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36 Ethical andLegal Dimensions ofProphylactic Surgery
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surgery can be performed if the complication rates resulting from prophylactic appendectomy are low enough, and the incidence of appendicitis is sufciently high [49]. Before a prophylactic intervention that does not originate from genetic risk, more reasonable remedies should be sought other than removing a healthy organ. In the absence of such an alternative, intervention should not be performed without carefully evalu­ating potential complications [49, 50]. However, since such an intervention can be foreseen as a prerequisite for starting a job, it also requires evaluating whether the free will of the person is under pressure. In addition to the obligation of indication, it must be performed with the care and attention required by medical science and its application for a medical intervention to be con­sidered lawful. Medical care and attention are also sought in the prophylactic method. In this context, the physician should carry out the opera­tion and treatment required by the medical sci­ence, avoid unprotected interventions, take appropriate measures for the complications that could occur, following the infection and hygiene rules, and the patient’s condition required. However, such interventions’ success is linked with the removal of tissue with the risk of devel­oping cancer, so the extent and the way physician removes the tissue gives another subject to us to be evaluated separately in terms of care and attention. Apart from this, there is no signicant difference between the usual medical interven­tions and the prophylactic method.
36.4 Conclusions
Nowadays, prophylactic interventions are among the most effective methods of risk reduction in modern medicine. Despite its important contribu­tions to reducing risk, the prophylactic method remains partially unknown due to the ethical, social, and psychological consequences it arises for individuals. Therefore, the prophylactic method can cause ethical and legal problems for individuals who need to assume the risk of uncer­tainty and genetic risk. Therefore, in the case of a
prophylactic method that is based on the poten­tial risk and which can have severe consequences for individuals, current medical standards should be more rigorously taken into account, consider­ing the features particular to this method. More attention should be paid to protecting the patient’s condentiality. At the same time, an appropriate illumination should be performed to the nature of the method. It should also be noted that obtaining consent for the intervention and the obligation of indication should be carefully approached within the concrete data framework.
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Psychiatric Aspects ofProphylactic Surgery inAdults
SemraEtyemez andWilliamW.Eaton
37
37.1 Introduction
This chapter describes the role of mental health in prophylactic surgery in adults. It begins with a presentation of the prevalence of mental disorder, followed by a discussion of risk factors for psy­chosocial distress and mental disorders. It describes the Angelina Jolie effect, the psychoso­cial impact of genetic testing, and highlights the impact of the prophylactic surgery on psychoso­cial health. The chapter closes with an overview of psychiatric assessment and treatment of patients undergoing surgery.
37.2 Epidemiology ofMental Disorders
Mental disorders are common worldwide and affect individuals’ cognitive, behavioral, emo­tional, and physical well-being. A systematic review and meta-analysis of the literature from 1980 to 2013 reported a prevalence of mental dis-
S. Etyemez (*) Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA e-mail: setyeme1@jhu.edu
W. W. Eaton Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA e-mail: weaton1@jhu.edu
orders in adults during a 12-month period as approximately 18% and the lifetime prevalence as 29% [1, 2]. Worldwide, one in ve adults experiences a mental disorder in a given year. Gender differences in psychiatric disorders are also reported; studies indicate that mood disor­ders and anxiety disorders are more common in females, whereas substance use disorders, attention- decit hyperactive disorder (ADHD), and autism spectrum disorders are more common in males [1, 3–5]. Individuals with mental disor­ders are at higher risks of comorbid medical con­ditions [6–9]. Also, the risk of developing a subsequent mental disorder is increased in indi­viduals with one mental disorder [10, 11]. Several risk factors for onset of mental disorders, includ­ing biological, psychosocial, socioeconomic, and environmental factors, have been investigated and identied [12–15]. Among these risk factors, experiencing early-life adverse events with phys­ical, psychological and emotional neglect, trauma, chronic stress, and physical illnesses are the most important factors making an individual vulnerable for developing psychiatric disorders over one’s life course. Similarly, family members of patients with chronic illnesses, such as cancer, experience psychological distress and are at ele­vated risk for developing mental disorders [16,
17]. The prevalence of depression and anxiety
among family caregivers of cancer patients is remarkably high, estimated at 42% for depres­sion and 47% for anxiety [16, 18].
