Psychosomatics 40:212-221, June 1999
© 1999 The Academy of Psychosomatic Medine
PTSD in Heart Transplant Recipients and Their Primary Family Caregivers
Arthur A. Stukas, Jr., Ph.D.,
Mary Amanda Dew, Ph.D.,
Galen E. Switzer, Ph.D.,
Andrea DiMartini, M.D.,
Robert L. Kormos, M.D., and
Bartley P. Griffith, M.D.
Received June 16, 1998; revised September 10, 1998; accepted November 6, 1998. From the Departments of Psychiatry, Psychology, Epidemiology, Medicine, and Surgery, University of Pittsburgh School of Medicine and Medical Center. Address correspondence and reprint requests to Dr. Stukas, Department of Psychology, University of Northern Colorado, McKee Hall, Greeley, CO 80639; e-mail: aastuka{at}bentley.unco.edu
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ABSTRACT
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Posttraumatic stress disorder associated with transplantation (PTSD-T) is a complication for some heart transplant recipients. By using a structured, standardized interview and DSM-III-R criteria, the authors examined whether recipients (n=158) and their family caregivers (n=142) showed similar PTSD-T rates and clinical characteristics during the first year posttransplant. Among the recipients, 10.5% met full criteria for the disorder and an additional 5% were probable cases. Among the caregivers, 7.7% met full criteria and an additional 11.0% were probable cases. Severity and duration of disorder were similar across the groups. Being female, having a history of psychiatric illness, and having lower friend support were increased risks for PTSD-T.
Key Words: Posttraumatic Stress Disorder • Transplants
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INTRODUCTION
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As a therapeutic option for patients with chronic end-stage heart disease, transplantation is now routinely performed and successfully prolongs life for most individuals. A recent review of the literature reported that not only do transplant recipients live longer than would otherwise be expected, but they also, on average, have improved quality of life.1 Yet the procedure is not without risks, and patients may experience significant psychological distress and behavioral difficulties in coping with the medical regimen even in the long-term after receiving a new heart.2
Posttraumatic stress disorder related to the transplant (PTSD-T) is a complication for some heart recipients.3 Given the life-and-death consequences of transplantation and the often long wait for a donor heart, it should come as no surprise that some recipients experience psychological trauma and its aftereffects. Indeed, the whole process of heart transplantation embodies a core element of PTSD, namely, that it is "outside the range of usual human experience" and for most recipients it involves a variety of distressing features.4 For example, heart recipients often describe the wait for a donor heart as an extremely stressful period that sometimes brings them to the brink of despair. Many experience guilt associated with the fact that another person must die for them to live. In our study, this was especially true for one recipient who received a heart from a sibling who met with a sudden, tragic accident.
Although the revised third edition of DSM-III-R5 specifically excluded chronic illnesses from among the traumatic events that might elicit PTSD, Alter and her colleagues6 demonstrated that a significant percentage of cancer survivors exhibited the re-experiencing, avoidance, and arousal symptoms that are characteristic of PTSD; 26% met all criteria for current or lifetime diagnoses of PTSD. Now, partly because Alter et al. performed their study as part of the field trials to aid revisions to the DSM, DSM-IV7 has modified the diagnostic specifications for PTSD to include chronic illness as a trauma that can potentially lead to the disorder.
Of course, many of the traumatic aspects of heart transplantation are not experienced by recipients alone. Family members and friends may feel great concern and even intense anxiety at the possibility of losing a significant other. For those who are responsible for the care and well-being of the recipient (often a spouse or parent), the anxiety might reach the traumatic levels associated with PTSD. Although family caregivers do not directly experience a life-threatening medical problem, both DSM-III-R and its successor acknowledge that threats to close others may be sufficiently traumatic to elicit PTSD. This inclusion is substantiated by recent research by Pelcovitz et al.,8 which found PTSD in mothers of pediatric cancer survivors.
Although individuals who are "indirectly" affected by traumatic events may experience PTSD, DSM-IV suggests "the likelihood of developing this disorder may increase as the intensity of and physical proximity to the stressor increase" (p. 424).7 As caregivers and recipients do vary in their proximity to the stress of transplantation, with recipients being decidedly closer to the threat, we might expect there to be lower rates of PTSD in caregivers than in recipients. By explicitly comparing transplant recipients and their caregivers on both rates of PTSD and levels of PTSD-related symptomatology, our study provides an empirical test of DSM-IV's "proximity hypothesis."
