Scoping review of end-of-life care for persons with anorexia nervosa.

BACKGROUND: End-of-life (EOL) care is the part of palliative care intended for persons nearing death. In anorexia nervosa (AN), providing EOL care instead of coercing life-sustaining measures is controversial. The existing literature has not been synthesized yet. To clearly delineate differing views and identify open questions as well as areas of possible consensus, we conducted the first-ever synthesis of the existing literature. METHODS: We searched EMBASE, PubMed, PsycInfo, and Web of Science for scientific publications on forgoing coerced life-sustaining measures and/or providing EOL care for persons with AN who refuse life-sustaining measures, typically artificial nutrition. Palliative care outside of the EOL context and medical assistance in dying were not reviewed. As very little quantitative studies were identified, we qualitatively analyzed conceptual questions, ethical reasoning, legal aspects, stakeholder attitudes, practical aspects, stakeholder needs, and outcome. RESULTS: We identified 117 eligible publications from 1984 to 2023, mainly case reports (n=26 different cases) and ethical analyses. Conceptualizations of key terms such as terminality, futility, and decision-making capacity (DMC) in AN varied widely and were often value-laden and circular. Ethical reasoning centered on weighing the preservation of life versus quality of life in the context of uncertainty about DMC and likelihood of clinical remission. Studies on stakeholder attitudes reflected this challenge. In some cases, courts ruled against coerced life-sustaining measures and/or in favor of EOL care for persons with AN. While eligibility criteria were contested, recommendations for deliberating about and providing EOL care were consistent. We identified only one study on stakeholder needs and none on outcome. Case reports described quality of life under EOL care as good and death as the most frequent outcome but engagement in voluntary treatment and (partial) clinical remission in some. CONCLUSIONS: The debate around EOL care in AN needs consented, coherent terminology whose value base is reduced to a minimum and made transparent. While more empirical research into decision-making in AN and predictors of outcome might help reduce uncertainty, fundamental normative questions need to be addressed, for example regarding the ethico-legal significance of treatment refusals, the weighing of quantity versus quality of life and the appropriateness of diagnosis-based ethico-legal exceptionalism such as hard paternalism. More research is needed on outcome of and stakeholder needs in EOL care for persons with AN.

Moral Intuitions About Futility as Prompts for Evaluating Goals in Mental Health Care.

Mental health professionals' moral intuitions about futility should prompt reevaluation of goals of care and care plans. Mostly, it will suffice to improve the care plan and/or slightly adjust the goal of care (eg, lower expectations), which is standard practice. Sometimes, however, all care plans that seek to reduce core symptoms (ie, that pursue a curative goal) are most likely futile and thus should not be imposed. Here, it may be in the patient's best interest to change the goal of care toward palliation (ie, harm reduction, relief of suffering, and best possible quality of life). Thus, futility can function as a moral counterweight to the duty to treat, helping mental health professionals find the right balance between over- and undertreatment.

Palliative psychiatry in a narrow and in a broad sense: A concept clarification.

Even with optimal treatment, some persons with severe and persistent mental illness do not achieve a level of mental health, psychosocial functioning and quality of life that is acceptable to them. With each unsuccessful treatment attempt, the probability of achieving symptom reduction declines while the probability of somatic and psychological side effects increases. This worsening benefit-harm ratio of treatment aiming at symptom reduction has motivated calls for implementing palliative approaches to care into psychiatry (palliative psychiatry). Palliative psychiatry accepts that some cases of severe and persistent mental illness can be irremediable and calls for a careful evaluation of goals of care in these cases. It aims at reducing harm, relieving suffering and thus improving quality of life directly, working around irremediable psychiatric symptoms. In a narrow sense, this refers to patients likely to die of their severe and persistent mental illness soon, but palliative psychiatry in a broad sense is not limited to end-of-life care. It can - and often should - be integrated with curative and rehabilitative approaches, as is the gold standard in somatic medicine. Palliative psychiatry constitutes a valuable addition to established non-curative approaches such as rehabilitative psychiatry (which focuses on psychosocial functioning instead of quality of life) and personal recovery (a journey that persons living with severe and persistent mental illness may undertake, not necessarily accompanied by mental health care professionals). Although the implementation of palliative psychiatry is met with several challenges such as difficulties regarding decision-making capacity and prognostication in severe and persistent mental illness, it is a promising new approach in caring for persons with severe and persistent mental illness, regardless of whether they are at the end of life.

Fat compartments in patients with depression: A meta-analysis.

INTRODUCTION: Depressive disorders are a common illness worldwide. Major depression is known as a significant predictor of the metabolic syndrome. However, the effects of depression on adipose tissue compartments are controversial. This meta-analysis aimed to evaluate the state of research on the relationship between patients with depression and adipose tissue compartments as compared to nondepressed individuals. METHODS: The PubMed database was searched for human studies that measured adipose tissue compartments such as visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT) and/or organ-specific adipose tissue measurements using dual-energy X-ray absorptiometry, magnetic resonance imaging or computed tomography scan and reported the means and a measure of variance separately for depressed individuals and healthy controls. Twelve articles were identified, including a total of 1,141 depressed and 2,545 nondepressed individuals. RESULTS: Major depressive disorder and self-reported depressive symptoms were associated with elevated visceral adipose tissue and elevated subcutaneous adipose tissue. Subanalyses for gender, age, method of adipose tissue measurement, and method of depression assessment showed elevated visceral adipose in depressed individuals. The results could be replicated when focussing on studies controlling for body mass index (BMI). Regarding other adipose tissue compartments, meta-analysis could not be carried out due to lack of studies. CONCLUSIONS: Depression is associated with enlarged visceral and subcutaneous adipose tissue. Further, especially longitudinal, research is needed to identify the mechanism through which depressive disorders contribute to visceral adiposity.

