**9. The importance of psychological aspects**

With regard to psychopathology, it is important to note that it is not always a contraindication for transplant *per se* (Jowsey, 2001; Gutteling, 2010)*.* Some studies however, show that psychiatric diagnosis is common among transplant candidates specially in patients with previous alcoholic liver disease and hepatitis C carriers who may have worse clinical outcome after transplantation (Sherman, 2004).

Telles-Correia, et al, found that in the pre-transplant period, the prevalence of depression was observed in 33% of patients, anxiety was observed in 34%, and dependency on alcohol or drugs was observed in 59%. After transplant, depression prevalence was observed in 30%, anxiety in 26%, and psychosis in 6.4% (Telles-Correia, 2006).

As we mentioned above, non-adherence before transplantation is predictive of nonadherence after transplantation. It is known that anti hepatitis C virus viral treatment is associated with neuropsychiatric side effects (Quelhas,& Lopes, 2009). Therefore, in these situations, psychopharmacological treatment is required to be initiated as soon as possible, especially in patients with a history of psychiatric disorder, to assure adherence to medication (Gangeri, 2007; Quelhas & Lopes, 2009). Many factors may affect the process of adaptation to the disease (Kendall; 1995; Uchino, 1996; Telles-Correia, 2008). Patients can have different coping strategies, the most common being, stoic acceptance, denial, hopelessness, anxious concern and fighting spirit.

Coping strategies may change over time, depending on specific stressors and the development that follows the disease. Studies show that fighting spirit and denial are ways of coping better than the rest, in the sense that facilitate adjustment to illness (Carver, 2005; Russell, 2008).