The current study is part of a research program designed to examine the relationships between physical and mental health in heart transplant recipients and their caregivers. Participants were interviewed about 2 months, 7 months, and 12 months after the surgery. In addition to examining the prevalence of PTSD related to the transplant experience (PTSD-T), we investigated the role of several potential risk factors for PTSD-T. These included measures of personal psychiatric history, family psychiatric history, social support, mastery, and demographic characteristics.
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METHODS
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Respondents
Heart transplant recipients (N=196) from the Cardiothoracic Transplantation Program at the University of Pittsburgh Medical Center were enrolled in a prospective study of health long-term posttransplant. Recipients were eligible for participation if they were adults (age 18 and above) and had survived beyond the initial posttransplant recovery period (the first 6 weeks after surgery). Eligible recipients were initially contacted between September 1989 and December 1995; the refusal rate was 4.6%. During the first year after transplantation, 15 recipients died (7.7%) and 23 refused one or more follow-up interviews (11.7%).
Each recipient was also asked to identify his or her primary family caregiver so that we could contact him or her for inclusion in the study. Of the 196 recipients, 14 reported that they had no primary caregiver or no consistent primary caregiver (2 of these recipients later died). Six caregivers refused to participate in the study. Of the 176 caregivers who were enrolled in the study, 15 caregivers (8.5%) were not followed through 12 months posttransplant because they (n=2) or their recipients (n=13) died, and 19 other caregivers refused follow-up interviews (10.8%).
Table 1 presents background, health-related, and psychosocial characteristics for all recipients and caregivers enrolled in the study, for the panel subgroups, and for the groups that left the study. Chi-square analyses suggest that panel members and those with incomplete follow-up were similar; not surprisingly, however, the recipients who later died had significantly lower pretransplant cardiac output (i.e., they were more gravely ill) than other recipients. Those who refused later interviews were more likely to have higher cardiac output than panel respondents. In addition, both the recipients and caregivers who left the study had somewhat higher family income than the panel participants. A large majority (85.8%) of the recipients named their spouses as their primary caregivers; the remainder were cared for primarily by a mother or daughter.
This Pittsburgh cohort is very similar to the International Society for Heart and Lung Transplantation Registry of adult heart transplant recipients worldwide during the study enrollment period9,10 in terms of the proportion with cardiomyopathies (86.7% vs. 93.0% in the registry) and the proportions of men (82.7% vs. 81.0% in the registry), and of persons less than age 50 (43.4% vs. 51.0% in the registry).
Procedure
After informed consent was obtained, individual 90- to 120-minute face-to-face interviews were conducted with the respondents. These occurred when the respondents returned for outpatient transplant team evaluations at 2, 7, and 12 months posttransplant. These interviews were conducted by clinically trained interviewers who had master's or doctoral degrees in a mental health discipline. Interviewers participated in an intensive, comprehensive training program before conducting interviews, and interrater reliability was monitored throughout the project.
Instruments
PTSD-T.
PTSD-T was assessed at 12-months posttransplant with the Michigan version of the WHO (World Health Organization)/ADAMHA (Alcohol, Drug Abuse, and Mental Health Administration) Composite International Diagnostic Instrument (CIDI.)11 The PTSD module of the CIDI yields a diagnosis of the disorder based on DSM-III-R criteria. In the present study, PTSD was assessed only with regard to stressor events that comprise the transplant process. Thus, the stem question in the PTSD module referrred to transplant-related stressors rather than all possible stressors that persons may have experienced in their lifetime. (After the assessment, they were, however, queried about their lifetime exposure to the full list of stressors included in the CIDI). The respondents were classified as definite PTSD-T cases, according to the DSM, if they reported the following for a period of at least 1 month: 1) persistently re-experiencing the traumatic event in at least one of four possible ways (e.g., recurrent nightmares about the transplant); 2) persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness, as indicated by the presence of three of seven possible symptoms (e.g., efforts to avoid thinking about the transplant); and 3) persistent increased arousal, as indicated by the presence of two of five possible symptoms (e.g., difficulty concentrating). We also classified persons as probable cases of PTSD-T if they either 1) met the duration criteria but were one symptom short in one of the three categories or 2) met the symptom criteria but reported a duration of less than 4 weeks but more than 2 weeks. To examine quantitative differences in symptomatology, as well as the presence or absence of PTSD-T, we also created a variable representing the total number of PTSD-T–related symptoms endorsed by each of our participants.
