NCPD Article
CJON Writing Mentorship Article

Standard of Care for Psychological Assessment of Patients Undergoing Allogeneic Hematopoietic Stem Cell Transplantation

Brooke E. Trigiani

Carolee Polek

alloHSCT, psychological assessment, psychological distress, quality of life
CJON 2024, 28(1), 71-78. DOI: 10.1188/24.CJON.71-78

Background: Comprehensive care prior to allogeneic hematopoietic stem cell transplantation (alloHSCT) can improve patient outcomes, yet psychological assessment prior to transplantation has been overlooked as a standard of care.

Objectives: This review summarizes the evidence on psychological assessment for patients undergoing alloHSCT and explores the impact of psychological distress and/or psychological disorders on clinical outcomes and overall survival.

Methods: A literature search was conducted using PubMed®, CINAHL®, Embase®, and PsycINFO® for studies focused on psychological screening of patients in the alloHSCT population.

Findings: alloHSCT is associated with patient psychological distress and disorders, which can result in negative outcomes such as poorer quality of life and overall survival. Future studies implementing a validated instrument for psychological assessment may allow for early identification of vulnerable patients undergoing alloHSCT and interventions, which may improve overall outcomes.

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    Because the number of patients who undergo allogeneic hematopoietic stem cell transplantation (alloHSCT) increases annually (Health Resources and Services Administration, 2021), psychological assessment is a valuable component in the standard of care (Dy et al., 2017). Psychological assessment is defined as the process of evaluating an individual’s mental health and behavioral functioning for the purpose of diagnosing or treating a problem, such as psychological distress or psychological disorders (American Psychological Association, 2018b). Psychological distress is defined as a set of painful mental and physical symptoms, which can indicate the beginning of a clinical psychological condition (American Psychological Association, 2018c). Psychological disorders are defined as cognitive and emotional disturbances, or behavioral abnormalities that impair the functioning of an individual (American Psychological Association, 2018a). Consideration of psychological assessment as the standard of care for all patients can help to diagnose and treat psychological distress or disorders. For patients living with cancer, maintaining psychological assessment as a standard-of-care assessment can help to improve overall care (Pirl et al., 2020).

    For patients with hematologic malignancies, alloHSCT is an invasive and traumatic yet lifesaving treatment option. The process of initiating alloHSCT is often an acute life-changing event. Because of the patient’s dire health status, providers will immediately proceed with alloHSCT treatment, starting the patient on induction chemotherapy and searching for a donor (Leukemia and Lymphoma Society, n.d.). For many patients, the only option for survival is undergoing alloHSCT because, left untreated, the life expectancy for patients with hematologic malignancies is about 17 weeks (Amonoo et al., 2019; Röllig et al., 2020), and the mortality rate is one in four patients even after undergoing treatment (Penack et al., 2020). Because alloHSCT has been shown to be an effective treatment for hematologic malignancies (Bittencourt & Ciurea, 2020), the rate of alloHSCTs among patients with cancer is expected to continue to increase over time (Health Resources and Services Administration, 2021). Therefore, oncology nurses can advance the standards of care for patients undergoing alloHSCT by improving components of the alloHSCT care plan, which includes consistent patient psychological assessment.

    The process of conducting an alloHSCT requires chemotherapy and radiation therapy to ablate the existing bone marrow of the patient, with the goal of destroying the diseased immune system. Stem cells that are a match from a donor are harvested for transplantation. The patient is transfused with these donor cells after completing the chemotherapy and radiation therapy regimen, with the intent that the cells will engraft and become the bone marrow, creating a new immune system that cures the malignancy (Vachani, 2022). This treatment is life-altering but can cause numerous complications, including infertility, organ damage, side effects from chemotherapy, graft-versus-host disease, veno-occlusive disease, or even failure to engraft (Amonoo et al., 2019; Kim et al., 2018; Pillay et al., 2014a; Scherer et al., 2021; Vachani, 2022). In the process of delivering comprehensive care to patients undergoing alloHSCT, providers have overlooked patient psychological assessment as a component of this complex, high-stakes treatment (Scherer et al., 2021; Yalvaç et al., 2016).

    Purpose

    The purpose of this comprehensive clinical literature review is to provide oncology nurses with insight into the current standard practice and outcomes of psychological assessment for patients undergoing alloHSCT. For the care of patients undergoing alloHSCT, this review also discusses the status of standardized psychological assessment and identifies the impact of psychological distress and/or psychological disorders on overall survival (OS) rates and alloHSCT outcomes.

