KeywordsA obesidade, condição cuja prevalência vem aumentando em níveis de epidemia no mundo inteiro, compartilha com os transtornos psiquiátricos de pesado preconceito tanto entre a população leiga quanto entre os profissionais de Saúde. Quando se considera a associação entre estas patologias, observa-se uma pobreza de dados quer em termos caracterização desta associação quer em termos de tratamentos específicos. Neste artigo, tópicos relativos à interface entre estes aspectos e a realização de operações bariátricas, assim como um breve resumo de suas indicações serão abordados, à luz da literatura mundial e da experiência dos autores.Cirurgia bariátrica. Obesidade mórbida. Obesidade grau III. Aspectos e contra-indicações psiquiátricas.
Objective: To evaluate the efficacy of diethylpropion on a long-term basis, with emphasis in cardiovascular and psychiatric safety aspects. Design: Randomized, double-blind, placebo-controlled trial Measurements: Following a 2-week screening period, 69 obese healthy adults received a hypocaloric diet and were randomized to diethylpropion 50 mg BID (n ¼ 37) or placebo (n ¼ 32) for 6 months. After this period, all participants received diethylpropion in an open-label extension for an additional 6 months. The primary outcome was percentage change in body weight. Electrocardiogram (ECG), echocardiography and clinical chemistry were performed at baseline and every 6 months. Psychiatric evaluation and application of Hamilton rating scales for depression and anxiety were also performed by experienced psychiatrists at baseline and every 3 months. Results: After 6 months, the diethylpropion group lost an average of 9.8% (s.d. 6.9%) of initial body weight vs 3.2% (3.7%) in the placebo group (Po0.0001). From baseline to month 12, the mean weight loss produced by diethylpropion was 10.6% (8.3%). Participants in the placebo group who were switched to diethylpropion after 6 months lost an average of 7.0% (7.7%) of initial body weight. The difference between groups at month 12 was not significant (P ¼ 0.07). No differences in blood pressure, pulse rate, ECG and psychiatric evaluation were observed. Dry mouth and insomnia were the most frequent adverse events. Conclusion: Diethylpropion plus diet produced sustained and clinically significant weight loss over 1 year. It seems to be safe in relation to cardiovascular and psychiatric aspects in a well-selected population.
Speculation concerning the role of psychiatric disorders in patients undergoing bariatric surgery is abundant in the literature. Psychiatric factors predicting the success or failure of bariatric surgery have not been adequately described. However, an increasing number of cases of eating disorders in the postoperative period are being reported. A concise literature review and 5 cases are presented with the purpose of studying the specific pathological eating habits of these patients. The criteria for Anorexia or Bulimia Nervosa were not fulfilled in most of the reports studied and were not met by the 5 patients described. The criteria for a new eating disorder (Post-Surgical Eating Avoidance Disorder, PSEAD) are proposed.
Grade III obesity (BMI > 39.9 kg/m2) is considered a chronic disease where clinical and diet therapy show poor results, with high rates of relapse. The most consistent results are those obtained through surgical procedures. Several authors discuss the contraindications for the performance of anti-obesity operations. Psychiatric disorders are often considered contraindications to these operations, especially affective disorders, psychotic disorders and personality disorders. The authors report the case of a 37-year-old patient, with obesity history since the age of 12, and anorexiant abuse (amphetamine-derived substances) during 20 years, binge-eating episodes, purgative compensatory behaviors and recurrent depressive symptoms. She was submitted to anti-obesity surgery in August 2000 (BMI 40.2). The outcome is reported and a discussion of the possible psychiatric contraindications for the anti-obesity surgeries is proposed.
RESUMOObjetivo: Os autores discutem, a partir de um relato de caso e de uma revisão da literatura, as implicações de uma operação bariátrica sobre o comportamento alimentar. Método: É apresentado o caso clínico de uma paciente submetida a uma operação bariátrica e que apresentou alterações comportamentais alimentares semelhantes às de uma anorexia nervosa, mas não apresentando peso abaixo do normal, o que levou a um diagnóstico de transtorno alimentar não especificado. Este caso é analisado em comparação com situações semelhantes na literatura. Discussão: Os dados da literatura são discutidos de acordo com aqueles apresentados no caso relatado e procura-se, a partir daí, obter uma conduta prudente frente aos candidatos à cirurgia bariátri-ca e no seguimento pós-operatório, analisando os possíveis riscos envolvidos. Objective: The authors discuss, based on a case report and on a literature review, the implications of a bariatric surgery for obesity on the eating behavior. Method: A case report is presented in which a patient was submitted to a bariatric surgery and show altered eating behavior like in anorexia nervosa, but without low weight, leading to the diagnostic of an otherwise unspecified eating disorder. This case is compared with the literature review. Discussion: Literature information is discussed according to data from the present case and based on this, aiming to establish a prudent conduct with bariatric surgery candidates and their follow up, analyzing the possible risks involved. Cirurgia bariátrica é a medida mais efetiva no tratamento da obesidade mórbida. Uma adequada avaliação psiquiátrica pré-cirúrgica é essencial para o diagnóstico e adequado tratamento precoce de um transtorno alimentar prévio. Powers e cols. (10), num grupo de 116 pacientes submetidos à cirurgia gástrica restritiva, estudados por 10 anos, encontraram episódios bulímicos em 52% dos casos, Transtorno da Compulsão Alimenapresentação de caso
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