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 O. N. Dilek et al. (eds.), Prophylactic Surgery, https://doi.org/10.1007/978-3-030-66853-2_37
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37.3 Physical Illnesses asRisk Factors forPsychological Distress
In the last decade, there has been an increased public awareness of genetic testing for severe ill­nesses such as cancer, and there is strong evi­dence that uptake of cancer screening is less likely among individuals with mental illness [19–22]. Additionally, many studies report a higher risk for cancer and higher mortality rates in individuals with mental illnesses compared to the general population [23–26]. Genetic testing to identify one’s risk for complex diseases has psychiatric implications, and the mental health needs of the population undergoing a genetic test should be considered. The literature is limited regarding whether there are different genetic test­ing rates among those with or without mental ill­ness. One study examined the effect of psychiatric disorders on genetic screening for breast and ovarian cancer and found no association between genetic cancer screening and coexisting psychiat­ric disorders [27]. Further, there have been sev­eral studies showing that individuals with underlying risk factors are at higher risk of expe­riencing psychological distress during the genetic testing process, and they are at higher risk of psy­chiatric complications. Distress at the baseline of the testing process, a history for psychiatric dis­orders, psychopharmacotherapy, use of a passive coping style, inaccurate risk perceptions, the experience of the death of a family member due to an inheritable cancer, complicated grief, being the rst person in the family or group who under­goes genetic testing, and women having children are potential risk factors for psychiatric compli­cations and long-term distress after the testing and surgical procedures [28, 29].
37.4 Angelina Jolie Eect
On May 14, 2013, Angelina Jolie disclosed that she had undergone a prophylactic mastectomy (PM) and bilateral salpingo-oophorectomy, due to a family history of cancer and being a BRCA1
gene mutation carrier. This announcement had a remarkable impact on public awareness about prophylactic surgery, and this topic has garnered much attention for researchers. A systematic review investigated the impact of the “Angelina Jolie effect” on referrals, patients’ attitudes, and decisions about genetic testing and risk-reducing mastectomies [30]. A signicant increase of referrals for breast and ovarian cancer and genetic testing of BRCA status was reported, but no signicant increase of risk-reducing surgery was observed [30]. Another important study con­ducted with 2572 adults demonstrated that 75% of participants were informed accurately about Angelina Jolie’s risk for developing breast can­cer, but only 10% of those 75% had sufcient knowledge about the risk of developing cancer in BRCA mutation carriers and in the general population [31]. Thus, although Angelina Jolie’s story increased awareness of, and interest in, genetic testing for cancer and prophylactic sur­gery, there remains a lack of accurate under­standing about the risk factors and treatment information for patients at high risk for heredi­tary cancer. This raises the need for understand­ing the psychosocial impact of genetic testing and prophylactic surgery, which has a signicant impact on diagnosis, treatment, and outcomes of patients.
37.5 Psychosocial Impact ofGenetic Testing
Although many are concerned about the negative mental health consequences of knowing one car­ries a mutation raising risk for cancer, the major­ity of individuals at high risk for cancer don’t experience negative mental health consequences from genetic testing [32–34]. The prevalence of distress varies in several studies for different dis­eases; several investigators have reported that approximately 6–24% of individuals undergoing predictive genetic testing for hereditary breast and ovarian cancer (HBOC), hereditary nonpolyposis colon cancer (HNPCC), and Li-Fraumeni syn­drome, presented elevated distress levels [29].
37 Psychiatric Aspects ofProphylactic Surgery inAdults
449
Also, a signicant percentage of individuals with familial adenomatous polyposis (FAP) undergoing genetic testing suffer from distress and anxiety symptoms [29]. The majority of studies found that depressive and anxiety symptoms decrease considerably after the disclosure of results of gene testing in breast and ovarian cancer in both gene carriers and non-carriers [28]. On the other hand, depressive and anxiety symptoms increase after positive genetic results for Huntington disease, whereas no signicant increase of these symp­toms occur in Alzheimer disease and cardiovascu­lar diseases after genetic testing [28].
