows: 1, not at all; 2, rarely; 3, sometimes; 4, occasionally; and 5, most of the time.

Instructions:

The items listed below are different feelings and activities. Think about how your lung disease has affected you over the past month and rate each of these items using the scale below.

  1. I am able to walk up a flight of stairs without getting winded.

  2. I am able to walk one block without getting winded.

  3. I can run a short distance (eg, 0.25 mile) without getting winded.

  4. I can lift heavy objects without getting winded.

  5. I have been feeling down, blue, or depressed.

  6. I have experienced feelings of panic.

  7. I have been worrying more than usual.

  8. I am able to enjoy things as I am used to.

  9. Because of my lung disease I have had to limit my household activities (eg, cooking and cleaning).

  10. I am able to bathe and dress myself.

  11. I am able to do moderate household work (eg, vacuuming and sweeping floors).

  12. I am able to do light housework (eg, dusting and washing dishes).

  13. Because of my lung disease, I have had to limit many of the activities that I enjoy.

  14. With my lung disease, I am able to go on trips (eg, away for the weekend).

  15. Because of my lung disease, the weather (either too hot or too cold), has affected my activities more than it used to.

  16. Because of my lung disease, I limit the amount of time I spend out of the house or in crowds.

  17. With my lung disease, I have had the energy to engage in sexual relations.

  18. With my lung disease, I have not had the energy to engage in sexual relations.

  19. Because of my lung disease, I have noticed that my family is more protective and doesn’t let me do as much as I’d like.

  20. Because of my lung disease, I have felt like a burden on my family and friends.

  21. Because of my lung disease, I have had to decrease the number of hours I work.

  22. Projects or tasks at work take longer to finish than they used to.

  23. I have been embarrassed by coughing in public.

  24. I have been self-conscious about my heavy breathing.

  25. I have felt bad that I have not been able to do as many activities as I would like because of my lung disease.

Transplant and General Social Support Scale

Responses are rated on a 4-point Likert-type response scale: 1, not at all; 2, somewhat; 3, moderately; and 4, very much.

Instructions:

We would like to know which people in your life provide you with psychological support. Please answer all of the questions on the following pages by circling the answer that you think most nearly applies to you. It is important that you answer all the questions.

I feel supported by:

  1. My family

  2. My friends

  3. My neighbors

  4. Clergy (eg, priest, minister, or rabbi)

  5. Members of the church

When interacting with the transplant team, I feel supported by:

  1. Pulmonologist

  2. Transplant surgeon

  3. Nurse coordinator

  4. Psychologist

  5. Social worker

Abbreviations: ANCOVA = analysis of covariance; GHQ = general health questionnaire; MANCOVA = multivariate analysis of covariance; PQLS = pulmonary-specific quality-of-life scale; SF-36 = short form-36; SI = special intervention; UC = usual care

Supported by grant LH-007 from the North Carolina Affiliate of the American Lung Association, and from grants MH49679, HL49572, HL 43028, and HL65503 from the National Institutes of Health.

Figure Jump LinkFigure 1. Flow chart of study participants.Grahic Jump Location
Table Graphic Jump Location
Table 1. Sample Characteristics*
* 

Dx = diagnosis; CF = cystic fibrosis; PPH = primary pulmonary hypertension.

 

Values given as mean (SD).

 

Values given as No. (%).

Table Graphic Jump Location
Table 2. Pretreatment and Posttreatment Values for GHQ Subscales*
* 

Values given as mean (SD), unless otherwise indicated.

Table Graphic Jump Location
Table 3. Pretreatment and Posttreatment Values for Quality-of-Life (SF-36) Subscales*
* 

Values given as mean (SD), unless otherwise indicated.

Table Graphic Jump Location
Table 4. Pretreatment and Posttreatment Values for Subscales of the PQLS*
* 

Values given as mean (SD), unless otherwise indicated.