Potential Risk Factors for PTSD-T
Psychiatric History.
Whether or not respondents had lifetime histories of major depressive disorder (MDD) and generalized anxiety disorder (GAD) prior to transplant was determined at the initial administration of the Structured Clinical Interview for DSM-III-R (SCID).12 Due to difficulties in diagnosing psychiatric disorders in physically ill populations, we adopted a conservative approach to diagnosis of these disorders. As suggested by Cavanaugh,13 we based our diagnoses primarily on affective/cognitive symptoms and used somatic symptoms only to support diagnoses when these symptoms were judged by the interviewer and by us to have been severe, disproportionate to the medical illness, and temporally related to the affective/cognitive symptoms. The respondents were questioned extensively about the nature and severity of any symptoms that they reported. In addition, we examined interview and medical records data on medications taken during the periods in which symptoms were reported.
Family Psychiatric History.
History of psychiatric disorder among first-degree relatives (parents, siblings, and children age 15 and older) was determined with a brief form of the family history section of the Renard Diagnostic Interview.14 The respondents were asked about their family members' history of psychiatric hospitalizations, suicides (or attempts), depression, anxiety, mania, schizophrenic symptomatology, and substance abuse.
Social Supports.
The quality of each recipient's relationship with his or her caregiver was assessed with a 20-item questionnaire modeled on the work of Spanier15 and Pearlin and Schooler.16 An index was created by averaging the items; both recipients and caregivers reported the support they felt from the other in the relationship. Alpha for the present sample was 0.91. Support from other family members was assessed with the cohesion subscale of the Family Environment Scale.17 Items designed to assess respondents' perceptions of the friendliness and supportiveness of members of their family toward each other were averaged to form an index (alpha=0.71 for the sample). Friend support was assessed with 14 items assessing the degree to which respondents felt that they could rely on friends for emotional and practical support.18 Items were averaged to form a summary index (alpha=0.88 for this sample). Median splits were performed on these variables to indicate greater or lesser support.
Coping Strategies and Self-Image.
Three indices of coping style were derived from the respondents' answers to the Coping Checklist,19 for which the respondents focused on what they considered to be the transplant recipient's most serious health problem since initial hospital discharge. Active behavioral coping was the sum of positive responses to six questions (e.g., "consulted a health professional"). Active cognitive coping was the sum of positive responses to eight questions (e.g., "drew on past experiences"). Poorer use of each of these coping strategies was defined as scoring in the lower third of the distributions of these variables (indicating less use of these coping styles). Avoidant coping was the sum of positive responses to six questions (e.g., "ate more to reduce feelings of tension"); poorer coping was defined as being in the upper third of the distribution of this variable (indicating more use of the coping style).
Finally, the 7-item Sense of Mastery Scale16 was used to assess the degree to which the respondents felt that they had personal control over the things that happened to them (alpha=0.80 for the present sample). Low mastery was defined as scoring in the lower third of the distribution on this variable.
Analysis
The 12-month posttransplant prevalence of PTSD-T, its clinical characteristics, and the nature of the precipitating trauma in this sample were determined. To examine the hypothesis that persons more proximal to a trauma will have a greater likelihood of PTSD or a greater number of more intense symptoms, rates of PTSD and its clinical characteristics were compared between recipients (who were, by definition, more proximal to the transplant-related trauma) and caregivers.
Univariate analyses were performed to examine the effects of potential risk factors on PTSD-T diagnostic status and on extent of PTSD-T symptomatology. Based on effect sizes, the most important risk factors emerging from these univariate analyses were then used in hierarchical multiple logistic and linear regression analyses. PTSD-T diagnostic status and extent of symptomatology were regressed upon risk factors shown to be important with regard to each respective outcome.
