To the Editor: Mr. A, in the clinical case conference by Stephanie M. Le Melle, M.D., M.S., and Charles Entelis, M.D. (1), is one of many patients with schizophrenia, schizoaffective disorder, and bipolar disorder who have undergone heart transplantation at New York Presbyterian Hospital–Columbia University Medical Center. The case conference provided an opportunity to reflect on what psychiatric consultants to heart transplant programs have learned about helping patients with severe mental illness and other psychosocial risk factors achieve successful heart transplant outcomes.

First, some psychiatric disorders and psychosocial variables do have an effect on transplant outcomes. Recent substance abuse, severe personality disorders, poor global function, and an avoidant coping style predict worse outcomes (2, 3). Second, in some cases, even high-risk patients can do well with expert management. Third, especially in such cases, good family support is invaluable. Fourth, a longitudinal relationship with the transplant team provides an opportunity to assess and modify psychosocial risks much better than evaluation at a single moment in time. Mr. A was undoubtedly a high-risk patient, but he had the benefit of devoted and expert psychiatric care, time to develop a relationship with his transplant cardiologist, and superb support from his family.

I would demur on one point made in the report. There has been no shortage of previous experiences with the development or exacerbation of psychosis in patients after transplantation who were receiving a high dose of corticosteroid immunosuppressant therapy. The role of steroids in precipitating psychosis and mood disorders in heart transplant recipients has been described repeatedly since the late 1960s (4–6).

As we noted previously (2), the presence of psychosocial risk factors should not be reason to prejudicially deny care; rather, it should stimulate efforts to mitigate these risks to provide the best possible care and outcome.