Deliberate self-harm among adolescent psychiatric outpatients in Singapore: prevalence,nature and risk factors

Background

Deliberate self-harm (DSH) is a prominent mental health concern among adolescents. Few studies have examined adolescent DSH in non-Western countries. This study examines the prevalence, types and associated risk factors of DSH in a clinical sample of adolescents in Singapore.

Methods

Using a retrospective review of medical records, demographic and clinical data were obtained from 398 consecutive adolescent psychiatric outpatients (mean age?=?17.5?±?1.4 years, range?=?13–19 years) who presented at Changi General Hospital from 2013 to 2015.

Results

23.1% (n?=?92) of adolescents engaged in at least one type of DSH. Cutting was the most common type of DSH reported. Females were three times more likely to engage in DSH than males. DSH was positively associated with female gender (odds ratio [OR] 5.03), depressive disorders (OR 2.45), alcohol use (OR 3.49) and forensic history (OR 3.66), but not with smoking behaviour, living arrangement, parental marital status, past abuse or family history of psychiatric illness.

Conclusion

Interventions targeting adolescent DSH should also alleviate depressive symptoms, alcohol use and delinquent behaviours.

     

Parenting style and mental disorders in a nationally representative sample of US adolescents

Purpose

We examined associations between parenting style and past-year mental disorders in a nationally representative cross-sectional survey of US adolescents and whether the associations differed by adolescent demographic characteristics.

Methods

The sample included 6483 adolescents aged 13–18 years who were interviewed for a full range of DSM-IV mental disorders. Parenting style was assessed by adolescent-reported maternal and paternal care and control using items from the Parental Bonding Instrument. We controlled for socio-demographics, parental history of mental disorders, stressful life events, sexual violence, inter-parental conflict, and household composition. We also tested for two-way interactions between parental care and control and adolescent age, sex, and race/ethnicity.

Results

In adjusted models, high maternal care was associated with lower odds of depressive, eating, and behavioral disorders, and high maternal control was associated with greater odds of depressive, anxiety, eating, and behavioral disorders. High paternal care was associated with lower odds of social phobia and alcohol abuse/dependence. High paternal control was associated with greater odds of agoraphobia and alcohol abuse/dependence but with lower odds of attention-deficit/hyperactivity disorder. Associations of maternal and paternal control with anxiety disorders and substance abuse/dependence differed by sex. High paternal care was associated with lower odds of anxiety disorders only among Hispanics and non-Hispanic blacks.

Conclusions

Perceived parental care and control were associated with adolescent mental disorders after controlling for multiple potential confounders. Differential patterns of association were found according to adolescent sex and race/ethnicity. Findings have implications for prevention and intervention programs that incorporate familial contextual factors.

     

The role of parent and offspring sex on risk for externalizing psychopathology in offspring with parental alcohol use disorder: a national Swedish study

Purpose

The substantial literature showing that offspring of parents with alcohol use disorder (AUD) is at increased risk for externalizing psychopathology rarely examines the differential effects of parental and offspring sex. This literature also has other important limitations, such as modest sample sizes and use of unrepresentative samples. Using a large, nationwide Swedish sample, we aim to investigate the roles of parental and offspring sex in externalizing psychopathology among offspring with parental AUD.

Methods

AUD diagnosis and externalizing measures were obtained from national registries. Associations between outcomes and parental AUD were examined using logistic regressions. Parental and offspring sex effects were examined with interaction terms.

Results

Risks for externalizing disorders were increased in sons and daughters with parental AUD, with significant differences between sons and daughters for criminal behavior; maternal AUD had a greater impact than paternal AUD (regardless of offspring sex), but having two parents with AUD increased risk for all outcomes substantially more than having one parent; and maternal AUD increased risk of drug abuse for daughters more than sons, while paternal AUD increased risk of AUD and criminal behavior for sons more than daughters.

Conclusions

Offspring of parents with AUD are at increased risk for externalizing psychopathology. Maternal and paternal AUD differentially affected sons’ vs. daughters’ risks for AUD, drug abuse, and criminal behavior. The transmission of psychopathology within the externalizing spectrum appears to have sex-specific elements.

     

Blood Pressure and Fibrinogen Responses to Mental Stress as Predictors of Incident Hypertension over an 8-Year Period

Background

Heightened blood pressure (BP) responses to mental stress predict raised BP levels over subsequent years, but evidence for associations with incident hypertension is limited, and the significance of inflammatory responses is uncertain.

