Disparities in Liver Transplantation Rates and Outcomes Among Adults with and without Mental Illnesses

Background Patients with mental illnesses face unique disparities in access to liver transplantation. We sought to compare rates of evaluation, transplantation, and post-transplant outcomes among patients with and without mental illnesses.Methods Patients aged 18-75 with decompensated cirrhosis or hepatocellular carcinoma were identified from the Medicare Standard Analytic Files from 2014-2020. Regression analyses were used to examine the association between mental illness and evaluation by a transplant surgeon, receipt of transplant, and post-transplant outcomes.Results Among 274,252 liver transplant candidates, 34,269 (12.5%) patients had depression and/or anxiety disorders and 8,184 (3.0%) had severe mental illnesses. The proportion of patients evaluated by a transplant surgeon was lower among patients with severe mental illnesses (14.1%), as well as individuals with depression and/or anxiety disorders (16.0%) versus the general population (18.5%) (p < 0.001). Similarly, utilization of transplantation rates was lower among patients with severe mental illness (1.1%) compared with depression and/or anxiety disorders (2.0%), as well as individuals without mental illnesses (3.8%) (p < 0.001). On multivariable regression analyses, mental illness remained independently associated with lower odds of evaluation and transplantation among patients with mental illnesses. In contrast, on adjusted analyses there were no differences in postoperative outcomes including perioperative complications, biliary complications, graft rejection, graft failure, and overall survival.Conclusion Despite lower rates of evaluation and transplant, patients with mental illnesses did not experience differences in most postoperative outcomes compared with patients without a mental illness.