    Methods

    A literature search was conducted using PubMed®, CINAHL®, Embase®, and PsycINFO® electronic databases. Exclusion criteria were pediatric patient populations, a focus on primary caretakers of patients undergoing transplantation, and mixed autologous and alloHSCT patient populations with undifferentiated results. Inclusion criteria were patients undergoing alloHSCT; psychiatric and/or psychosocial assessment; and measurable outcomes, such as readmission, mortality, quality of life (QOL), length of stay, nonadherence to medication, and pretransplantation assessments and transplants that occurred in acute care facilities. The date range for the search was 2013–2023, and the initial search identified 93 studies. After reviewing the studies, 9 duplicate studies were removed, 44 were excluded based on a review of the title and abstract, and another 28 were excluded based on the previously defined inclusion and exclusion criteria. Twelve studies were included in the final review (see Figure 1).

    “FIGURE1”

    Findings

    Patients Undergoing alloHSCT and Psychological Distress

    Previous studies of patients undergoing alloHSCT suggest that they are at risk for psychological distress, with lower OS rates and poorer outcomes after transplantation (Harashima et al., 2019; Pillay et al., 2014b; Scherer et al., 2021). In addition, patients who had psychological assessment with poor psychological findings had lower OS rates (Harashima et al., 2019; Pillay et al., 2014b; Scherer et al., 2021). Details of the included studies are presented in Table 1.

    “TABLE1a”

    “TABLE1b”

    For patients undergoing alloHSCT, QOL was negatively associated with psychological distress. For example, Thiele et al. (2020) found that patients with significant fear of disease progression had higher levels of anxiety and depression compared to those with lower fear of disease progression levels, which ultimately affected QOL and mental health. Nelson et al. (2019) reported similar findings, in which patients who had higher levels of anxiety and depression related to their hematologic malignancy had lower levels of well-being. In a study of 39 patients undergoing alloHSCT, Çuhadar et al. (2016) evaluated the relationship between psychological outcomes and resilience by applying the Resilience Scale for Adults and the Brief Symptom Inventory. Psychological symptoms during transplantation included symptoms of obsessive-compulsive disorder, anxiety, and depression, and a statistically significant negative relationship was established between patient resilience and psychological outcomes (Çuhadar et al., 2016). For a sample of patients undergoing alloHSCT, Morishita et al. (2013) evaluated whether gender affected QOL related to psychological status. Study results indicated that men with anxiety and/or depression had worse QOL scores pre- and post-transplantation (Morishita et al., 2013). Identifying similar trends, Pillay et al. (2014a) reported that higher levels of psychological distress correlated with worse QOL scores.

    El-Jawahri et al. (2016) reviewed the impact of inpatient stays on QOL and psychological status and how this affected alloHSCT-related psychological disorder outcomes at six months post-transplantation. In a six-month longitudinal study, Kim et al. (2018) examined QOL and psychological distress and identified fatigue as the primary factor associated with a decrease in QOL. Based on their findings, Kim et al. (2018) suggested further evaluation and treatment for psychological conditions, such as depression, because fatigue can be diagnostic. In addition, the researchers encouraged root cause analysis of fatigue and evaluation for depression in patients undergoing alloHSCT because reducing fatigue can improve symptoms and QOL (Kim et al., 2018). Fatigue has been shown to be a primary presentation of psychological distress in patients undergoing alloHSCT, and studies have suggested a relationship between fatigue and depression in patients undergoing alloHSCT (Kim et al., 2018; Mayo Clinic, 2022; Noyan et al., 2023).

    OS rates and QOL scores have been found to be negatively associated with psychological distress. Previous studies have recommended psychological distress assessment as a strategy to improve OS rates and QOL scores (Çuhadar et al., 2016; El-Jawahri et al., 2016; Kim et al., 2018). Amonoo et al. (2019) emphasized that providers can identify factors that lead to psychological vulnerability. For the alloHSCT population, identifying these factors can provide a foundation for distress reduction interventions, which can improve patient outcomes.

    Most patients undergoing alloHSCT will experience some form of psychological distress (Amonoo et al., 2019). Three longitudinal studies were identified in the current review that investigated patients’ psychological experience prior to transplantation to two years post-alloHSCT. In a study of 67 patients, El-Jawahri et al. (2016) found that 43.3% of patients had depression and 28.4% had post-traumatic stress disorder six months after transplantation. Results from the Kim et al. (2018) study suggest that anxiety was heightened prior to transplantation day and improved over time. Depression rates were highest immediately after transplantation, and for patients who had depression that persisted at the six-month mark, depression was a significant factor that affected QOL.