Purpose

We investigated the relationship between BP and plasma fibrinogen responses to stress and incident hypertension over an average 8-year follow-up.

Method

Participants were 636 men and women (mean age 59.1 years) from the Whitehall II epidemiological cohort with no history of cardiovascular disease and hypertension. They performed standardized behavioral tasks (color/word conflict and mirror tracing), and hypertension was defined by clinic measures and medication status.

Results

Of participants in the highest systolic BP reactivity tertile, 29.3 % became hypertensive over the follow-up period compared with 16.5 % of those in the lowest tertile, with an odds ratio of 2.02 (95 % CI 1.17–3.88, p?=?0.012) after adjustment for age, sex, grade of employment, body mass index, smoking, alcohol consumption, physical activity, follow-up time, subjective stress response, perceived task difficulty, perceived task engagement, and baseline BP. Similar associations were observed for diastolic BP reactivity (odds ratio 2.05, 95 % CI 1.23–3.40, p?=?0.006) and for impaired systolic BP post-stress recovery (odds ratio 2.06, 95 % CI 1.19–3.57, p?=?0.010). Fibrinogen reactions to tasks also predicted future hypertension in women (odds ratio 2.64, 95 % CI 1.11–6.30, p?=?0.029) but not men.

Conclusions

These data suggest that heightened cardiovascular and inflammatory reactivity to mental stress is associated with hypertension risk, and may be a mechanism through which psychosocial factors impact on the development of hypertension.

     

Direct and Indirect Associations Between the Built Environment and Leisure and Utilitarian Walking in Older Women

Background

The built environment predicts walking in older adults, but the degree to which associations between the objective built environment and walking for different purposes are mediated by environmental perceptions is unknown.

Purpose

We examined associations between the neighborhood built environment and leisure and utilitarian walking and mediation by the perceived environment among older women.

Methods

Women (N = 2732, M _age = 72.8 ± 6.8 years) from Massachusetts, Pennsylvania, and California completed a neighborhood built environment and walking survey. Objective population and intersection density and density of stores and services variables were created within residential buffers. Perceived built environment variables included measures of land use mix, street connectivity, infrastructure for walking, esthetics, traffic safety, and personal safety. Regression and bootstrapping were used to test associations and indirect effects.

Results

Objective population, stores/services, and intersection density indirectly predicted leisure and utilitarian walking via perceived land use mix (odds ratios (ORs) = 1.01–1.08, 95 % bias corrected and accelerated confidence intervals do not include 1). Objective density of stores/services directly predicted ≥150 min utilitarian walking (OR = 1.11; 95% CI = 1.02, 1.22). Perceived land use mix (ORs = 1.16–1.44) and esthetics (ORs = 1.24–1.61) significantly predicted leisure and utilitarian walking,

Conclusions

Perceived built environment mediated associations between objective built environment variables and walking for leisure and utilitarian purposes. Interventions for older adults should take into account how objective built environment characteristics may influence environmental perceptions and walking.

     

The Role of Stigma in Weight Loss Maintenance Among U.S. Adults

Background

Challenges of maintaining long-term weight loss are well-established and present significant obstacles in obesity prevention and treatment. A neglected but potentially important barrier to weight-loss maintenance is weight stigmatization.

Purpose

We examined the role of weight stigma—experienced and internalized—as a contributor to weight-loss maintenance and weight regain in adults.

Methods

A diverse, national sample of 2702 American adults completed an online battery of questionnaires assessing demographics, weight-loss history, subjective weight category, experienced and internalized weight stigma, weight-monitoring behaviors, physical activity, perceived stress, and physical health. Analyses focused exclusively on participants who indicated that their body weight a year ago was at least 10% less than their highest weight ever (excluding pregnancy), the weight loss was intentional, and that attempts to lose or maintain weight occurred during the past year (n = 549). Participants were further classified as weight regainers (n = 235) or weight-loss maintainers (n = 314) based on subsequent weight loss/gain. Data were collected in 2015 and analyzed in 2016.

Results

Hierarchical logistic regression models showed that internalized weight stigma and subjective weight category made significant individual contributions to prediction of weight-loss maintenance, even after accounting for demographics, perceived stress, experienced stigma, physical health, and weight-loss behaviors. For every one-unit increase in internalized weight stigma, the odds of maintaining weight loss decreased by 28% (95% CI: 14–40%, p < .001).

