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Patients Selection for Bariatric Surgery. ( Psychiatric Aspects ) Yana M. Van Arsdale, MD, PHD. Thanks. Special thanks Dr. Strung & Dr. Alan Saber – for ongoing support Dr. Martos & Dr. Flachier – for manuscript preparation Dr. Picard – for passing grade on research project .

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patients selection for bariatric surgery

Patients Selection for Bariatric Surgery

(Psychiatric Aspects)

Yana M. Van Arsdale, MD, PHD

thanks
Thanks
  • Special thanks
    • Dr. Strung & Dr. Alan Saber – for ongoing support
    • Dr. Martos & Dr. Flachier – for manuscript preparation
    • Dr. Picard – for passing grade on research project
background
Background
  • Literature review
  • Attempt to answer some questions
  • Help to provide first evaluations of bariatric surgery candidates
  • Research directions recommended by the National Institute of Health Consensus
obesity
Obesity
  • Fastest growing epidemics – US
  • BMI equal or greater than 40 kg/m2 – extreme obesity – 2.8% prevalence (adults, US)
  • The more severe, the more serious the medical complications & mortality risk – term “morbid”
terminology
Terminology
  • “Clinically severe obesity” - preferred to “morbid” or “extreme”
  • “Weight loss surgery” vs. “bariatric surgery”
  • “Baric” – pertaining to weight, esp. that of the atmosphere
  • “Iatric” – pertaining to a physician or medicine, Gk iatriko(os) - healing
severe obesity
Severe obesity
  • Medical, social, psychological & economic problem
  • Social stigmatization
  • Almost always refractory to lifestyle modification / pharmacotherapy
  • No long-term effect of participation in weight loss programs
reasons to have a surgery
Reasons to have a surgery
  • Medical problems
  • Inability to perform desired tasks
  • Social isolation
  • Discrimination
  • Depression
eligibility
Eligibility
  • National Institutes of Health Consensus Conference (1991)
  • Severely obese adults
  • BMI equal to or greater than
    • 35 kg/m2 with obesity comorbidity
    • 40 kg/m2 without obesity comorbidity
bariatric surgery
Bariatric surgery
  • Substantial, sustained weight loss
  • The only broadly successful Tx of severe obesity
  • Improvement in quality of life
  • No curative intent
  • Mortality rate 0.14-1.0%
bariatric surgery11
Bariatric surgery
  • Life threatening complications
    • peritonitis
    • pulmonary embolism
    • pneumonia
    • atelectasis
  • Failed weight loss 5-30%
  • Weight regain 18-24 months postsurgery
inability to maintain weight loss
Inability to maintain weight loss
  • Inadequate coping strategies
  • Physiological factors
  • A need to determine behavioral strategies to treat various subgroups of Pts
bariatric surgery13
Bariatric surgery
  • “Behavioral surgery”
  • Psychosocial evaluation is critical in selection of Pts
  • Effective assessment is difficult if the clinician is not familiar with
    • the procedure
    • expected results
    • postoperative management / lifestyle modification
bariatric surgery categories
Bariatric surgery, categories
  • Malabsorptive
  • Restrictive
    • gastric banding
  • Malabsorptive / restrictive
    • gastric bypass
  • Experimental
bariatric surgery techniques
Bariatric surgery, techniques
  • Laparoscopy – < complications
  • Open surgery
gastric bypass surgery
Gastric bypasssurgery
  • Surgery of choice – majority of countries
  • Requirement - substantial change of eating patterns
    • amount
    • frequency
    • choice of food
consensus i
Consensus I
  • Gastric bypass procedure could be considered for
    • well informed
    • motivated Pts
    • acceptable operative risk
consensus ii
Consensus II
  • The mandate to perform psychiatric evaluation of “emotional stability” was replaced - 1991
  • Careful selection of Pts after evaluation by a multidisciplinary team with expertise
    • medical
    • surgical
    • nutritional
    • psychiatric
no consensus
No consensus
  • Potential psychosocial contraindications to bariatric surgery
  • Recommendations to Pts with psychiatric problems
  • Recommendations to the Tx team
  • Nolong-termpredictorsof success
  • Use diagnostic tools / psychometric tests
  • Multiaxial DSM-IV-TR Dx
inappropriate for surgery
Inappropriate for surgery
  • No formal description of contraindications
  • Severe psychopathology that
    • preclude the Pt from informed consent
    • is uncontrolled at the time of evaluation
    • precludes from perioperative cooperation
    • may require re-evaluation
  • Recommendation
    • surgery is not an appropriate Tx option at thistime
general tendency
General tendency
  • Exclude
    • severely mentally ill (consider dynamic/ re-evaluate?) – 5 successful pts Schizophrenia