Association of Genetic Variation at AQP4 Locus with Vascular Depression.

Despite its substantial clinical importance, specific genetic variants associated with depression have not yet been identified. We sought to identify genetic variants associated with depression by (a) focusing on a more homogenous subsample (vascular depression) and (b) applying a three-stage approach. First, we contacted 730 participants with a confirmed atherosclerotic disease (coronary artery disease) from a population-based study population (German Myocardial Infarction Family Study IV) for psychiatric assessment with the Mini International Neuropsychiatric Interview. Second, we genotyped these patients using genome-wide single nucleotide polymorphism (SNP) arrays. Third, we characterized the SNP via in-silico analysis. The final sample consisted of 342 patients (78.3% male, age = 63.2 ± 9.9 years), 22.8% with a severe depressive disorder. Variant rs528732638 on chromosome 18q11.2 was a genome-wide significant variant and was associated with 3.6-fold increase in the odds of lifetime depression. The locus belongs to a linkage disequilibrium block showing expression quantitative trait loci effects on three putative cis-regulated genes, including the aquaporin 4 (AQP4) locus. AQP4 is already known to mediate the formation of ischemic edema in the brain and heart, increasing the size and extent of resulting lesions. Our findings indicate that AQP4 may also play a role in the etiopathology of vascular depression.

Mental Health and Psychosocial Functioning Over the Lifespan of German Patients Undergoing Cardiac Catheterization for Coronary Artery Disease.

Background: Psychological problems are common in patients with coronary artery disease (CAD) and are associated with poor outcome. However, data on the prevalence of distinct mental disorders and their relevance to patients' functioning in daily life are scarce. Method: In this retrospective study, a total of 514 German patients with CAD as diagnosed by cardiac catheterization were assessed using the Mini International Neuropsychiatric Interview 5.0.0 (M.I.N.I.) and psychosocial functioning was evaluated using the Global Assessment of Functioning (GAF) scale. Results: Twenty-nine percent of the participants suffered from at least one mental disorder after the onset of their CAD (mean time since onset = 10.86 years, SD = 8.15). In comparison to the period before onset of CAD, elevated prevalence rates were found for severe depressive episodes, agoraphobia, dysthymia, panic disorder, and hypochondria. Predictors of mental disorders after the onset of CAD were female gender, younger age at onset of CAD as well as mental disorders and low GAF scores before onset. GAF scores decreased after the onset of CAD, recovered only partially, and were influenced by mental disorders before onset in women but not in men. Conclusions: Mental disorders-especially depression and agoraphobia-are frequent in patients with CAD, with women, patients with a younger age at onset of CAD and patients with any history of mental disorders especially at risk. Regardless of whether patients meet any specific diagnostic criteria, psychosocial functioning is markedly impaired after the onset of CAD, underscoring the need for specific mental health programs for this patient population. Future research, ideally using a prospective design, is necessary to confirm these findings and to further the knowledge of prevalence rates of mental disorders and of modifiable risk factors for the development of mental disorders in patients with CAD.

All Unhappy Childhoods Are Unhappy in Their Own Way-Differential Impact of Dimensions of Adverse Childhood Experiences on Adult Mental Health and Health Behavior.

Adverse childhood experiences have consistently been linked with poor mental and somatic health in adulthood. However, due to methodological restraints of the main lines of research using cumulative or selective models, little is known about the differential impact of different dimensions of adverse childhood experiences. Therefore, we gathered data from 396 psychiatric in-patients on the Adverse Childhood Experiences (ACE) questionnaire, extracted dimensions using factor analysis and compared this dimensional model of adverse childhood experiences to cumulative and selective models. Household Dysfunction (violence against the mother, parental divorce, substance abuse or incarceration of a household member) was associated with poor health behaviors (smoking, alcohol dependency and obesity as proxy marker for an imbalance between energy intake and physical activity) and with poorer socio-economic achievement (lower education and income) in adulthood. The previously reported associations of maltreatment and sexual abuse with these outcome criteria could not be corroborated. Both Maltreatment (emotional and physical neglect and abuse) and Sexual Abuse predicted BPD, PTSD and suicidal behavior. However, the two ACE dimensions showed sufficiently divergent validity to warrant separate consideration in future studies: Maltreatment was associated with affective and anxiety disorders such as social phobia, panic disorder and major depressive disorder, whereas Sexual Abuse was associated with dysregulation of bodily sensations such as pain intensity and hunger/satiation. Also, we found both quantitative and qualitative evidence for the superiority of the dimensional approach to exploring the consequences of adverse childhood experiences in comparison to the cumulative and selective approaches.