Conclusions

Findings provide initial evidence that overlooked psychosocial factors, like weight stigma, may hinder weight-loss maintenance. Implications for addressing stigma in obesity-focused clinical interventions are highlighted.

     

Prospective associations between recalled parental bonding and perinatal depression: a cohort study in urban and rural Turkey

Purpose

Recalled experiences of parental bonding may be important in the aetiology of perinatal depression. We hypothesized that lower recalled parental bonding would be associated with perinatal depression.

Method

In a cohort study of perinatal depression in Turkey, 677 women were recruited in their third trimester. Parental Bonding Inventory (PBI) scores at baseline were investigated as predictors of depression on the Edinburgh Postnatal Depression Scale (EPDS) at 4, 14 and 21 months after childbirth in mothers without depression at baseline.

Results

Poor parental bonding scores, apart from paternal control and overprotection, were independently associated with antenatal depression. Incident postnatal depression at 4 months was predicted by parental overprotection, at 14 months by parental care and overprotection, and at 21 months by paternal control and overprotection.

Conclusions

Less satisfactory parenting recalled in the antenatal period was an independent predictor of postnatal depression; however, the different bonding subscales varied as predictors according to the timing of the depression assessment after childbirth.

     

Examining the Conditions Under Which Internalized Homophobia Is Associated with Substance Use and Condomless Sex in Young MSM: the Moderating Role of Impulsivity

Background

Internalized homophobia (IH) is the internalization of homophobic attitudes by sexual minorities due to social bias. IH has been inconsistently related to substance use and condomless sex for young men who have sex with men (YMSM).

Purpose

We examined negative urgency (the tendency to act impulsively in response to negative emotional experiences), positive urgency (the tendency to act impulsively in response to positive emotional experiences), and sensation seeking as independent moderators of the association of IH with binge drinking, drug use, and condomless anal sex.

Methods

Data were collected from 450 YMSM (mean age = 18.9) over the course of 18 months (baseline, 6-, 12-, and 18-month follow-up).

Results

Hierarchical generalized linear modeling revealed that there was a significant moderation for binge drinking and receptive condomless anal sex, with the association between IH and these risk behaviors increased for those with higher levels of negative urgency and positive urgency.

Conclusions

IH is important to the negative health outcomes of binge drinking and condomless anal sex for individuals high in negative and/or positive urgency, who may act impulsively to avoid subjective negative experiences or in the face of positive emotional experiences. Future research is needed to further establish additional conditions under which IH may be important to understanding risk behaviors in YMSM, which is essential to developing targeted prevention and intervention efforts.

     

Extended family and friendship support and suicidality among African Americans

Purpose

This study examined the relationship between informal social support from extended family and friends and suicidality among African Americans.

Methods

Logistic regression analysis was based on a nationally representative sample of African Americans from the National Survey of American Life (N = 3263). Subjective closeness and frequency of contact with extended family and friends and negative family interaction were examined in relation to lifetime suicide ideation and attempts.

Results

Subjective closeness to family and frequency of contact with friends were negatively associated with suicide ideation and attempts. Subjective closeness to friends and negative family interaction were positively associated with suicide ideation and attempts. Significant interactions between social support and negative interaction showed that social support buffers against the harmful effects of negative interaction on suicidality.

Conclusions

Findings are discussed in relation to the functions of positive and negative social ties in suicidality.

     

Perceived stigma among non-professional caregivers of people with severe mental illness,Bahir Dar,northwest Ethiopia

Background

The stigmatization of mental illness is currently considered to be one of the most important issues facing caregivers of severely mentally ill individuals. There is a dearth of information about the prevalence and associated factors of perceived stigma among caregivers of people with severe mental illness in the study area.

Objective

To assess the prevalence and associated factors of perceived stigma among non-professional caregivers of people with severe mental illness, Bahir Dar, northwest Ethiopia.

Method

Institutional based cross-sectional study was conducted from May to June, 2016 at Felege Hiwot Referral Hospital among 495 caregivers of people with the severe mental illness. Pre-tested structured family interview schedule questionnaire was used. Binary logistic regression was applied to identify factors associated with perceived stigma and interpreted using odds ratio with 95% confidence interval. Statistical significance was considered at p value?<?0.05.

