Psychiatric Assessment for Fitness for Organ Donation

I. Who Performs the Assessment

• Consultation-liaison psychiatrist, transplant psychologist, or master's-level licensed clinical social worker (LICSW)
• The donor must be seen independently (alone, without the recipient or recipient's family present) to allow free disclosure
• An Independent Living Donor Advocate (ILDA) - separate from the transplant team - may also participate to protect the donor's interests

II. Standard Format of the Psychiatric Assessment

A. Pre-Assessment Preparation

1. Review all available records: medical history, prior psychiatric records, substance use history, legal records
2. Use standardized instruments alongside the clinical interview
3. Standard tools include:
   • SIPAT (Stanford Integrated Psychosocial Assessment for Transplant) - most widely validated
   • PACT (Psychosocial Assessment of Candidates for Transplant)
   • TERS (Transplant Evaluation Rating Scale)
   • PHQ-9 / PHQ-2 for depression; GAD-7 / BAI for anxiety
   • MMSE or MoCA for cognitive screening
   • DAST (Drug Abuse Screening Test); CAGE-AID for substance use

B. Structure of the Interview

III. Key Assessment Points (SIPAT Domains)

Domain A: Patient Readiness Level

Domain B: Social Support System

Domain C: Psychological Stability and Psychopathology

Domain D: Lifestyle and Effect of Substance Use

IV. SIPAT Score Interpretation

V. Specific Points for Living Donor Assessment

1. Voluntariness - donation must be free of coercion, guilt, financial pressure, or obligation
2. Donor motivation - altruism vs. obligation vs. expectation of relationship change
3. Understanding of risks and benefits - both for self and recipient; understand the permanent nature of donation
4. Donor-recipient relationship - duration, closeness, nature; internet/social media only relationships require further evaluation
5. Coercion screening - employer/employee, family pressure, faith community, past debts, financial dependency
6. Ability to cope with major surgery - coping style, prior trauma, resilience
7. Employment and family impact - financial readiness, time off work, care of dependents
8. Post-operative support - availability of post-operative care, transportation, care at home
9. Consistency with prior beliefs/behaviors - history of altruistic acts, values alignment
10. Experience with grief and loss - in case the recipient dies; donor must be prepared for this possibility
11. Ability to withdraw - must be reinforced that the donor can withdraw at any point up until anesthesia, without consequence

VI. Psychiatric Contraindications to Listing

Absolute Contraindications

• Active suicidal or homicidal ideation
• Active psychosis (untreated)
• Dementia (severe/advanced)
• Personality disorder severely impeding collaborative work with the transplant team
• Persistent absence of adequate social support
• Active illicit substance use with failure to engage in treatment
• Active non-compliance with medical treatment (documented, sustained)

Relative Contraindications (may defer, not automatically exclude)

• Recent substance use (typically require 6 months abstinence minimum, 2 years for alcohol-related organ failure at many centers)
• Unstable psychiatric illness currently responding to treatment
• Mild-moderate cognitive impairment
• Moderate personality psychopathology with some treatment interfering traits
• Inadequate social support with potential to be remediated

VII. Post-Assessment Recommendation Format

1. Patient identification and referral context
2. Method (clinical interview, sources reviewed, instruments used with scores)
3. Relevant history (psychiatric, substance use, medical, social, occupational)
4. Mental status findings
5. Formulation - synthesizing psychiatric risk and protective factors
6. Psychiatric diagnoses (DSM-5 format, if applicable)
7. Specific risk factors identified (SIPAT domains)
8. Recommendation - one of:
   • Clear for listing
   • Conditional clearance (with specified conditions, e.g., sobriety contract, psychiatric treatment, re-evaluation date)
   • Deferral (with plan for re-evaluation)
   • Not a candidate at this time
9. Treatment recommendations if psychiatric issues require management pre/post-transplant
10. Follow-up plan

VIII. Special Populations / Additional Considerations

• Substance use disorder (especially alcohol-related liver disease): Document sobriety period, substance use disorder treatment, relapse prevention plan, insight, and social supports. SALT score used for early liver transplant in alcoholic hepatitis.
• Depression/anxiety: Assess severity, prior treatment response, current stability. Pre-transplant depression is a strong predictor of post-transplant non-adherence and mortality.
• Personality disorders: Assess impact on capacity to collaborate with team, impulsivity, history of non-adherence.
• Cognitive impairment: MoCA/MMSE. Mild impairment may be acceptable with adequate caregiving support; severe impairment is a contraindication.
• Pediatric donors: Additional safeguards; assent and parental consent; best-interest standard.

