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Bariatric surgery : the psychiatric perspective

Bariatric surgery : the psychiatric perspective. Vineka Heeramun, MD june 2014 PGY3 MedPsych. disclosures. Nil. Case scenario.

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Bariatric surgery : the psychiatric perspective

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  1. Bariatricsurgery :the psychiatricperspective Vineka Heeramun, MD june 2014 PGY3 MedPsych

  2. disclosures • Nil

  3. Case scenario • 39 yearold lady with BMI of 45, history of diabetes , hyperlipidemia, major depressivedisorder, (MDD), panic attacks, alcoholdependence, bingeeatingdisorder. • Was on sertralinewhichwasdiscontinued due to failure to follow up. • Last hospitalizationwas 8 monthsago for MDD. No suicidalattempt. • Sober for 2 years. Still has panic attacks and somebingingepisodes. WHAT ARE HER RISKS FOR BARIATRIC SURGERY?

  4. Obesity trends

  5. obesity • Obesity is a worldwide epidemic • BMI of >30 kg/m2. • Severe obesity : BMI >40 kg/m2 (or ≥35 kg/m2 in the presence of comorbidities). • 33.8 percent of adults in the United States and Canada are classified as obese.

  6. Obesity trends

  7. Cause-specific mortality ●Ischemic heart disease (HR 1.39) and stroke (HR 1.39) ●Diabetes (HR 2.16) ●Neoplastic disease (HR 1.10) liver, kidney, breast, endometrial, prostate, and colon ●Respiratory diseases (HR 1.20)

  8. Obesity:comorbidities

  9. Psychosocial function • Exposed to public disapproval . • This stigma is seen in education, employment, and health care, among other areas. • Fewer years of school (0.3 year less) • 20 percent less likely to be married • Lower household incomes ($6710 less per year) • 10 percent higher rates of household poverty • Depression -severe obesity, particularly in younger patients and in women • Disorders of sexual arousal and orgasm more common in overweight and obese women. • In men, obesity is an independent risk factor for erectile dysfunction

  10. Financial impact • Obese subjects had 1.4 to 2.4 times the number of days of sick leave • 1.5 to 2.8 times as likely to draw a disability pension • Increase in annual rates of days of hospitalization, - number and costs of outpatient visits -costs of outpatient pharmacy and laboratory services • 25 percent greater among subjects with a BMI 30 to 34.9 kg/m2 versus BMI of 20 to 24.9 kg/m2 • 44 percent greater among those with a BMI of 35 kg/m2 or higher. • Higher costs were predominantly explained by the presence of coronary heart disease, hypertension, and diabetes.

  11. Treatment: medical vs surgical • All patients – Lifestyle modifications, diet, exercise, behavioral therapy • Pharmacologic therapy added - BMI >30 kg/m2 or a BMI of 27 to 29.9 kg/m2 with comorbidities, who have failed to achieve weight loss goals through diet and exercise alone • Bariatric surgery in : -BMI ≥40 kg/m2 who have failed to lose weight with diet, exercise, and drug therapy -BMI >35 kg/m2 with obesity-related comorbidities who have failed diet, exercise, and drug therapy (if anticipated benefits outweigh the risks of the procedure)

  12. Treatment: medical vs surgical

  13. Financial impact OF BARIATRIC SURGERY • May be more efficacious than medical or lifestyle intervention for long-term weight loss and remission of diabetes. • Short-term cost-savings have been reported in some studies, and long-term cost-saving and cost-effectiveness is strongly debated. • Surgical treatment for obesity lowered diabetes and cardiovascular disease-related drug costs but increased gastrointestinal drug costs, resulting in similar total drug costs for surgically and conventionally-treated obese patients.

  14. Financial impact • Compared with controls, surgically treated patients used more inpatient and nonprimary outpatient care during the first 6-year period after undergoing bariatric surgery but not thereafter. • Drug costs from years 7 through 20 were lower for surgery patients than for control patients. (Neovius M, Narbro K, Keating C, et al. JAMA 2012 ) • Downstream savings associated with bariatric surgery are estimated to offset the initial costs in 2 to 4 years. (Am J Manag Care. 2008;14(9):589-596) • Bariatric surgery does not reduce overallhealth care costs in the long term. JAMA Surg. 2013;148(6):555-562.