Result

The overall prevalence of perceived stigma was found to be 89.3%. Being female, rural residency, lack of social support, long duration of relationship with the patient and currently not married were found significantly associated with the perceived stigma of caregivers.

Conclusion

Prevalence of perceived stigma is very high in the current study. Thus, stigma reduction program and expanding of strong social support should better be implemented by different stakeholders for caregivers of people with severe mental illness.

     

Single-Session Behavioral Interventions for Sexual Risk Reduction: A Meta-Analysis

Background

Evidence-based, single-session STI/HIV interventions to reduce sexual risk taking are potentially effective options for implementation in resource-limited settings and may solve problems associated with poor participant retention.

Purpose

The purpose of the study is to estimate the efficacy of single-session, behavioral interventions in reducing unprotected sex or increasing condom use.

Methods

Data sources were searched through April 2013 producing 67 single-session interventions (52 unique reports; N?=?20,039) that included outcomes on condom use and/or unprotected sex.

Results

Overall, participants in single-session interventions reduced sexual risk taking relative to control groups (d ₊ ?=?0.19, 95 % CI?=?0.11, 0.27). Within-group effects of the interventions were larger than the between-groups effects when compared to controls.

Conclusions

Brief, targeted single-session sexual risk reduction interventions demonstrate a small but significant effect and should be prioritized.

     

Lay Awareness of the Relationship between Age and Cancer Risk

Background

Cross-sectional studies suggest many people are unaware that cancer risk increases with age, but this misbelief has rarely been studied prospectively, nor are its moderators known.

Purpose

To assess whether people recognize that cancer risk increases with age and whether beliefs differ according to gender, education, smoking status, and family history of cancer.

Methods

First, items from the cross-sectional Health Information National Trends Survey (n = 2069) were analyzed to examine the association of age and perceived cancer risk. Second, the prospective National Survey of Midlife Development in the United States (n = 3896) was used to assess whether perceived cancer risk changes over a decade. Third, beliefs about the age at which cancer occurs were analyzed using the US Awareness and Beliefs about Cancer survey (n = 1080). As a comparator, perceived risk of heart disease was also examined.

Results

Cross-sectionally, older age was associated with lower perceived cancer risk but higher perceived heart disease risk. Prospectively, perceived cancer risk remained stable, whereas perceived heart attack risk increased. Seventy percent of participants reported a belief that cancer is equally likely to affect people of any age. Across three surveys, women and former smokers/smokers who recently quit tended to misunderstand the relationship between age and cancer risk and also expressed relatively higher perceived cancer risk overall.

Conclusions

Data from three national surveys indicated that people are unaware that age is a risk factor for cancer. Moreover, those who were least aware perceived the highest risk of cancer regardless of age.

     

Gender differences in patterns of drug use and sexual risky behaviour among crack cocaine users in Central Brazil

Background

The aim of this study was to compare sociodemographic characteristics, patterns of drug use, and risky sexual behaviour among female and male users of crack cocaine.

Methods

Between 2012 and 2013, we conducted a cross-sectional study of 919 crack cocaine users (783 men and 136 women) in Central Brazil using face-to-face interviews. Blood samples were collected to test for syphilis. The Chi-Square Automatic Interaction Detector (CHAID) was used to explore the differences between genders. We implemented two models: the first model included previous incarceration and variables related to patterns of drug use, and the second model included variables related to sexual risky behaviours and syphilis exposure.

Results

Women consumed more crack cocaine than men on a regular basis; however, poly-drug use was more common among men. More women than men reported exchanging sex for money and/or drugs and inconsistent condom use during sexual intercourse; women also reported more sexual partners. In addition, the frequency of sexual violence was higher for women than men. A higher proportion of women than men were positive for syphilis (27.2% vs. 9.2%; p?<?0.001). The CHAID decision tree analysis identified seven variables that differentiated the genders: previous incarceration, marijuana use, daily crack cocaine consumption, age at first illicit drug use, sexual violence, exchange of sex for money and/or drugs, and syphilis exposure.

Conclusion

Our findings demonstrate a difference in patterns of crack cocaine consumption and sexual risky behaviours between genders, thus indicating a need for gender-specific interventions in this population.

     

Dietary behaviour,psychological well-being and mental distress among adolescents in Korea

Background

Dietary intake is important for physical and mental health. The aim of this investigation was to assess associations between dietary behaviours and psychological well-being and distress among school-going adolescents in Korea.

