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36 Ethical andLegal Dimensions ofProphylactic Surgery
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443
surgery can be performed if the complication
rates resulting from prophylactic appendectomy
are low enough, and the incidence of appendicitis
is sufciently 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 signicant
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
condentiality. 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 ofProphylactic
Surgery inAdults
SemraEtyemez andWilliamW.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 ofMental
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- decit 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 identied [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
447
448
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S. Etyemez and W. W. Eaton
37.3 Physical Illnesses asRisk
Factors forPsychological
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 Eect
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 signicant increase of
referrals for breast and ovarian cancer and
genetic testing of BRCA status was reported, but
no signicant 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 sufcient
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 signicant
impact on diagnosis, treatment, and outcomes of
patients.
37.5 Psychosocial Impact
ofGenetic 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 ofProphylactic Surgery inAdults
449
Also, a signicant 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 signicant 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. Signicantly, 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 ofProphylactic
Surgery onPsychosocial
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 signicantly 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 satised 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 signicant 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 signicant 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 dened
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 ofProphylactic Surgery inAdults
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
signicantly 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
andTreatment ofSurgery
Patients
This information underscores the necessity and
benets 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 specic 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,
inuence 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 dened 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 signicantly
inuence 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 signicant 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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