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Patients Selection for Bariatric Surgery

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

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  1. Patients Selection for Bariatric Surgery (Psychiatric Aspects) Yana M. Van Arsdale, MD, PHD

  2. 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

  3. 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

  4. 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”

  5. 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

  6. 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

  7. Reasons to have a surgery • Medical problems • Inability to perform desired tasks • Social isolation • Discrimination • Depression

  8. 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

  9. 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%

  10. Bariatric surgery • Life threatening complications • peritonitis • pulmonary embolism • pneumonia • atelectasis • Failed weight loss 5-30% • Weight regain 18-24 months postsurgery

  11. Inability to maintain weight loss • Inadequate coping strategies • Physiological factors • A need to determine behavioral strategies to treat various subgroups of Pts

  12. 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

  13. Bariatric surgery, categories • Malabsorptive • Restrictive • gastric banding • Malabsorptive / restrictive • gastric bypass • Experimental

  14. Bariatric surgery, techniques • Laparoscopy – < complications • Open surgery

  15. Gastric bypasssurgery • Surgery of choice – majority of countries • Requirement - substantial change of eating patterns • amount • frequency • choice of food

  16. Consensus I • Gastric bypass procedure could be considered for • well informed • motivated Pts • acceptable operative risk

  17. 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

  18. 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

  19. 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

  20. 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?)

  21. Limitations • Perioperative behavior modification • Biopsychosocial aspects of severe obesity • No Hx of evolution of contraindications for surgery • Psychiatric complications after surgery

  22. Goals • Up-date & summarize important facts in selecting Pts for • Optimal long-term outcomes • Comorbidity reduction • Improvement in quality of life

  23. 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% (???)

  24. 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%

  25. Prevalence • Psychosis - 2.4 – 5 % • Personality DO - 15 - 89% • < borderline • > schizoid, paranoid, histrionic, compulsive

  26. 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 (?)

  27. 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

  28. 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

  29. 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

  30. 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

  31. 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

  32. 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

  33. 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

  34. 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.

  35. Psychological tests, challenges • Symptoms vs syndromes vs disorders • Substitution for DSM-IV-TR / structured interview • Misinterpretation • somatization – ego defense vs symptom • Omissions • nicotine dependence

  36. MSU/KCMS psychiatry clinic method (cont.) • Additional self-reports • Gastric bypass quiz • Gastric bypass evaluation form • Confidential report • DSM-IV – diagnostic tool

  37. MSU/KCMS psychiatry clinic method (cont.) • Psychiatric interview • structured • modified • Hx obesity & weight loss is a part of an interview

  38. 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

  39. 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

  40. 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

  41. 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

  42. Questions to be answered • Cognitive functioning • Knowledge • Coping skills • Motivations & expectations • Psychopathology • Psychosocial risk factors / lifestyle

  43. 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

  44. 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?

  45. 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%)

  46. Knowledge (cont.) • Is there a good understanding of what is expected postoperatively • diet • exercise • follow-up • support group attendance • rules of eating & vomiting, etc.

  47. 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?

  48. 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

  49. 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

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