Methods

In a cross-sectional nationally representative survey, 65,212 students (Mean age = 15.1 years, SE = 0.02 and 52.2% male and 47.8% female) responded to a questionnaire that included measures of dietary behaviour, psychological well-being and mental distress.

Results

In logistic regression analyses, adjusted for age, sex, socioeconomic status, school level, school types, Body Mass Index, physical activity, and substance use, positive dietary behaviours (regular breakfast, fruit, vegetable, and milk consumption) were positively and unhealthy dietary behaviours (intake of caffeine, soft drinks, sweet drinks and fast food consumption) were negatively associated with self-reported health, happiness and sleep satisfaction. Positive dietary behaviours (regular breakfast, fruit, vegetable, and milk consumption) were negatively associated with perceived stress and depression symptoms. Unhealthy dietary behaviours (consumption of fast food, caffeine, sweetened drinks and soft drinks) were associated with perceived stress and depression symptoms.

Conclusions

The study found strong cross-sectional evidence that healthy dietary behaviours were associated with lower mental distress and higher psychological well-being. It remains unclear, if a healthier dietary behaviour is the cause or the sequela of a more positive well-being.

     

Parental History of Diabetes,Positive Affect,and Diabetes Risk in Adults: Findings from MIDUS

Background

Family history of diabetes is one of the major risk factors for diabetes, but significant variability in this association remains unexplained, suggesting the presence of important effect modifiers.

Purpose

To our knowledge, no previous work has examined whether psychological factors moderate the degree to which family history of diabetes increases diabetes risk.

Methods

We investigated the relationships among parental history of diabetes, affective states (positive affect, negative affect, and depressed affect), and diabetes in 978 adults from the MIDUS 2 national sample.

Results

As expected, parental history of diabetes was associated with an almost threefold increase in diabetes risk. We found a significant interaction between positive affect and parental history of diabetes on diabetes (p?=?.009): higher positive affect was associated with a statistically significant lower relative risk for diabetes in participants who reported having a parental history of diabetes (RR?=?.66 per unit increase in positive affect; 95 % CI?=?.47; .93), but it did not influence diabetes risk for participants who reported no parental history of diabetes (p?=?.34). This pattern persisted after adjusting for an extensive set of health and sociodemographic covariates and was independent of negative and depressed affect.

Conclusions

These results suggest that psychological well-being may protect individuals at increased risk from developing diabetes. Understanding such interactions between non-modifiable risk factors and modifiable psychological resources is important for delineating biopsychosocial pathways to diabetes and informing theory-based, patient-centered interventions to prevent the development of diabetes.

     

Autonomic symptoms following Zika virus infection

Purpose

To determine if autonomic symptoms are associated with previous Zika virus infection.

Methods

Case–control study including 35 patients with Zika virus infection without evidence of neurological disease and 105 controls. Symptoms of autonomic dysfunction were assessed with the composite autonomic symptom scale 31 (COMPASS-31).

Results

Patients with previous Zika virus infection had significantly higher COMPASS-31 score than controls regardless of age and sex (p = 0.007). The main drivers for the higher scores where orthostatic intolerance (p = 0.003), secretomotor (p = 0.04) and bladder symptoms (p < 0.001).

Conclusion

Zika virus infection is associated with autonomic dysfunction. The mechanisms remain to be elucidated.

     

Use of electroconvulsive therapy in adolescents with schizophrenia in China

Background

Electroconvulsive therapy (ECT) is an effective treatment for psychiatric disorders such as schizophrenia, major depression and bipolar disorder. However, few studies have addressed the use of ECT in adolescents with schizophrenia. The aims of our study were to investigate the frequency of ECT, and its relationship with clinical and demographic correlates among adolescents with schizophrenia in China.

Methods

The study was a retrospective study and conducted in the Child and Adolescent Psychiatry Department of Beijing Anding Hospital, and adolescents with schizophrenia over a period of 10 years (2007–2016) were enrolled. The demographic and clinical data were collected from the electronic chart management system.

Results

A total of 835 patients were included, 411/835 (49.2%) of the adolescent inpatients diagnosed with schizophrenia were in ECT group. There were significant differences in the sex, age, high risk for aggression and suicide, family history of psychiatric disorders and concomitant psychotropic medication (antidepressants and benzodiazepines) between the ECT and non-ECT groups. Multiple logistic regression analysis revealed that ECT use was independently and positively associated with sex, high risk for suicide.

