Ethical Issues in Consultation-Liaison Psychiatry

This article contextualizes several key ethical issues in consultation-liaison (C-L) psychiatry within historical and principlist frameworks. After summarizing the history of the field, it focuses on 3 main areas of ethical import in C-L psychiatry: decisional capacity assessment, psychosocial evaluations for transplant, and treating mental illness in pregnant patients.

Preoperative psychological characteristics affecting mid-term outcome after bariatric surgery: a follow-up study

BACKGROUND

The purpose of this study was to investigate the relationship between preoperative psychological factors and percentage of total weight loss (%TWL) after laparoscopic Roux-en-Y gastric bypass (LRYGB) to identify possible psychological therapy targets to improve the outcome of bariatric surgery.

METHODS

Seventy-six patients completed the Hamilton's Anxiety and Depression Scales (HAM-A, HAM-D) and Toronto Alexithymia Scale (TAS-20) the day before surgery (T0). The pre-operative body weight and the %TWL at 3 (T1), 6 (T2), and 24-30 (T3) months were collected.

RESULTS

At T3, depressed and alexithymic patients showed a lower %TWL compared to non-depressed patients (p = 0.03) and to non-alexithymic patients (p = 0.02), respectively. Finally, patients who had at least one of the three analyzed psychological factors showed less weight loss, at T2 (p = 0.02) and T3 (p = 0.0004).

CONCLUSIONS

Psychological factors may also affect long-term outcome of bariatric surgery. This study shows an association between alexithymia/depression pre-operative levels and the weight loss at 30 months'follow-up after bariatric surgery.

LEVEL OF EVIDENCE

Level III, longitudinal cohort study.

Bariatric and Cosmetic Surgery in People with Eating Disorders

Rates of eating disorders (EDs) are increasing in Australia, as are rates of bariatric and cosmetic surgery including weight-related procedures. It is known that binge eating disorder (BED) is common in bariatric surgery candidates and that people with EDs are likely to undergo weight-related cosmetic procedures, however, most of the literature is based on clinic samples and focuses on young women and BED. Aims of this study were to determine the prevalence of (1) actual or intended bariatric surgery and (2) actual or intended cosmetic surgery including weight-related procedures in people with a current ED and a lifetime history of BED or bulimia nervosa (BN), and the associations with actual or intended bariatric or cosmetic surgery and demographic features. Using a general population survey, 2977 individuals were interviewed regarding sociodemographic status, ED symptoms, mental health-related quality of life (MHRQoL) and actual or intended use of bariatric and cosmetic surgery, prevalence estimates of which were 2.0% and 1.1%, respectively. People who had planned or received either type of surgery were more likely to be (1) women and (2) have a higher BMI, (3) poorer MHRQoL and (4) a current ED, lifetime BN or BED or features of EDs (all p < 0.05). Age and household income were not significantly associated with increased use of either type of surgery. Given the potential for an ED to affect outcomes of surgery, screening and treatment for EDs should be considered in such surgical candidates.

The role of ethics consultation in decision making for bariatric surgery in pediatrics

The decision to pursue metabolic and bariatric surgery (MBS) for pediatric patients has become increasingly accepted by patients and their families and by health care professionals. The advancement of pre- and post-operative MBS guidelines, based on accumulating evidence for safety, efficacy, and cost-effectiveness help to map the clinical pathway for MBS consideration. Ethical issues remain possible for each case, however, and consultation with ethical experts can provide clarity in the consideration of MBS. Specifically, ethical issues related to principles of autonomy, justice, beneficence, and non-maleficence may need to be resolved based on patient characteristics, including preadolescent patients and those who present with intellectual disabilities. Institutions that offer MBS for pediatric patients will benefit from collaborating with ethics consultants to develop a structured approach that helps ensure that ethical principles have been adequately addressed for patients presenting for MBS.

Ética na Avaliação Psicológica: Velhas Questões, Novas Reflexões

Resumo: O objetivo do artigo foi trazer reflexões adicionais à temática da ética na avaliação psicológica. O trabalho foi organizado em três principais discussões. A primeira aborda o quanto os documentos normativos, no contexto brasileiro, reafirmam o caráter dinâmico, transformador, cultural e benéfico de uma Psicologia e avaliação psicológica pautadas na ética. Na segunda parte, analisando artigos internacionais e nacionais, surgem dois pontos principais de reflexão: as mudanças na ética em avaliação psicológica provocadas por demandas sociais, e o quanto mais mudanças ainda são necessárias em razão de questões negligenciadas, que carecem de um maior cuidado pela avaliação psicológica. Num terceiro momento, discutiu-se a formação em avaliação psicológica, a partir de uma análise de processos éticos julgados pelo CRP-SP entre os anos de 2014 e 2018 (primeiro trimestre). Por fim, buscou-se argumentar sobre a necessidade de uma formação ética permanente, para além de uma formação estritamente profissional, a ocorrer nos mais variados espaços da sociedade, ao longo do desenvolvimento do ser humano, que estimule uma consciência social baseada na teoria e na práxis.