    Finally, in a sample of 122 patients, Pillay et al. (2014b) reported that 15 (12%) patients had psychological distress prior to the start of transplantation. In a separate study, Pillay et al. (2014a) investigated the relationship between psychological distress and OS; however, the results were incongruent with those in Pillay et al. (2014b) because of study limitations, including the use of a self-reporting tool. To further establish a relationship between psychological distress and OS, future studies can use a validated and unbiased tool (Pillay et al., 2014a). Yalvaç et al. (2016) investigated whether pretransplantation psychological assessment would predict psychiatric consultations during the transplantation period. In their sample of 78 patients undergoing HSCT (n = 37 undergoing alloHSCT), 27% of the sample presented with anxiety, 23% with adjustment disorder, 10% with depression, and 10% with insomnia. Overall, 44% of patients had a psychiatric consultation ordered once, 27% had a consultation ordered twice, and 29% had a consultation ordered three times or more (Yalvaç et al., 2016).

    Psychological Screening of Patients Undergoing alloHSCT

    To date, there is no identified standard of practice for psychological assessment of patients in the alloHSCT population. Studies indicate that psychological disorders can lead to negative outcomes for this patient population (Çuhadar et al., 2016; Harashima et al., 2019; Pillay et al., 2014b; Scherer et al., 2021). In the current review, a variety of validated instruments were used to measure the same concepts across the spectrum of psychological distress in the alloHSCT population. These instruments included an adapted Transplant Evaluation Rating Scale (Scherer et al., 2021), the Hospital Anxiety and Depression Scale (El-Jawahri et al., 2016; Kim et al., 2018; Morishita et al., 2013; Pillay et al., 2014a; Thiele et al., 2020), the Patient Health Questionnaire–9 (Amonoo et al., 2019; Hoodin et al., 2013; Scherer et al., 2021), and the Posttraumatic Stress Disorder Checklist (El-Jawahri et al., 2016).

    Based on this literature review, there is no standardized psychological assessment process for patients undergoing alloHSCT (Amonoo et al., 2019; Harashima et al., 2019; Pillay et al., 2014a, 2014b; Scherer et al., 2021). However, for this patient population, two validated psychological assessment instruments were identified: the Psychosocial Assessment of Candidates for Transplantation scale and the Transplant Evaluation Rating Scale (Harashima et al., 2019; Scherer et al., 2021). In addition, as a standard of care, there is no standardized intervention process for psychological distress in this patient population. The findings from this review also revealed that patients undergoing alloHSCT with poor psychological status had lower OS rates and overall poorer clinical outcomes. Consistent pre-assessment factors correlated with the psychological state of the patient undergoing alloHSCT, which supports the need for a standardized assessment method to identify psychologically vulnerable patients undergoing alloHSCT.

    Discussion

    Psychological assessment is a need for all patient care. The integration of psychological assessment into the standard of care creates a clinical practice that models a comprehensive approach, which can identify and address psychological problems that may affect outcomes for and the experiences of patients undergoing alloHSCT (Dy et al., 2017). Psychological assessment is needed for patients undergoing alloHSCT because collaborative care models involving psychological assessment have become evidence-based care models for all patients, particularly patients with cancer (Dy et al., 2017; Reist et al., 2022). As previously discussed, the nature of an alloHSCT is intensive and sudden, which has led to psychological assessments for this treatment modality being overlooked while delivering comprehensive care during this high-stakes treatment (Scherer et al., 2021; Yalvaç et al., 2016). This comprehensive clinical literature review revealed a lack of standard practice and outcomes for psychological assessment for patients undergoing alloHSCT. In addition, this lack of standard psychological assessment can influence how psychological distress affects OS rates and HSCT outcomes (Harashima et al., 2019; Pillay et al., 2014b; Scherer et al., 2021).

    Nevertheless, this literature review suggests that a standardized process for psychological assessment of patients undergoing alloHSCT may mitigate poor outcomes and improve OS rates (Kim et al., 2018; Morishita et al., 2013; Nelson et al., 2019; Pillay et al., 2014a; Scherer et al., 2021; Thiele et al., 2020). By implementing a standard process, providers can initially assess for predictive factors that are associated with psychological distress and poor HSCT outcomes. Those factors could then be addressed prior to transplantation (Amonoo et al., 2019; Harashima et al., 2019; Pillay et al., 2014b; Scherer et al., 2021; Yalvaç et al., 2016).