Conclusions

In a major psychiatric center in China, the use of ECT was common, and reasons for the high use of ECT for adolescent patients in this hospital should warrant urgent investigations.

     

A program of family-centered care for adolescents in short-term stay groups of juvenile justice institutions

Background

To provide successful treatment to detained adolescents, staff in juvenile justice institutions need to work in family-centered ways. As juvenile justice institutions struggled to involve parents in their child’s treatment, we developed a program for family-centered care.

Methods

The program was developed in close collaboration with staff from the two juvenile justice institutions participating in the Dutch Academic Workplace Forensic Care for Youth. To achieve an attainable program, we chose a bottom-up approach in which ideas for family-centered care were detailed and discussed by workgroups consisting of group leaders, family therapists, psychologists, other staff, researchers, and a parent.

Results

The family-centered care program distinguishes four categories of parental participation: (a) informing parents, (b) parents meeting their child, (c) parents meeting staff, and (d) parents taking part in the treatment program. Additionally, the family-centered care program includes the option to start family therapy during detention of the youths, to be continued after discharge from the juvenile justice institutions. Training and coaching of staff are core components of the family-centered care program.

Conclusions

The combination of training and the identification of attainable ways for staff to promote parental involvement makes the family-centered care program valuable for practice. Because the program builds on suggestions from previous research and on the theoretical background of evidence-based family therapies, it has potential to improve care for detained adolescents and their parents. Further research is required to confirm if this assumption is correct.

     

Education as a social pathway from parental socioeconomic position to depression in late adolescence and early adulthood: a Finnish population-based register study

Purpose

There is inconsistent evidence for social differentials in the risk of depression in youth, and little is known about how education at this age influences the risk. We assess how parental socioeconomic position (SEP) and education predict depression from late adolescence to early adulthood, a time of major educational transitions.

Methods

We followed a nationally representative 20 % sample of Finnish adolescents born in 1986–1990 (n = 60,829) over two educational transitory stages at the age of 17–19 and 20–23 covering the years 2003–2011. We identified incident depression using health care register data. We estimated the risk of depression by parental SEP and personal education using Cox regression, adjusting for family structure, parental depression and the individual’s own psychiatric history.

Results

Lower parental income was associated with up to a twofold risk of depression. This effect was almost fully attributable to other parental characteristics or mediated by the individual’s own education. Educational differences in risk were attenuated following adjustment for prior psychiatric history. Adjusted for all covariates, not being in education increased the risk up to 2.5-fold compared to being enrolled in general upper secondary school at the age of 17–19 and in tertiary education at the age of 20–23. Vocationally oriented women experienced a 20 % higher risk than their academically oriented counterparts in both age groups.

Conclusions

Education constitutes a social pathway from parental SEP to the risk of depression in youth, whereby educational differences previously shown in adults are observed already before the establishment of adulthood SEP.

     

Marijuana Use and Organ Transplantation: a Review and Implications for Clinical Practice

Purpose of Review

Physicians of all disciplines must rapidly adjust their clinical practices following the expansion of marijuana legalization across the country. Organ transplantation teams are uniquely struggling in this gray zone with eight states having passed laws explicitly banning the denial of transplant listing based on a patient’s use of medical marijuana. In this review, we examine the clinical evidence of marijuana use in transplant patients to enable psychiatric providers to meaningfully contribute to the relevant medical and psychiatric aspects of this issue in a unique patient population.

Recent Findings

There is no consensus among experts regarding marijuana use in transplantation patients. There are extant case reports of post-transplant complications attributed to marijuana use including membranous glomerulonephritis, ventricular tachycardia, and tacrolimus toxicity. However, recent studies suggest that the overall survival rates in kidney, liver, lung, and heart transplant patients using marijuana are equivalent to non-users.

Summary

Transplant teams should not de facto exclude marijuana users from transplant listing but instead holistically evaluate a patient’s candidacy, integrating meaningful medical, psychiatric, and social variables into the complex decision-making process. Psychiatric providers can play a key role in this process. Appropriate stewardship over donor organs, a limited and precious resource, will require a balance of high-clinical standards with inclusive efforts to treat as many patients as possible.