Figure Jump LinkFigure 2. Perceived social support for UC and SI treatment groups at baseline (ie, before treatment) and following 8 weeks of treatment (ie, after treatment).Grahic Jump Location

This research was performed at Duke University as the first author’s doctoral dissertation in partial fulfillment for a doctoral degree in clinical psychology under the direction of the senior author. The authors thank Jessica Gibson for her help with the data collection and management. In addition, the authors would like to recognize Robert Carson, PhD, and Francis Keefe, PhD, for serving on the first author’s dissertation committee.

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Jalowiec, A, Grady, KL, White-Williams, C Stressors in patients awaiting a heart transplant.Behav Med1994;19,145-153. [PubMed]
 
Mai, FM, McKenzie, FN, Kostuk, WJ Psychosocial adjustment and quality of life following heart transplantation.Can J Psychiatry1990;35,223-227. [PubMed]
 
Schweizer, RT, Rovelli, M, Palmeri, D, et al Noncompliance in organ transplant recipients.Transplantation1990;43,374-377
 
Shapiro, PA, Williams, DL, Foray, AT, et al Psychosocial evaluation and prediction of compliance problems and morbidity after heart transplantation.Transplantation1995;60,1462-1466. [PubMed]
 
Cohen, L, Littlefield, C, Kelly, P, et al Predictors of quality of life and adjustment after lung transplantation.Chest1998;113,633-644. [PubMed]
 
Dew, MA, Simmons, RG, Schulberg, HC, et al Psychosocial predictors of vulnerability to distress in the year following transplantation.Psychol Med1994;24,929-945. [PubMed]
 
Hirth, AM, Stewart, MJ Hope and social support as coping resources for adults waiting for cardiac transplantation.Can J Nurs Res1991;26,32-47
 

Figures

Figure Jump LinkFigure 1. Flow chart of study participants.Grahic Jump Location
Figure Jump LinkFigure 2. Perceived social support for UC and SI treatment groups at baseline (ie, before treatment) and following 8 weeks of treatment (ie, after treatment).Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1. Sample Characteristics*
* 

Dx = diagnosis; CF = cystic fibrosis; PPH = primary pulmonary hypertension.

 

Values given as mean (SD).

 

Values given as No. (%).

Table Graphic Jump Location
Table 2. Pretreatment and Posttreatment Values for GHQ Subscales*
* 

Values given as mean (SD), unless otherwise indicated.

Table Graphic Jump Location
Table 3. Pretreatment and Posttreatment Values for Quality-of-Life (SF-36) Subscales*
* 

Values given as mean (SD), unless otherwise indicated.

Table Graphic Jump Location
Table 4. Pretreatment and Posttreatment Values for Subscales of the PQLS*
* 

Values given as mean (SD), unless otherwise indicated.

References

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Jalowiec, A, Grady, KL, White-Williams, C Stressors in patients awaiting a heart transplant.Behav Med1994;19,145-153. [PubMed]
 
Mai, FM, McKenzie, FN, Kostuk, WJ Psychosocial adjustment and quality of life following heart transplantation.Can J Psychiatry1990;35,223-227. [PubMed]
 
Schweizer, RT, Rovelli, M, Palmeri, D, et al Noncompliance in organ transplant recipients.Transplantation1990;43,374-377
 
Shapiro, PA, Williams, DL, Foray, AT, et al Psychosocial evaluation and prediction of compliance problems and morbidity after heart transplantation.Transplantation1995;60,1462-1466. [PubMed]
 
Cohen, L, Littlefield, C, Kelly, P, et al Predictors of quality of life and adjustment after lung transplantation.Chest1998;113,633-644. [PubMed]
 
Dew, MA, Simmons, RG, Schulberg, HC, et al Psychosocial predictors of vulnerability to distress in the year following transplantation.Psychol Med1994;24,929-945. [PubMed]
 
Hirth, AM, Stewart, MJ Hope and social support as coping resources for adults waiting for cardiac transplantation.Can J Nurs Res1991;26,32-47
 
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