Living donor liver transplantation is an alternative for patients in need for liver transplantation who are not likely to receive a cadaveric donor for liver transplant in a timely manner. There are a few studies, which evaluated both the preoperative and postoperative psychological statuses of liver donors [11]. Consequently, our study aimed to evaluate the psychiatric morbidity and the associated risk factors in a sample of Egyptian liver donors preoperatively and 3-months post donation.
Psycho-demographic characteristics of Egyptian living donor liver transplantation
Our demographic information of donors was approximately similar to those reported in previous studies [23, 24, 25]. However, there were some differences as regards the donor’s gender as the majority of the actual donors in our study were males (69.7%) compared to (30.3%) females. This gender disparity was non-congruent with a previous study in which women had a higher motivation and readiness for life organ donation [11]. In a study done by Chan and his colleagues [26], the actual donors in their series were females and most of them were wives of the recipients.
Donation patterns had consistently showed a greater number of women as living donors than men, especially in most of the western countries. Herman and his colleagues [27] found that there were more male than female donors in eight countries (Japan, Korea, Egypt, Saudi Arabia, Spain, Turkey, Germany, and the USA), with a proportion higher than 70% of male donors was observed in three countries only (Egypt, Saudi Arabia, and Korea).
Two thirds of our donors were married, which may reflect the degree of social support provided by family members. We were in agreement with Erim and his coworkers [11] who found that when family members in Germany were involved and gave all possible support to donors, the mean values of anxiety and depression were much reduced.
In the current study, a considerable percentage (42.4%) received technical education and (30.3%) were university graduates, (9%) were illiterate, and the rest received different types of non-university education. We believed that educational level can affect the degree to which the donors grasp and understand the information given to them about surgical details and this could allow them to communicate their decision better with the transplant team.
Relation of donors to recipients
The reported dynamic factors underlying a donor’s motivation included the social environment, the relationship to the recipient, and the donor’s personal attitude and benefits [28]. Many donors are blood-related to the recipients. This was already assumed because those donors have close emotional ties to the recipients, and the matching of the genetic materials is often successful [27].
Surprisingly, in our research, 42.2% of the actual donors were volunteers who had no close or remote relation to the recipients; unfortunately, we did not study thoroughly their motivation to donate; thus, we were not able to clarify the reasons for their altruistic attitudes. Moreover, in some western communities, a considerable percentage of donors were not blood-related [27].
In an Egyptian study [8], it was stated that donation of the non-relative recipient is a complex procedure. It identified donors who justified their will to donate by their religious beliefs. Informed consent is very important, and ethically speaking, it is necessary to exclude financial inducement before donation, as the primary selection criterion for a living liver donor should be volunteerism not being vendor donors.
Spouses are the most common “voluntary living donors” for adult recipients in Europe and Asian [27, 29, 30]. Surprisingly, none of our recipients received the donation from their spouses. This point will need further studying from a cultural perspective. In our study, those who donated to their fathers were 21.2%, their mothers 3%, and sibs 12.1%. The motivation behind this donation is simply understood by their strong emotional relation and bonding to their family members and their wish to keep their beloved ones alive. We are in agreement with previous authors who ascribed donation to parents as a way to express love and gratitude, for whom it is considered a salvation step to relieve them from suffering [8].
Satisfaction with the decision to donate
Findings related to the satisfaction with the decision to donate and willingness to donate again were different; in some centers, the majority of donors confirmed that they would consent to donate once more [25, 31]. In this current study, on asking about the possibility of donating again, 33% of actual donors were willing to donate again yet the majority (67%) reported that they were not willing to due to their experiences of losing their recipients or feeling traumatized shortly after surgery.
Contrary to our findings, previous researchers reported that all donors in their samples would willingly donate again, as they believed they had benefited from the donation, whereas others reported that most of the donors (73.8%) would donate again, 19.2% would not, and 7% did not answer this question [25, 32].
Personality traits of donors
The assessment of personality traits is an essential step in the donation procedure; it may be helpful in explaining whether the donor might be inherently more prone to a psychological sequel or whether the stress of the operation increases the risk of such complications.
Our findings indicate that the personality trait assessment may be helpful to provide necessary psychological support to help donors cope appropriately with the post-surgical stressful situation. Supporting this view, various studies [29, 33, 34] emphasized the importance of assessing the personality of the potential donors prior to the individual’s decision-making to donate; some potential donors with high trait anxiety tended to decide to donate in a “postponement” pattern than a “deliberate” pattern.