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RESULTS
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Prevalence and Clinical Characteristics of PTSD-T
The upper section of Table 2 presents the percentages of heart transplant recipients and family caregivers who met criteria for definite or probable PTSD-T. There was no significant difference in the percentages of each group who had definite PTSD-T vs. probable PTSD-T vs. no diagnosis. The small and nonsignificant difference in total PTSD-T prevalence (definite and probable) between the recipients and caregivers also does not support the proximity hypothesis. In fact, the total number of cases was slightly higher in the caregiver group. The caregivers were, however, more likely than the recipients to be assessed as probable cases rather than definite cases,  2=3.88, df=1 P<0.05 (when only cases are considered). It is interesting to note that in only two dyads were both the caregiver and recipient classified as having definite or probable PTSD-T; this association was less than one would expect sheerly on the basis of chance, given the rates of the disorder in recipients and in caregivers, though we know of no easy explanation for this finding. One possible explanation might be that having a spouse or partner with PTSD-T suppresses PTSD-T in the other partner (perhaps because of the necessity of providing extra support), but clearly additional work is needed to understand our observation. We know of no other investigation of patients and partners that has looked at PTSD in both members of the couple, but our findings suggest that it is important to consider it in both.
Clinical characteristics of PTSD-T in probable and definite cases are shown in the lower section of Table 2. The caregivers were significantly more likely to experience immediate onset of their disorder (which we defined as starting on the same day as the upsetting experience), but they did not differ from the recipients in duration of disorder. Nor did the caregivers differ from the recipients in the number and recency of PTSD-T symptoms or the proportions of each group experiencing symptoms within the cardinal clusters required for diagnosis. Rates of seeking professional help and of taking psychotropic medications were also similar for the recipients and caregivers. With regard to the specific element of the transplant experience that the respondents cited as eliciting the traumatic response, both the recipients and caregivers most frequently reported that learning about the need for a transplant and the waiting period for a donor heart were marked stressors.
Risk Factors for PTSD-T
Because the likelihood of PTSD-T was uncorrelated in recipient–caregiver pairs (phi=-0.11, P>0.20), the data from caregivers and recipients were pooled (i.e., considered as independent observations) for subsequent analyses. However, status as a recipient vs. caregiver was included as a variable in analyses of risk factors for PTSD-T.
Univariate Effects.
Categories of potential risk factors applicable to both caregivers and recipients were examined in relation to both diagnosable PTSD-T and PTSD-T symptomatology. The risk factors we examined included variables that have been significantly related to the prevalence of PTSD in other research,20,21,22 such as age, gender, presence of prior traumas, and personal and family psychiatric history. As shown in Table 3, the respondents with PTSD-T were significantly more likely to be female, have a personal history of either MDD or GAD, have lower friend support, and have a lower sense of mastery than the respondents who did not meet criteria. PTSD-T cases were marginally more likely to have a family history of psychiatric disorder and to have a family lower in cohesiveness. Interestingly, the respondents identified as PTSD-T cases were no more likely to report additional prior traumas than were the respondents without PTSD-T.
Table 4 presents data on each potential risk factor's association with the total number of PTSD-T symptoms endorsed by the respondents on the CIDI. The respondents who were female, younger, had a personal history of psychiatric illness, had lower friend support, had a lower sense of mastery, and used more avoidance coping strategies experienced a significantly greater number of the symptoms of PTSD-T. The respondents who reported lower income had marginally more symptoms.
Multivariate Analyses.
To select variables for inclusion in multivariate regression analyses, effect sizes were computed for each of the univariate analyses. Variables that had effects of 0.10 or greater (phi for diagnostic status; r for symptomatology)23 were included in regression analyses. In the first regression, PTSD-T diagnostic status was the dependent variable, and potential predictors included gender, personal psychiatric history, family psychiatric history, friend support, family cohesion, and mastery. A separate factor was also added to indicate whether a given respondent was the heart transplant recipient or the caregiver.
Variables were entered into the logistic regression hierarchically in blocks (see Table 5 for the results). The first block included pretransplant characteristics (study group, gender, personal psychiatric history, and family psychiatric history). Results indicated that the female respondents and respondents with a pretransplant history of MDD or GAD were significantly more likely to experience PTSD-T. On the second block, friend support, family cohesion, and mastery were entered, controlling for Block 1 variables. Lower friend support was associated with a greater risk of PTSD-T. Finally, a third block was added, which consisted of the interactions of each Block 1 variable with each Block 2 variable (e.g., gender by mastery). Two interaction terms were significant. Family cohesion interacted with both personal psychiatric history (Beta=1.77, P<0.05) and family psychiatric history (Beta=2.16, P<0.05) to predict PTSD-T diagnostic status. Specifically, 40% of the individuals who had low family cohesion and a personal history of psychiatric illness had PTSD-T, compared with 10% to 20% of the persons with just one of these risk factors or neither of them. With respect to the family cohesion–family psychiatric history interaction, only 6% of the individuals with high family cohesion and no family history experienced PTSD-T, compared with 20% to 30% of the persons with one or both of these risk factors.