Anxiety about potential psychological effects of genetic test results have implications in decision- making throughout the genetic testing process. There have been indications that one in three individuals coming from high-risk cancer families may decline or defer a genetic test [35,
36]. It has been reported that approximately one
in two women coming from high-risk breast and ovarian cancer families did not follow up with genetic counseling sessions after the rst session, and 36.3% of those declining genetic testing reported being concerned with the psychological consequences of the test outcome [37]. Being afraid of the negative impacts of the test results was one prevalent explanation for withdrawal after the rst genetic counseling session [38]. Depression was also correlated with reduced uptake of HNPCC testing, as well as with delay­ing genetic testing; depression among people who delayed genetic testing for HBOC was con­sistently high at baseline and during 1- and 6-month follow-up periods [38, 39]. It has been reported that depression is a predictor for not undergoing genetic testing as well as withdrawal from BRCA1/2 testing [40].
Psychological factors affect the decision­making process as well as adherence to recom­mended risk-reduction plans after a positive test. Studies have explored adherence to potential risk-reduction strategies and found that the majority of HNPCC mutation carriers (60–70%) were adherent to the recommended screenings guidelines compared to 10–15% of noncarriers of HNPCC mutation [41]. Also, HNPCC mutation carriers who were adherent to recommended
colonoscopy guidelines were less likely to have depressive symptoms than noncarriers [42]. Communication about cancer risk, involvement of the family and encouragement for screening were important predictors of increased compli­ance to the recommended screening [43]. There was also a correlation between genetic test results and adherence rates to screening guidelines in BRCA1/BRCA2 carriers. Signicantly, higher rates of mammography uptake, but lower rates in adherence to ovarian cancer screening guidelines in BRCA1/BRCA2 carriers than noncarriers are reported [44].
37.6 Impact ofProphylactic Surgery onPsychosocial Health
There have been indications that some psychiat­ric diagnoses are associated with undergoing pro­phylactic surgery. For instance, mood disorders, anxiety disorders, and schizophrenia, are associ­ated with an elevated risk for undergoing hyster­ectomy, with and without concurrent bilateral oophorectomy for benign ovarian conditions [45,
46]. Preexisting somatoform disorders and per-
sonality disorders are associated with an increased risk of bilateral oophorectomy [46]. This study also reported that the risk of bilateral oophorectomy changed with age and psychiatric diagnosis; the odds ratio for adjustment disorders was considerably higher in ages 46–49, whereas odds ratio for mood disorders and anxiety disor­ders were signicantly higher in those less than 45 years of age.
As with genetic testing, prophylactic surgeries also have psychosocial impacts on individuals who decide to undergo risk-reducing surgery. PM, oophorectomy, and bariatric surgery are invasive and irreversible interventions, which may affect individuals’ mental health. One study reported that the majority of women undergoing (PM) were satised with the surgery outcome and reported decreased worry for cancer, but 9–25% of individuals described negative psycho­logical and social impact of PM on emotional stability, level of stress, self-esteem, sexual rela-
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S. Etyemez and W. W. Eaton
tionship, and feelings of femininity [47]. Studies have reported a decrease of depression and anxi­ety symptoms in BRCA1/BRCA2 carriers after risk-reducing bilateral salpingo-oophorectomy (RRBSO) compared to these symptoms after cancer screening but before surgery [29, 48–50]. Nevertheless, studies didn’t discuss the effect of age, education level, and occupation in the psy­chosocial consequences of the risk-reducing sur­geries. One study conducted on younger women undergoing risk-reducing surgery with prophy­lactic mastectomy and oophorectomy reported no decrease in cancer worries [51]. Younger age at the prophylactic salpingo-oophorectomy was also correlated with lower social and sexual func­tioning, more endocrine impairments and increased anxiety [52]. Women with a loweduca­tion level and no occupation are more likely to experience adverse effects of the prophylactic salpingo-oophorectomy [52]. Also, most women undergoing PM, RRBSO, or hysterectomy reported impairments in sexuality and libido [53]. Poor self-image, vaginal dryness, decrease in interest in sex, as well as change in interper­sonal relationships are listed as reasons for reduced sexual activity [53]. Another striking nding was that 60–80% of BRCA1/BRCA2 car­riers who underwent RRBSO reported that they did not receive any information about the avail­ability of services for sex counseling, impact of surgery on self-image, and impact of surgery on sexual life as well as on their risk for cardiovas­cular disease [54]. These are important consider­ations for developing preintervention counseling. It seems that most of these women would have preferred receiving more information about the consequences of the surgical intervention before the procedure [54].