In our study, we found that the actual donors did not score higher in D-score of Guilford’s battery, which means that they had no trait depression or inherited susceptibility to depression. On the other hand, our data on personality traits of donors using the EPQ revealed that their mean scores in the EPQ, psychoticism, and impulsivity were higher than those of the published Egyptian norms, which may indicate that they had tendencies to experience negative effect on facing stress. Their impulsivity may reflect that the donation process for them is a personal challenge and an opportunity for an exceptional experience or to initiate life change. Their high scores on neuroticism may reflect their vulnerability to anxiety as was extensively explained by Eysenck and Eysenck [17].
Psychiatric morbidity among Egyptian living donor liver transplantation
There are few data describing long-term psychiatric complications in living liver donor post donation [25]. The infrequent recording of such problems was explained by the absence of careful donor monitoring during long-term follow-up visits.
On the contrary, some studies reported that liver donors reached improved mental well-being in the long-term follow-up period [7, 26, 35, 36]. Other findings reported that donors had an increased rate of psychiatric complications, including depression, anxiety, bipolar disorder, and substance abuse [11].
In the current study using SCID-I for diagnosis of psychiatric disorders according to DSM-IV criteria, 3 months after donation revealed that 15% of the Egyptian actual donors had an Axis-I diagnosis. Our results were consistent with previous findings, which found that the occurrence of post donation depression rates ranged between 0.2 and 15% among donors [37]. Moreover, Gokce and coworkers [32] found that 12.5% of donors had low mood and 6.3% were in need for pharmacological and psychotherapeutic interventions. Other studies showed a lower prevalence reported in Germany (9.3%) [11] and Japan (9.7%) [38]. Different results could be attributed to the socio-cultural quality of living confounding factors and the difference in sampling and methods of assessment.
In our research, major depression and anxiety disorders were by far the commonest diagnostic categories encountered being 6% and 6% respectively. A higher rate of major depression was reported in Japan by Kizilisik and colleagues [39] who found a rate of 7.1% for major depression post donation. However, only one of those donors received antidepressants.
On the other hand, a lower rate of clinical depression was recorded by other investigators with a range from only 3 to 4.9% [24, 38]. These discrepancies may reflect cultural and methodological differences.
Depression reported in donors may reflect their feeling of loss of capacity, helplessness, loss of function, and inability to cope. Anxiety may be due to the fear and threat of the loss of a beloved person. We are in agreement with a previous Egyptian study which considered that the donation is an attempt to become like the recipient by undergoing a similar serious operation [8].
In the current study, the severity of anxiety and depression was generally mild, which necessitates minor psychotherapeutic and pharmacological intervention. It seems mandatory to follow those donors for a longer time after they return successfully back to normal life and to decide whether their symptoms will persist or not.
On elucidating the predictive risk factors associated with psychiatric morbidity in our study, we found that being a female was a risk for developing psychiatric disorders. This notion agrees with various studies’ findings [11, 36, 40]. It could be explained by their gender-related anxiety and heightened stress upon their responsibilities towards their homes.
In our study, young donors were more prone to develop psychiatric morbidity. Similarly, previous studies found that donors under the age of 55 were subjected to more health-related stressors, while donors aged from 55 to 60 years of age were found to have significantly better mental health [29].
Having secondary educational level was statistically significantly correlated with psychological symptoms in both univariate and linear regression analyses in our research. This is similar to results of a study by Erim and colleagues [11]. This may be attributed to the fact that persons with low educational level were less confident, and they could not handle the physical, mental, and financial burdens of organ transplantation.
Regarding personality traits of donors, we found that having high scores in psychoticism, neuroticism, and impulsivity was correlated with the development of psychiatric morbidity, which was statistically significant in both univariate and linear regression analysis. Nevertheless, extraversion proved to be highly significant on using linear regression analysis. Other studies showed that low extraversion scores were linked to emotional distress and anxiety; specifically social phobia [23, 41].
It is worth mentioning that individuals with high neuroticism had low activation thresholds, were unable to inhibit or control their emotional reactions, and experienced negative effect in the face of minor stressors; hence they were more liable to anxiety under stress. On the other hand, those with high psychoticism had tough-mindedness, suspiciousness, recklessness, hostility, anger, and impulsiveness that made them more prone to develop psychiatric illness [24]. Moreover, donors who scored high in impulsivity automatically responded to donate to save their loved ones’ lives, and this might be conflicting with their family fears and work responsibilities, which caused additional stress on them that increased their tendency to experience psychological symptoms.