    • active substance abuse (excluding nicotine dependence?)
    • limited cognitive capacity (dynamic/ degree?)
limitations
Limitations
  • Perioperative behavior modification
  • Biopsychosocial aspects of severe obesity
  • No Hx of evolution of contraindications for surgery
  • Psychiatric complications after surgery
goals
Goals
  • Up-date & summarize important facts in selecting Pts for
    • Optimal long-term outcomes
    • Comorbidity reduction
    • Improvement in quality of life
prevalence
Prevalence
  • Hx mood, anxiety DO, bulimia, nicotine dependence – most frequent
  • Depressive DO - 4.4 - 71% (???)
  • Somatization DO - 29.3 (???)
  • Substance abuse/ dependence, remission - 12 - 23%
  • Nicotine dependence – 48% (???)
prevalence25
Prevalence
  • Social phobia – 18% (?)
  • Hypochondriasis – 15 % (?)
  • OCD – 5 - 13.6% (?)
  • GAD – 6.8 – 16 %
  • PTSD – 0.9 - 16 % (???)
  • Hx physical / sexual abuse – 12 %, each (?)
  • Bulimia & binge eating DO – 0.6 - 26.7%
prevalence26
Prevalence
  • Psychosis - 2.4 – 5 %
  • Personality DO - 15 - 89%
  • < borderline
  • > schizoid, paranoid, histrionic, compulsive
nocturnal eating do
Nocturnal eating DO (?)
  • Night eating syndrome - 30.9 - 55 %
    • skipping breakfast >/=4 d/wk
    • consuming >50% of calories after 7 pm
    • difficultiy falling/ staying asleep >/=4 d/wk
  • No research criteria in DSM-IV-TR
  • Eating DO NOS (?)
binge eating do
Binge eating DO
  • The most studied mental disorder among bariatric surgery candidates
  • Increased risk of depression
  • General population - 2%
  • Bariatric surgery candidates – 18 - 48 %
  • Binge eating but not DO– 8.8 - 68 % obese
binge eating do29
Binge eating DO
  • Research criteria – DSM-IV-TR
  • Consumption
    • objectively large quantity of food
    • brief period (<2 hrs) during which
    • subjective loss of control
    • significant emotional distress
    • notfollowed byvomiting
maladaptive eating behavior
Maladaptive eating behavior
  • Vs eating DO – hypothesis (?)
  • Binge eating vs syndrome vs DO
  • Night eating vs syndrome vs DO
  • Overeating
    • lack of interceptive awareness
    • inability to discern internal cues such as hunger, appetite, satiety, or fullness
  • Grazing
challenge
Challenge
  • Substantial difference in methods utilized in research use of tests vs standardized interview
  • Different diagnostic tools, no DSM-IV-TR
  • > or < close approximation to currentDSM-IV-TR criteria
  • Reliance on self reports
  • Difference in pre- & postoperative reports
challenge32
Challenge
  • Difficult to distinguish between
    • obesity-related symptoms
    • symptoms related to management of obesity
    • symptoms with no specific connections to obesity
  • Controversy about data & dynamic of symptoms
  • Lack of comparison group
msu kcms psychiatry clinic method
MSU/KCMS psychiatry clinic method
  • Pre-surgical assessment only
  • Restrictive/malabsorptive surgery candidates (gastric bypass) only
  • Adults only
  • Provided by psychiatrist
  • Psychometric tests used are
    • MMPI-II
    • BDI
psychological tests
Psychological tests
  • Aids in assessment
  • Only a supplemental part of a thorough clinical evaluation
  • No consensus
  • No standardizedpsychological work-up
  • Relatively normal pre-operative profile (!!!)
  • Use BDI cut-off score of 10 (???) instead of 23
psychological tests hypotheses
Psychological tests,hypotheses
  • Personality tests do not adequately reflect subtle psychiatric symptoms relevant to bariatric surgery
  • BDI does not provide a distinction between symptoms of depression & symptoms related to obesity
    • low level of energy
    • sleep disturbances
    • recent weight loss >15 lb, etc.
psychological tests challenges
Psychological tests, challenges
  • Symptoms vs syndromes vs disorders
  • Substitution for DSM-IV-TR / structured interview
  • Misinterpretation
    • somatization – ego defense vs symptom
  • Omissions
    • nicotine dependence
msu kcms psychiatry clinic method cont
MSU/KCMS psychiatry clinic method (cont.)
  • Additional self-reports
    • Gastric bypass quiz
    • Gastric bypass evaluation form
  • Confidential report
  • DSM-IV – diagnostic tool
msu kcms psychiatry clinic method cont38
MSU/KCMS psychiatry clinic method (cont.)
  • Psychiatric interview
    • structured
    • modified
  • Hx obesity & weight loss is a part of an interview
structured interview
Structured interview
  • Objective approach
  • Measurable device / diagnostic tool
  • Detection of attitudes / styles
  • Straightforward test stimuli
    • Direct questions
    • One and the same questions to each Pt
    • Unambiguous instructions
modified interview
Modified interview
  • How obesity influences quality of life
    • health condition
    • relationship
    • achievements