Psychosocial factors of individuals undergo­ing prophylactic bariatric surgery are also an important concern. Approximately, 40% of patients seeking bariatric surgery present with at least one mental health condition, such as depres­sion, anxiety, BED, alcohol use disorder, or impulse control disorders [55]. A meta-analysis investigated the prevalence of psychiatric disor­ders among bariatric surgery candidates and recipients; the prevalence rates of any mood dis-
orders reported were 23%, depression 19%, psy­chosis 1%, binge eating disorder (BED) 17%, anxiety 12%, suicidal ideation 9%, substance abuse disorders 3%, and PTSD 1% [
56]. Another
study investigating 8192 patients undergoing bar­iatric surgery reported that 57% of these patients had preoperative psychiatric disorders [57], thus, higher than the general population. There is ample evidence that bariatric surgery has a posi­tive impact on psychopathology, quality of life, body image, socioeconomic status, and social relationships [58–61]. There is strong evidence of postoperative weight loss and maintenance after bariatric surgery [
55, 60–62]. However, the
weight loss is less in patients with depression and anxiety disorders compared to those without depression or anxiety [63]. A signicant improve­ment in depressive symptoms is reported postop­eratively, whereas no changes in anxiety is observed [63]. Nevertheless, over a longer term, depressive symptoms may reoccur and demon­strate increased depressive symptoms compared to preoperative levels [64–66]. The mood status of stable bipolar patients undergoing bariatric surgery does not seem to be altered [67]. Further, a reduction in suicide rates in bariatric surgery patients after surgery is also reported, however; the suicide rates still remain higher than the gen­eral population [68, 69]. Postoperative weight loss is less in patients with depression and anxi­ety disorders compared to those without depres­sion or anxiety [63]. A signicant improvement in cognitive function, such as memory and atten­tion 1–3 years postsurgery, is also described in the literature [70, 71]. Cognitive functions are positively correlated with compliance to postop­erative recommendations [72, 73].
As with depression and anxiety, eating disor­ders are common in patients seeking bariatric surgery. Binge eating disorder (BED) is dened by recurrent and frequent eating episodes with overeating, sense of loss of control, and embar­rassment. Studies have shown that the preva­lence of BED ranges between 10%–27% in patients seeking bariatric surgery [60, 61]. Postoperatively, a decrease in the prevalence of BED is reported, however some studies note the prevalence remained the same, that patients
37 Psychiatric Aspects ofProphylactic Surgery inAdults
451
exhibited “loss of control” eating and in some cases self-induced vomiting, which had adverse effects on weight loss and weight loss mainte­nance [60, 61]. Following bariatric surgery binge eating has been shown to be correlated with weight loss and emotional distress [74, 75]. The prevalence of night eating syndrome (NES), a condition characterized by evening hyperphagia, nocturnal eating, and morning anorexia is also higher in presurgical bariatric patients compared to the general population [76, 77] which appears to decrease after bariatric surgery [78]. Individuals after bariatric surgery are also at higher risk for developing alcohol use disorders [79]. An interesting nding is that individuals with Roux-en-Y gastric bypass demonstrated signicantly higher rates of alcohol use com­pared to those with laparoscopic adjustable gas­tric banding (LAGB) [79]. Finally, Impulse Control Disorders (ICD) occur more frequently in individuals seeking bariatric surgery than the general population [61]. Excessive exercising to prevent weight gain, and occurrence or re-occur­rence of ICD after bariatric surgery, are observed in some cases [61, 80, 81].
37.7 Psychiatric Assessment andTreatment ofSurgery Patients
This information underscores the necessity and benets of incorporating other disciplines, such as psychiatrists, psychologists, and sexual health counselors, throughout the whole process (genetic testing, preoperative, postoperative) to identify individuals at risk for worse postsurgical outcomes, to prevent adverse effects of the inter­vention, and to provide specic personalized treatment for each individual. Considering the high psychiatric comorbidity and its effect on outcomes of prophylactic surgery patients, a mul­timodal medical approach, including a compre­hensive psychiatric assessment, is recommended along the course of genetic counseling, preopera­tive, and postoperative process. During the genetic testing process, patients should be screened for underlying risk factors and acute
psychiatric disorders, and reevaluation of the mental status as well as the need for psychologi­cal and psychiatric support must be considered in every stage of the process.
