Liver transplant candidate with depression and prior alcohol use (MEQ)

(i) Evaluation domains. Structure the interview and collateral across readiness for transplant and lifelong self-management; social support and caregiver plan; psychopathology (current depression, suicide risk, history); substance use history and treatment engagement; lifestyle and health behaviours; cognition/health literacy and capacity for informed consent; and expectations/health beliefs. SIPAT operationalises many of these domains into a stratified risk profile; ISHLT/APM/AST-style recommendations emphasise multidisciplinary, documented process (even though written for cardiothoracic/MCS candidates, the domain logic is examinable across solid organ programmes).[1][2]

(ii) Substance and adherence risk. For alcohol: timeline of use, last drink, insight, treatment dose (programme intensity), triggers, partner drinking, prior relapses, and monitoring plan if listed — without inventing a universal statutory abstinence duration. Meta-analytic data support meaningful post-transplant relapse risk that varies with pre-transplant factors.[5] For adherence: map DNAs, medication-taking history, barriers (energy from depression vs beliefs), and supports; Dew meta-analysis shows nonadherence is common enough to plan for and has identifiable risk factors including psychopathology and poor support.[3]

(iii) Absolute vs relative barriers. Avoid the phrase "psychiatric contraindication" as a global label. High-barrier factors until resolved may include active uncontrolled major psychiatric illness impairing cooperation, active substance use without engagement, or no feasible support for a complex regimen. Relative factors include treated depression, sustained abstinence with structure, and improvable clinic attendance. Centre policy and organ-specific rules apply.[1][5]

(iv) Management plan. Treat depression promptly (psychotherapy and/or antidepressant chosen with hepatic impairment and interaction awareness; monitor suicide risk). Intensify alcohol recovery structure if needed; confirm caregiver plan; education/teach-back on immunosuppression; reduce DNA barriers (transport, appointments clustered); reassess after optimisation; present residual risk transparently to MDT rather than binary "clear/not clear."[1][4]

(v) Evidence anchors. Examples: SIPAT development/outcome linkage (Maldonado); Dew nonadherence meta-analysis; Dew depression/anxiety morbidity-mortality meta-analysis; Dew substance relapse meta-analysis; ISHLT 2018 psychosocial evaluation recommendations.[1][2][3][4][5]