  15. BARIATRIC SURGERY TRENDS

  16. BARIATRIC SURGERY TRENDS

  17. PREVALENCE OF PSYCHIATRIC DISORDERS BY INTERVENTION MODALITIES(lin et al bmcpsychiatry 2013,13:1) • Mood disorders, anxiety disorders, eating disorders most prevalent • More in females • The surgical group had more binge-eating disorder, adjustment disorder and sleep disorders

  18. BARIATRIC SURGERY PROCEDURES

  19. FINALLY…

  20. LIFE AFTER BARIATRIC SURGERY • Specificways to eat • Separateliquidsfromsolids by 30 minutes • Eatslowly /small bites • Chewfood well-20/30 times per bite • Mindfuleating • Pay attention to feeling full • Eatevery 3-4 hours

  21. POST SURGERY • Weight loss occurs rapidly over the first few months • Average weight loss is 10 to 15 pounds (4.5 to 7 kg) per month • At the six-month follow up visit is 60 to 80 lb (27 to 36 kg). • Total weight loss reaches a peak at 12 months postoperatively, averaging 100 to 120 lb (45 to 54 kg).

  22. AFTER SURGERY • Diabetes mellitus • more likely to achieve optimal blood sugars • Dyslipidemia – • total cholesterol levels decreased by 16 percent • triglyceride levels decreased by 63 percent • low-density lipoprotein cholesterol levels decreased by 31 percent, • high-density lipoprotein cholesterol levels increased by 39 percent. • 82 percent no longer required medical therapy • Polycystic ovary syndrome —30 percent to 70 percent of obese women • restored menstrual cycles at three months following the operation • lessening of hirsutism and hyperandrogenemia at eight months • increased ability to conceive within two years of surgery

  23. MOOD DISORDERS • Depression is a significant co-morbidity in obese individuals. • Depression significantly improves after bariatric surgery. • Symptoms remain significantly below pre-surgery levels as much as 5–10 years post-surgery. • Other findings indicate that the improvements in symptoms of depression may begin to decline over time, and in some cases may even return to pre-surgery levels. • Higher depression scores after surgery have been found to be associated with less weight loss.

  24. suicide • There may be an increased risk of suicide after bariatric surgery • Adams et. al. They matched 7925 surgical patients to 7925 controls on BMI, gender and age. Although the 7 years post-surgery long-term mortality was reduced by 40 % in the surgery group, there were 15 suicides in this sample compared to five in the control group. • Tindle et al. found a substantial excess of suicides (31 in 16,683 operations) among patients • Mitchell, Crosby, de Zwaan and colleagues proposed reasons including - Disappointment with the amount of weight loss -Unresolved or recurring medical comorbidities, continued or recurrent physical mobility restrictions.

  25. Body contour aftersurgery • Many patients feel worse about their appearance than when they were obese • Redundant skin –cosmetic disappointment • Risk factors include severity of obesity, amount of weight lost, age, smoking, sun tanning, fair complexion, and genetic make-up. • Excess skin is predominately found on the abdomen, breasts, upper arms, and thighs

  26. Body contour aftersurgery • 70% to 85% of patients express a wish for Body contour (BC) procedure • 11% and 47 \% patients perform it • Generally, patients’ self-perception of their appearance as well as their psychological and social health and well-being improve significantly with BC

  27. Body contour aftersurgery • Some patients continue to express dissatisfaction with the contoured regions after Body contour surgery • Relative high complication rate such as delayed wound healing, infections, and visible scars

  28. EATING DISORDERS • Binge eating and binge eating disorder (BED) are common among obese patients seeking bariatric surgery. • Average prevalence 25%. • After bariatric surgery, the prevalence of binge eating usually decreases significantly. • However a subgroup of patients after weight loss surgery will develop subjective binge or “loss of control” eating, self-induced vomiting for weight and shape reasons. • A pre-surgery eating disorder - clear predictor. • Postsurgery “loss of control” eating has been shown to be associated with less weight loss and increased subjective distress.

  29. EATING DISORDERS • Marked changes in their eating behavior • Require the frequent intake of small amounts of food with extensive chewing before swallowing. • Many ill-defined behaviors have been reported - “grazing,” nibbling,” and “snacking.” • Once weight loss slows down or stops, some patients will engage in restrictive or compensatory behaviors in an effort to prevent weight regain. • Development of bulimia nervosa and anorexia nervosa.

  30. DetectingeaTING DISORDERS 1. Assess patient’s motivation 2. Distress 3. Preoccupation with such behaviors STRUCTURED INTERVIEWS: Eating disorder exam questionnaire Structured clinical interview for DSM (SCID) MINI International Neuropsychiatric interview (MINI)

  31. SUBSTANCE USE • Ertelt and colleagues - alcohol use problems after bariatric surgery among those not having had the problem before surgery. • Suzuki et al. - lifetime diagnosis of alcohol use disorders were more likely to develop this problem again after surgery especially RYGB rather than LAGB. • King et al. reported data from the • Longitudinal Assessment of Bariatric Surgery-2 • (LABS-2) consortium on 1945 patients • 7.6% at baseline and 7.3% at 1 year • 2 years the rate had increased to 9.6