Underestimating the impact of the mental status during the process of prophylactic sur­gery is a fundamental medical malpractice. The presence of mental illness, such as acute psy­chosis, major depression, bipolar disorder, active substance abuse, eating disorders, cancer phobia, or body dysmorphic syndrome, may affect the cognitive functions of individuals, inuence decision- making, and impair postsur­gical outcomes. If an untreated or inadequately managed psychiatric illness is present in indi­viduals seeking prophylactic surgery, the sur­gery should be moved forward only after the acute severe mental illness is treated and stable. The presence of acute severe mental illness can lead to awed decisions due to the lack of understanding the risks, consequences, pre and postoperative guidelines, which may lead to denying clearance for surgery, delay and denial of the procedures, and nonadherence to the rec­ommended care after surgery [61]. In addition to the treatment of psychiatric comorbidities, pre­operative assessment should also include con­sidering potential interactions between psychopharmacological treatment and anesthet­ics to avoid peri and postoperative complications.
Discontinuation or dose reduction of any psy­chotropic drug should be done under psychiatric supervision to prevent relapse or an exacerbation of psychiatric symptoms. Continuing antidepres­sive treatments, mood stabilizers, and antipsy­chotic medication are recommended to prevent serotonin discontinuation syndrome, exacerba­tion of a depressive, manic, mixed, and psychotic episode. However, attention should be paid to the pharmacological management since several emergencies related to psychotropic drug actions can occur. For instance, among anti-depressive agents, particular attention should be given to monoamine oxidase inhibitors (MAOIs) due to high interaction potential with anesthetics and analgesics. Also, depressive patients taking selective serotonin reuptake inhibitors are at risk
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S. Etyemez and W. W. Eaton
for developing serotonin syndrome, character­ized by excitement or confusion, excessive neu­romuscular activity, and autonomic instability, which can be a fatal condition if untreated. Lithium serum level as well as the individual’s clinical status should be monitored to avoid lith­ium toxicity with seizures, delirium, coma, and arrhythmias. Fluid, electrolytes, and renal func­tion of patients taking lithium should be checked closely to avoid dyselectrolytemia. In addition, patients taking antipsychotics are at risk for neu­roleptic malignant syndrome (NMS), usually found in a phase of early treatment, which is a life-threating condition dened by acute hyper­pyrexia, muscle rigidity, and autonomic instabil­ity. Also, electrocardiographic abnormalities commonly occur in patients taking antipsychotic drugs; therefore, anesthetics, which have elec­trocardiographic side effects, should be avoided to prevent arrhythmia.
Postoperative monitoring of mental status must also be undertaken since psychiatric com­plications, such as postoperative cognitive impairment, postoperative delirium (hypoactive, hyperactive), adjustment disorder, postoperative depression, posttraumatic stress disorder related to surgery, and substance use, are often encoun­tered. Each of the listed postoperative psychiatric complications requires clinical attention, and pharmacological and/or psychotherapy treatment may be required [61, 82]. Postoperative pain can also cause severe psychological distress and may require an individualized multimodal pain man­agement plan, including pharmacological and nonpharmacological treatment. Careful attention should be paid to postoperative management of psychopharmacological treatment of patients undergoing bariatric surgery. Anatomic altera­tions due to the bariatric surgery signicantly inuence the pharmacokinetic effects as well as the overall effectiveness of the medications, which should be monitored with caution to detect ineffectiveness and prevent side effects and intoxication [82–84]. Monitoring medication blood level pre and postoperatively, adjusting medication doses, and if necessary, changing psychotropics to an immediate-release or paren­teral formulation is recommended [82].
37.8 Conclusion
This chapter provided an overview of psychiatric aspects of prophylactic surgery. The scope of this chapter does not allow us to elaborate on each potential psychiatric disorder and its treatment and to cover all the relevant aspects of the periop­erative process. More details can be found in the work of Zimbrean et al. on Perioperative Psychiatry [82]. This chapter has made it clear that throughout the genetic testing, preoperative and postoperative process for surgery, psychiatric assessment is critical to identify psychosocial risk factors and the psychiatric comorbidities, which may have a signicant impact on the decision- making, treatment, complications, and postsurgical outcomes of the patient.
Acknowledgment We would like to thank to Dr. Bhavna Seth and Dr. Marina Mihaljevic for their valuable com­ments on the chapter.
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