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TABLE 5. Multiple regression results for PTSD-T and PTSD-T symptomatology in a combined sample of heart transplant recipients and their caregivers
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Table 5 also reports results for the linear regression analysis with number of PTSD symptoms (square-root transformed) as the outcome, using a similar hierarchical strategy. Among variables in the first block, only personal psychiatric history had a significant effect on level of PTSD-T symptomatology. In the second block, lower friend support and lower mastery each significantly increased symptomatology levels. All possible interactions between Block 1 and Block 2 variables were entered in the third block. No interaction terms reached statistical significance.
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DISCUSSION
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The present study found similar rates of PTSD-T in heart transplant recipients and their family caregivers, a finding that might not be expected were one to consider the proximity of each of these groups to the trauma of heart transplantation. Nevertheless, not only was the prevalence of PTSD-T similar, but also the characteristic features of the disorder were largely the same across the two groups.
Indeed, our study underscores two recent trends in considering the origins and prevalence of PTSD.6,8 First, it now seems even more clear that events and circumstances that occur in chronic illness can be perceived as traumatic and can lead to PTSD. Further research has shown that, in our cohort of heart transplant recipients itself, diagnoses of PTSD-T were related to subsequent survival.24 Among the recipients who survived the first year posttransplant, those who met criteria for PTSD during that year were over 13 times more likely to be dead by 3 years posttransplant (after controlling for known transplant-related predictors of mortality). Other research also suggests that mental health in chronic illness is related to survival rates.25 Second, caregivers to the chronically ill are also at risk for PTSD. Our study has demonstrated that family caregivers may experience PTSD at rates equivalent to transplant recipients. Indeed, the prevalence and clinical characteristics of PTSD in our study groups were similar to the prevalence and clinical characteristics of PTSD in groups exposed to non-illness–related traumatic events.20,26
Recently, however, Green et al.27 questioned whether the clinical phenomenon (patient response) was really the entity that we mean by a diagnosis of PTSD. She also questioned whether the nature of stressors stemming from chronic illness make them appropriate for use in a PTSD model; specifically, the most traumatizing aspects of chronic illness may involve receiving information (such as a diagnosis of cancer) rather than experiencing tangible physical assault or possibly imminent death. Indeed, the most frequently cited "traumatic event" in our study was the wait for a donor heart, certainly a diffuse rather than discrete event that might not fit the specific criteria of the PTSD model. Nevertheless, denoting these chronic illness-related stressors as traumas does allow researchers to identify PTSD symptoms that often attain levels that are clearly diagnosable as cases, if only these stressors were identified as traumatic events.
As Green et al.27 suggest, different types of chronic illness may yield different rates of PTSD and its symptoms. For example, the breast cancer survivors in Green et al.'s study demonstrated a high rate of distress but a low rate of actual PTSD diagnosis; this is the basis for the argument that these symptoms might not represent what has been called PTSD. Our data suggest, however, that heart transplantation yields higher rates of PTSD. Indeed, by using a structured clinical interview traditionally used to test for PTSD, we found higher rates of symptoms and diagnoses in our study group than Green et al. found in theirs. Even without including our probable cases, we found that 7.7% to 10.8% of our cohorts met full criteria for a diagnosis of PTSD; these prevalance rates are quite similar to the rates of PTSD found in cancer survivors6 and quite a bit lower than the rates of PTSD found in the mothers of pediatric cancer survivors.8 Differences may, of course, be explained by the fact that all of these studies varied considerably in their instruments and methodologies. Nevertheless, we feel it would be premature to suggest that PTSD does not occur as a result of the traumas associated with chronic illness.
Yet even though PTSD-T occurred at a comparatively high rate in our study, it was not a result of the transplant process for all of our heart recipients and their caregivers. Instead, we found that individuals who had a history of psychiatric illness prior to the transplant were more likely to develop PTSD-T and/or its symptoms. The impact of this factor has been noted in studies of PTSD associated with other traumas as well.21,28–30 Although many transplant programs routinely screen the mental health histories of potential recipients, thus allowing this information to be used in easing the adaptation to transplant, this is not a practice applied to caregivers. Our findings suggest that these caregivers also deserve attention from mental health professionals and transplant team members.