  32. SUBSTANCE USE • RYGB rather than LAGB: significant increase in the frequency of alcohol use from baseline to 24 months after surgery. • Pharmacokinetic changes in alcohol absorption after bariatric surgery. • Blood alcohol concentrations /breath alcohol concentration - an accelerated and higher peak alcohol concentration in post-surgery patients, longer metabolic half-life • Steffen et al. found that blood alcohol levels peaked very quickly, usually before 10 minutes

  33. PSYCHOTROPIC MEDICATIONS Changes in gastrointestinal tract leading to decreaseddrug absorption

  34. antidepressants • Pilot study indicated that patients who had undergone RYGB showed a significantly lower area under the curve and maximal plasma concentrations of sertraline. • A longitudinal study suggested that SSRIs but not SNRIs had a lower bioavailability 1 month after gastric bypass surgery which returned to baseline levels or greater by 6 months. • Roerig et al. demonstrated a significant decrease in the plasma levels of duloxetine.

  35. AntipsychoticS • No change in haldol concentration post RYGB (Fuller 1986) • Olanzapine, clozapine, quetiapine, risperidone, ziprasidonedecrease in dissolved portions after RYGB (Seaman et al 2005) • Risperdalconsta post surgery due to inability to tolerate oral medications(Brietzke and Lafer 2011)

  36. lITHIUM • Absorbed in small intestine • Hydrophilic,notproteinbound • Case report of Lithium toxicity post RYGB • Lithium dissolution increase in vitro(Seaman et al 2005) • Main concerns: • Lithium toxicity due to changes in food and fluidintake, electrolytes • Subtherapeuticlevels due to decreased absorption

  37. PSYCHOTROPIC MEDICATIONS:recommendations • Lithium- • 0-6 weeksaftersurgery: weeklylevels • Monitor foodintolerance/vomitting • Decrease dose if level >1.2 mmol/l • Switch medicationsfromextended to immediate release if possible/available • Close monitoring of mental statusaftersurgery • Monitor for discontinuation syndrome e.g. withpaxil • Drug levels as possible e.g. valproicacid,TCAs • Communicatewith PCP

  38. PSYCHIATRIC ASSESSMENTOF BARIATRIC SURGERY PATIENTS • Identify potential psychosocial factors that may negatively influence post-surgical outcome and to evaluate the candidates’ suitability for bariatric surgery. • Pre-bariatric assessments -face-to-face interviews and questionnaires. • Note that a psychiatric disorder per se is not a general contraindication for bariatric surgery. • There may be psychological reasons for denying clearance for surgery • Acute or inadequately managed mental illness such as psychotic symptoms, active substance abuse, bulimia nervosa, untreated depression or suicidal ideations. • Lack of commitment with the post-surgical protocol. • Deficient understanding about the risks of surgery and the requirements for pre- and post-operative medical care, life-long changes in diet and activity.

  39. SOCIAL SUPPORT • Livhits et al. found a positive association between social support and weight loss after bariatric surgery. • Meta-analysis of randomized controlled trials including 15 studies could confirm a positive effect of support groups as well as behavioral lifestyle interventions on weight loss • 2 % greater degree of percent excess weight loss following behavioral lifestyle intervention -lower levels of maladaptive eating patterns, higher levels of physical activity, and greater adherence to dietary recommendations. • Best time to deliver behavioral management strategies after “honeymoon phase”

  40. TREATMENT PLAN: 10 steps 1. Thoroughassessment • Medical/surgical • Psychosocial 2. Determine and communicatediagnosis 3. Behavioraleducation 4. Assess motivation to change 5. Considermedications 6. Involvedieticians

  41. TREATMENT PLAN:10 steps 7. Monitor physical markers 8. Treatpsychiatriccomorbidities 9. Psychotherapy/Suppport groups 10. Referral for more intensive treatment

  42. Back to the case • 39 yearold lady with BMI of 45,history of diabetes , hyperlipidemia, major depressivedisorder, (MDD), panic attacks, alcoholdependence, bingeeatingdisorder. • Was on sertralinewhichwasdiscontinued due to failure to follow up • Last hospitalizationwas 8 monthsago for MDD. No suicidalattempt. • Sober for 2 years. Still has panic attacks and somebingingepisodes. • WHAT ARE HER RISKS FOR BARIATRIC SURGERY?

  43. conclusion • Assesspresurgeryriskfactors • Presurgerypsychiatricstabilityiskey • Engage in psychosocial interventions early • Ongoing care after the post ‘honeymoon’ period • Importance of multidisciplinaryapproach

  44. Thankyou! • Dr Hasanat • Dr Bennett • Dr Hammer • K.Paskiewicz

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