    • lifestyle, etc
  • How the Pt learned about bariatric surgery
  • Pt’s coping with any previous surgeries
hx obesity weight loss
Hx Obesity & weight loss
  • Family Hx of obesity
  • Hx maladaptive eating behavior
    • inability tocontrol food intake, etc
  • Hx progression of morbid obesity
  • Hx failed weight loss trials
    • Physical exercise
    • Dietarystyles
    • Pharmacological Tx
hx obesity weight loss42
Hx Obesity & weight loss
  • Factors that have contributed to past successes or failures
    • behavioral
    • emotional
  • Current motivations & expectations
  • Ability to comply adequately with the perioperative lifestyle modifications
  • Support system
questions to be answered
Questions to be answered
  • Cognitive functioning
  • Knowledge
  • Coping skills
  • Motivations & expectations
  • Psychopathology
  • Psychosocial risk factors / lifestyle
cognitive functioning
Cognitivefunctioning
  • Does the Pt have the intellectual resources (cognitive capacity) to understand
    • the surgical procedure
    • the associated risks
    • the behavioral changes required to manage the surgically altered stomach
cognitive functioning cont
Cognitive functioning (cont.)
  • Is the Pt able to understand the profound changes associated with bariatric surgery?
  • If there are deficits in cognitive functioning, to what degree is candidate able tocompensate for these deficits?
  • What is the nature & extent (type & degree) of any revealed cognitive dysfunction?
knowledge
Knowledge
  • Is the Pt able to articulate her/his rationale for surgery?
  • Why it is right at this time in her/his life?
  • Does the Pt understand
    • the nature & mechanics of the surgery
    • possible risks & complications of the procedure, including possibility of death (0.3-0.5%)
knowledge cont
Knowledge (cont.)
  • Is there a good understanding of what is expected postoperatively
    • diet
    • exercise
    • follow-up
    • support group attendance
    • rules of eating & vomiting, etc.
knowledge cont48
Knowledge (cont.)
  • How the Pt has obtained this information?
  • How accurate the information is?
  • If additional recommendations were being made, does the Pt understand what they are?
coping skills
Coping skills
  • What coping strategies does candidate use to manage stress, associated with surgery
    • reaching out for help
    • reliance on personal resources
  • Does the Pt feel in control over her/his environment, hopeful, supported & helped
motivation expectations
Motivation & Expectations
  • Is the Pt motivated to undergo the procedure?
  • Is the Pt motivated for recovery?
  • What motivates the candidate to pursue surgery at this time
    • to reduce medical (health) complications of obesity
    • to improve self-esteem
motivation expectations cont
Motivation & Expectations (cont.)
  • Is the Pt committed to following post surgical guidelines?
  • Are the Pt’s expectations realistic concerning the effect of weight loss on their
    • physical & mental condition
    • social life
motivation expectations cont52
Motivation & Expectations (cont.)
  • Are there any irrational or unrealisticexpectations to the point of being relative contraindication to bariatric surgery
    • the operation to be a Tx for all problems of life
    • attributes their problem solely to being overweight
    • expects total change by the operation
psychopathology
Psychopathology
  • Do revealed mental disorder(s) or symptoms preclude a candidate from having bariatric surgical procedure?
  • Are there any risk factors of
    • relapse
    • deterioration
    • recurrence
    • exacerbation

possibly precipitated by surgery

psychopathology cont
Psychopathology (cont.)
  • Are symptoms stableenough?
  • Is a period of documented stability or remission long enough?
  • Is the patient compliant with current treatment?
psychopathology cont55
Psychopathology (cont.)
  • Is there any need for additional treatment?
  • Is continuity of care & follow-upappointment arranged?
  • Is re-evaluation required?
psychosocial risk factors including lifestyle
Psychosocial risk factors,including lifestyle
  • Is there any potential for destabilizing life stressors or crisis?
  • Is social support available?
  • What is the quality of social support system?
psychosocial risk factors including lifestyle57
Psychosocial risk factors, including Lifestyle
  • Who is included in social support system
    • family
    • friends
    • co-workers
    • community
  • Does the patient attend a support group?
  • Is support group attendance recommended?
summary
Summary
  • Is the candidate adequately prepared, from a psychological prospective, to proceed with a surgery?
  • Are there evidence of any barriers that may interfere with patient’s safety and adjustmentto surgical procedure?