We also found that the unique combination of having a personal history of psychiatric illness, plus having a family low in cohesiveness, led to a particularly elevated risk of PTSD-T. Additionally, individuals with families that were both high in cohesiveness and free from a family history of psychiatric illness were less likely to report PTSD-T. This finding suggests that a cohesive and well-adjusted family may provide support that buffers against PTSD-T, whereas a lack of family cohesiveness may serve to exacerbate the effects of preexisting problems (e.g., past psychiatric illnesses). This finding is consistent with recent discussions of the effects of social support (and the lack thereof) on rates of PTSD.29,30 The chronically ill may also be at risk for social isolation from friends and acquaintances, either through their own actions or the actions of those in their social networks.31 Our study suggests that the consequences of such isolation may be severe; PTSD-T and its symptoms were more likely for individuals who reported lower emotional and instrumental support from friends. As others have discussed,25,31 it seems that one focus of assisting the chronically ill and their family caregivers to adapt to the stresses of illness should be the elimination or amelioration of social isolation.
In addition, we found that PTSD-T was more likely for women than for men, even after controlling for the fact that patient vs. caregiver group status was strongly correlated with gender. Thus, the female heart recipients were more likely to report PTSD-T than the male recipients, and the female caregivers were also more likely than male caregivers to report the disorder. This gender difference in rates of PTSD has substantial research support and has been demonstrated to exist over and above any gender differences in rates of exposure to traumatic experiences.20,22 Also, consistent with past research, our study found higher reports of symptomatology in younger individuals than in older individuals21,26 and in individuals with a lower sense of mastery.29,30
Although our study does allow for prospective analyses of the risk factor–PTSD association, it would have been strengthened if we had measured PTSD-T at earlier time points, rather than relying on retrospective reports at 12 months posttransplant. It is worth mentioning, however, that, of those who we classified as having definite or probable PTSD-T, half of the caregivers and a third of the recipients reported having symptoms within the past 30 days. It may also have been useful to have pretransplant measures of symptomatology and other psychosocial variables with which to compare our findings; unfortunately, as we have previously discussed,3 such pretransplant measures—when obtained during the often tumultuous waiting period for a transplant—are likely to provide inaccurate "baseline" data. Finally, our decision to combine recipients and caregivers in our risk factor analyses—justified as it was by our relatively small sample of PTSD-T cases and by the lack of correlation between diagnostic status within recipient–caregiver pairs—may be criticized. Certainly, with a larger sample of each subgroup (recipients and caregivers), it would be advisable to examine possible risk factors that are unique to each. For recipients, these factors pertain to physical health and current status. For caregivers, these factors concern elements of burden and responsibility for the patient. And, of course, it would be valuable to study other important risk factors in both groups, such as the presence or absence of early childhood trauma, that we did not measure.
Despite these limitations, our findings have significant implications for the development of interventions to attenuate the traumatic effects of heart transplantation for both recipients and caregivers. Indeed, even when information about the risk factors attributable to specific recipients and caregivers is unavailable, we hope that increased awareness that PTSD-T is a possible complication for a significant minority of heart transplant recipients and their caregivers will lead to an increased focus on the attenuation of the disorder. However, it seems clear that earlier identification of those with heightened risk, whether from preexisting factors or those related to the psychosocial environment to which recipients and their families return after hospital discharge posttransplant, will go a long way toward improving efforts to monitor, treat, and prevent the symptoms associated with PTSD-T.
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ACKNOWLEDGMENTS
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This research was supported by Grants MH45020 and MH30915 from the National Institute of Mental Health and Grant HL54326 from the National Heart, Lung, and Blood Institute.
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E. Shemesh, R. Keshavarz, N. K. Leichtling, E. Weinberg, A. Mousavi, K. Sadow, J. H. Newcorn, J. Schmeidler, and R. Yehuda
Pediatric Emergency Department Assessment of Psychological Trauma and Posttraumatic Stress
Psychiatr Serv,
September 1, 2003;
54(9):
1277 - 1281.
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M. A. Dew, R. L. Kormos, A. F. DiMartini, G. E. Switzer, H. C. Schulberg, L. H. Roth, and B. P. Griffith
Prevalence and Risk of Depression and Anxiety-Related Disorders During the First Three Years After Heart Transplantation
Psychosomatics,
August 1, 2001;
42(4):
300 - 313.
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ABSTRACT
INTRODUCTION