Ethical considerations in bariatric surgery in a developing country

Background and aims

Obesity is the fastest growing health problem worldwide. Ethical issues linked to obesity are numerous and still under debate even in countries with a long history in obesity treatment.

Methods

From 2007 to 2015 we performed several types of bariatric surgical approaches on 250 patients with an average body mass index (BMI) of 42. The age range was 12–64 years. No death was recorded. Direct or phone contact was possible with 90% of them during follow-up. Starting from a specific question based approach in ethics we present aspects regarding obesity surgery in Romania. Patients’ safety, informed consent, cost cover, the role of bariatric surgery in children and bariatric surgeons’ training are discussed.

Results

Co-morbidities improved or even disappeared in 90% of our patients. Informed consent is a major problem, due to the lack of public knowledge necessary. The private system in Romania offers bariatric surgery at lower prices than Western Europe but is still out of reach for a person with an average income. Lack of maturity and disharmonic family relations raise a series of challenges in assessing the best interest of children and adolescents. Ethics committees, which operate according to well-defined processes, are more and more active in universities and research centers in Romania, checking that methods and performance of scientific studies meet adequate standards.

Conclusions

A detailed informed consent, thorough preoperative patient assessment and method selection are mandatory for good results in obesity surgery. Insufficient financial resources combined with the long time necessary to acquire the expertise for laparoscopic bariatric surgery may represent an additional pressure on both physicians and patients.

Aggressive clinical approach to obesity improves metabolic and clinical outcomes and can prevent bariatric surgery: a single center experience

BACKGROUND

The number of bariatric procedures has exponentially increased in the past decade, as a result of the lack of successful clinical weight-loss interventions. The main reasons for the failure of clinical obesity management are: (1) anti-obesity medications are administered as monotherapies (or pre-combined drugs); (2) lack of combination between pharmacotherapy and non-pharmacological modalities; (3) short duration of pharmacotherapy for obesity; (4) lack of weight-loss maintenance strategies; (5) misunderstanding of the complex pathophysiology of obesity; and (6) underprescription of anti-obesity medications. We developed a protocol that can potentially overcome the drawbacks that may lead to the failure of clinical therapy for obesity. The aim of this study is therefore to report the clinical and metabolic effects of our proposed obesity-management protocol over a 2-year period, and to determine whether this more intensive approach to obesity management is feasible and a possible alternative to bariatric surgery in patients with moderate-to-severe obesity.

METHODS

This retrospective study involved 43 patients in whom bariatric surgery was indicated. Patients underwent an intensive anti-obesity protocol that included pharmacotherapy with multiple drugs; intense surveillance with monthly body analysis by air-displacement plethysmography, electrical bioimpedance, and 3D body scans; weekly psychotherapy; diet planning with a dietician every 2 months; and exercises at least 3 times a week with exercises prescribed by a personal trainer at least once a month. Body weight (BW), total weight excess (TWE), obesity class, body mass index, fat weight, muscle weight, waist circumference, and visceral fat were analyzed. Markers of lipid and glucose metabolism, liver function, and inflammation were also evaluated. Therapeutic success was defined as >20% BW loss or >50% decrease in TWE after 1 year.

RESULTS

Significant improvements were observed in all clinical and metabolic parameters. Thirty-eight (88.4%) patients achieved 10% BW loss, and 32 (74.4%) achieved 20% BW loss. TWE decreased by >50% in 35 (81.4%) patients. Forty (93.0%) patients were able to avoid bariatric surgery.

CONCLUSION

An intensive clinical approach to obesity management can be an effective alternative to bariatric surgery, although further randomized controlled studies are necessary to validate our findings.

The influence of preoperative psychological factors on weight loss after bariatric surgery: A preliminary report

Aim of this study was to investigate relationship between preoperative psychological factors and % total weight loss after gastric bypass. 76 adult patients scheduled for bariatric surgery were preoperatively asked to complete anxiety and depression Hamilton scales and Toronto Alexithymia Scale. At 3- and 6-month follow-up, body weight was assessed. At 6-month follow-up, alexithymic patients showed a poorer % total weight loss compared with non-alexithymic patients ( p = .017), and moderately depressed patients showed a lower % total weight loss compared with non-depressed patients ( p = .011). Focused pre- and postoperative psychological support could be useful in bariatric patients in order to improve surgical outcome.