• Kaplan & Sadock's Comprehensive Textbook of Psychiatry, Section 27.13 (Organ Transplantation), pp. 7366-7388
• Stanford Integrated Psychosocial Assessment for Transplant (SIPAT) - Maldonado et al., Psychosomatics 2012
• Academy of Consultation-Liaison Psychiatry (ACLP) How-To Guide: Transplantation (Soeprono & Zimbrean, 2020)
• Meyer et al., Comprehensive Assessment of Solid Organ Transplant Recipients - BWH/MGH CME 2025

Psychiatric Clearance Certificate for Organ Donation - Indian Guidelines

Legal Basis (THOTA 1994, Amended 2011; Rules 2014)

Key Legal Provision (Mohan Foundation / THOA Review Committee): "Psychiatrist clearance would be mandatory to certify the donor's mental condition, awareness, absence of any overt or latent psychiatric disease, and ability to give free consent." - This applies mandatorily for unrelated/other donors going before the Authorisation Committee (AC), and is strongly recommended for all living donors.

Format of the Psychiatric Clearance Certificate (India)

PSYCHIATRIC FITNESS CERTIFICATE FOR ORGAN DONATION

• Information obtained from: Donor (interview), family members (name), case records, treating physician's summary

1. Identity verification - Donor identity confirmed; relationship with recipient confirmed
2. Competence assessment - Capacity to consent evaluated
3. Understanding of procedure - Assessed for knowledge of:
   • The organ/tissue to be donated
   • The surgical procedure and its risks
   • Short-term and long-term implications for donor health
   • Alternatives to donation
4. Motivation for donation - Assessed; nature of motivation documented (altruistic / familial / other)
5. Voluntariness - Assessed for presence/absence of coercion, undue pressure, financial inducement
6. Psychiatric history - Past and present
7. Substance use history - Alcohol, tobacco, illicit substances
8. Mental Status Examination (MSE) - Full MSE conducted

• Understands the information: Yes / No
• Retains the information: Yes / No
• Weighs the information: Yes / No
• Communicates a decision: Yes / No

• Evidence of coercion: Present / Absent
• Evidence of financial inducement: Present / Absent
• Evidence of undue family/social pressure: Present / Absent

• Current diagnosis: _______________
• Past diagnosis: _______________
• On treatment: Yes / No - Medication: _______________

1. The donor is / is not mentally competent to give informed consent for organ donation.
2. The donor is / is not free from any overt or latent psychiatric illness that would preclude donation.
3. The donor's consent is voluntary / not voluntary.
4. The donor does / does not have any active substance use disorder.
5. The donor is / is not psychiatrically fit to donate the organ in question.

Key Points Required Under Indian Law (Mandatory Certification Points)

1. Mental condition - Assessment of current and baseline mental state
2. Awareness - The donor is aware of what they are consenting to
3. Absence of overt psychiatric disease - No active psychosis, severe depression, mania, delirium
4. Absence of latent psychiatric disease - No subclinical illness likely to impair capacity
5. Ability to give free consent - No coercion, no cognitive impairment, no undue influence

Donor Categories and Who Goes Before the Authorisation Committee

IPS Recommended Instruments (Indian Context)

Practical Notes for Indian Psychiatrists

• The certificate must be on hospital/institution letterhead, signed with MCI/state council registration number and official seal
• For unrelated donors, the psychiatrist's certificate is submitted as part of Form 11 (Application for Approval of Transplantation from Living Donor) to the Hospital Authorisation Committee
• The Authorisation Committee interviews the donor at least twice with a gap of time between interviews before approving unrelated donors
• Psychiatric clearance is required before the AC meeting, not after
• A short narrative format (not just check-boxes) is preferred by ACs to allow them to understand clinical reasoning
• If there is any psychiatric disorder - even treated and stable - it must be declared and managed, not concealed; the opinion can still be "fit to donate" with appropriate qualification

• Sarkar S, Grover S, Chadda RK. "Psychiatric assessment of persons for solid-organ transplant." Indian J Psychiatry 2022;64:S308-S318 (IPS guidelines, PMC9122170)
• Transplantation of Human Organs and Tissues Act (THOTA), 1994 (as amended 2011); THOTA Rules, 2014
• THOA Review Committee Report (Authorisation Committee conditions)
• NOTTO Forms 1-11 (notto.mohfw.gov.in)
• Anil Kumar BN, Mattoo SK. "Organ transplant & the psychiatrist: An overview." Indian J Med Res 2015;141:408-416