    For a standardized psychological assessment process, providers can use validated psychological instruments to assess patients who are candidates for transplantation (Harashima et al., 2019; Scherer et al., 2021). In addition, interventions tailored to patients undergoing alloHSCT can be implemented based on standardized psychological assessment (Amonoo et al., 2019; Çuhadar et al., 2016; Harashima et al., 2019; Kim et al., 2018; Scherer et al., 2021). Data from routine psychological assessment processes for patients undergoing alloHSCT can also contribute to studies that address poor OS rates and QOL outcomes, as well as prevent the development of long-term psychological disorders such as depression and post-traumatic stress disorder (Çuhadar et al., 2016; El-Jawahri et al., 2016; Hoodin et al., 2013; Kim et al., 2018; Morishita et al., 2013; Pillay et al., 2014a, 2014b; Scherer et al., 2021; Thiele et al., 2020).

    Based on the findings from this review, there is a need for an optimal psychological assessment tool for patients undergoing alloHSCT to provide long-term psychological care for this vulnerable patient population (Amonoo et al., 2019). Men may be at higher risk for developing psychological disorders compared to women and may need additional intervention and/or diligent assessment to manage psychological care (Morishita et al., 2013). In addition, improving patient perception of the disease process for alloHSCT may result in improved outcomes and lower levels of psychological distress (Nelson et al., 2019).

    To establish psychological assessment as a standard of care for patients undergoing alloHSCT, pilot studies can use validated assessment tools. Previous studies of validated assessment tools, such as the Psychosocial Assessment of Candidates for Transplantation scale and the Transplant Evaluation Rating Scale, have shown high efficacy and predictive value of psychological distress in patients undergoing alloHSCT (Harashima et al., 2019; Scherer et al., 2021). For psychological assessment of patients prior to alloHSCT, these tools could be implemented in practice as the standard of care. When psychological assessment has been added to the plan of care, patients and providers have responded positively about the process and reported that the process can improve the management of psychological care (Hoodin et al., 2013).

    Limitations

    One major limitation of this review was the limited research available on this topic. Many studies grouped autologous and alloHSCT together, and the focus of the current review was alloHSCT alone rather than autologous HSCT or both. Because patient outcomes are different during the course trajectory for alloHSCT, this review focused on alloHSCT. However, with this focus, the number of studies available to review was limited. In addition, most studies identified in this review were conducted more than 10 years ago; therefore, the results may not represent the current clinical environment of alloHSCT care.

    Implications for Nursing

    Patient advocacy is central to the role of oncology nurses. A process for standardized psychological assessment of patients undergoing alloHSCT can help promote psychological interventions for this vulnerable patient population. This can ensure that such interventions have a positive effect on OS rates and clinical outcomes. As members of the interprofessional team caring for patients undergoing alloHSCT during their inpatient stays, nurses can provide psychological assessment that can support psychosocial interventions to improve OS rates and patients’ QOL post-alloHSCT. By using an alloHSCT standard of care that includes patient psychological assessment, the interprofessional team can advocate for patients and establish treatment for their psychological concerns.

    To establish standards of care that include psychological assessment for patients undergoing alloHSCT, oncology nurses can lead and participate in projects in the clinical setting that validate the application and effectiveness of psychological assessment tools. Based on psychological assessment data collected prior to transplantation, targeted interventions can be developed to address psychological distress and psychological disorders. These interventions can include one-on-one therapy, medication, support groups, Reiki therapy, art therapy, creative writing, and pet therapy, as well as engagement with community support. Oncology nurses can promote these interventions and improve alloHSCT outcomes by advocating for the inclusion of psychological assessment in the standard of care for patients undergoing alloHSCT.

    “IMPLICATIONS”

    Conclusion

    Although it is a curative treatment for hematologic malignancy, alloHSCT is an intensive process that often involves myeloablation of the patient’s bone marrow and a sequela of complications and side effects. Psychological assessment prior to or during transplantation is not a standard of care. With a focus on patients undergoing alloHSCT, this comprehensive clinical literature review revealed a lack of standardized psychological assessment and negative OS and QOL outcomes for patients who experience or develop a psychological disorder during the alloHSCT process. As members of the interprofessional care team for patients undergoing alloHSCT, oncology nurses can establish and implement a standardized psychological assessment process to support the development of effective psychosocial interventions for this vulnerable patient population.

    About the Authors

    Brooke E. Trigiani, RN, MSN, OCN®, is a nurse at the Penn Medicine Hospital of the University of Pennsylvania in Philadelphia; and Carolee Polek, PhD, RN, AOCNS®, BMTCN®, is an associate professor emeritus in the School of Nursing at the University of Delaware in Newark. The authors take full responsibility for this content. The authors were participants in the Clinical Journal of Oncology Nursing Writing Mentorship Program. The article has been reviewed by independent peer reviewers to ensure that it is objective and free from bias. Trigiani can be reached at brooke.trigiani@gmail.com, with copy to CJONEditor@ons.org. (Submitted December 2022. Accepted November 3, 2023.)

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