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THE CLINICIAN'S ROUNDTABLE - POSSIBLE PSYCHIATRIC PROBLEMS IN BARIATRIC SURGERY PATIENTS

In recent years, bariatric surgery has had a tremendous growth in popularity, understanding the psychosocial aspects of treating morbid obesity may help us improve the success rate of these patients postoperatively. Welcome to The Clinician's Roundtable. I am Dr. Leslie Lundt and with me today is Dr. David Sarwer, The Director of Clinical Services at the Center for Weight and Eating Disorders at the University of Pennsylvania School of Medicine.

DR. LESLIE LUNDT:

Welcome to ReachMD.

DR. DAVID SARWER:

Thank you Dr. Lundt. It is a pleasure being with you today.

DR. LESLIE LUNDT:

How commonly is bariatric surgery performed now in this country.

DR. DAVID SARWER:

Well, the best estimates come from the American Society of Metabolic and Bariatric Surgery suggest that we are probably somewhere between 250,000 and 300,000 cases per year currently. Unfortunately, if we look at the most reliable statistics in the literature based on chart reviews and such from the early 2000s, we were probably around 100,000 cases in about 2003, but since that time that surveys have been done of surgeons and data extracted from other resources have really suggested that that number has doubled if not tripled just in the last 5 years alone.

DR. LESLIE LUNDT:

Wow, so a huge increase.

DR. DAVID SARWER:

Absolutely.

DR. LESLIE LUNDT:

What is the rate of significant psychopathology in these patients.

DR. DAVID SARWER:

You know, there is really when we talk about bariatric surgery and the psychosocial aspects, it is important to realize that there is really almost 2 different generations of this procedure. These procedures were very popular in the 80s and early 90s, and then really fell out of favor, and the studies that were done at that time suggested the patients were very highly psychopathological. More recent studies have also suggested that there is a relatively high rate of psychopathology among these patients, but not as high as the previous reports. But most studies now suggest that it is some more in the neighborhood of about 40% of all patients who come in for bariatric surgery have a current or at least a lifetime axis I diagnosis. The most common of those are things like major depression and the anxiety disorders, which aren’t particularly surprising. So, really those seem like we see higher rates of psychopathology in this patient group as compared to the general population.

DR. LESLIE LUNDT:

And in about 40% you said.

DR. DAVID SARWER:

That is what some of estimates and unfortunately we haven’t seen large scale epidemiological like studies, but one of more recent studies that has been done that used structured clinical interviews on several hundred patients replicated many of these previous findings and did, in fact, suggest about 40% of the patient.

DR. LESLIE LUNDT:

And, most common diagnosis is depression, you said.

DR. DAVID SARWER:

Most common diagnosis seemed to be the mood disorders and whether it is a single episode of major depression or recurrent disorders, but at least 1 study has shown actually a higher rate of the anxiety disorders, not any specific anxiety disorder, but the entire cluster of anxiety disorders were, in fact, a little more common than were the mood disorders. But, we also see higher than expected rates of previous substance abuse and in some studies, although it hasn’t been studied as frequently, we see elevated rate of axis II psychopathology, the personality disorders than we would see in the general population, and I think it is important to note here that a lot of people when they hear this statistic think that somehow it is the psychopathology that has caused the obesity, which I think is very much the interpretation that was made 20 and 30 years ago, that people become obese because of their psychopathology, and in fact, a number of different studies have suggested that that relationship is probably quite bidirectional. In that living in a society which puts such a premium on thinness to be extremely obese and 100 or 200 more pounds than our bodies were designed to carry, probably significantly and negatively impacts the mood and experience of anxiety of many of the people who suffer from the disease.

DR. LESLIE LUNDT:

It makes sense now. Since the likelihood of psychopathology is so high in these bariatric surgery candidates, is there is an established requirement for psychiatric clearance before surgery.

DR. DAVID SARWER:

Well, unfortunately, as in many other areas of medicine, insurance companies often require what types of testing need to be done and are required before given surgical procedure, the understanding and it while this varies from state to state is that the insurance companies in most states now do require some formal mental health evaluation prior to bariatric surgery, but I think even before the insurance companies got on board with requiring this, there are a number of studies from the early 2000s that showed that about 80% of all bariatric surgery programs throughout the country were even independent of an insurance requirement were having their patients undergo a psychological evaluation prior to surgery, which I think really suggests that the bariatric surgeons and other members of the bariatric team recognize that there was a significant psychosocial overlay to bariatric surgery.

DR. LESLIE LUNDT:

And what is the focus of these psych evaluations?

DR. DAVID SARWER:

Well really the focus is probably two-fold, the first of which is to really look for the presence of significant psychopathology that would actually contraindicate surgery and so that would be an uncontrolled major depressive disorder, an active substance abuse problem, an active thought disorder such as schizophrenia that is not particularly well controlled, but the other part of the evaluation is really to for lack of a better term, to really help educate patients about what they are getting themselves into and to really help them understand that in order to be successful after bariatric surgery, it is important that patients are in the position to make the very demanding and rigorous behavioral and dietary changes, which are believed to be so critical to success, that if a patient is struggling with a mood disorder or is overly anxious and feels that they are going to have a difficult time, you know, following this very rigorous diet, it may not be the optimal time for them to go forward with bariatric surgery. So, in addition to their being an evaluative component to this, there clearly is a psychoeducational component to many of these evaluations as well.

DR. LESLIE LUNDT:

If you are just joining us, you are listening to The Clinician's Roundtable on ReachMD, The Channel for Medical Professionals. I am Dr. Leslie Lundt, your host and with me today is Dr. David Sarwer. We are discussing the possible psychiatric problems in bariatric surgery patients.

Now, David, are many patients, in fact, disqualified because of their psych evaluation.

DR. DAVID SARWER:

Well, the rumor on the street is yes, and that if you go to the …. and bariatric patients are very internet and web site savvy. So they learn awful lot from, you know chat rooms and bariatric surgery web sites and also as you probably are well aware, great deal of mass media coverage on bariatric surgery from reality-based television shows to you know more educational programs, but the reality is that while patients often think that most psychologists will disqualify them, studies suggest that only a very small percentage, probably less than 5% of the patients are disqualified from bariatric surgery on the basis of the psych evaluation. The much more likely recommendation, which is true in about 60% of cases is that patient are unconditionally recommended for surgery, which is that their psychological status is judged to be appropriate and that they are not struggling from significant psychopathology that would contraindicate surgery, and in about a third of patients, the recommendation from the mental health professional will often be that the individual get some additional treatment, whether that is an adjustment of their psychiatric medications, to consider entering into psychotherapy, or that they spend some time focusing more on cleaning up their diet prior to surgery, and in those cases, those patients are often brought back for reevaluation in 3-6 months.

DR. LESLIE LUNDT:

So if you flunk, it is not necessarily for ever.

DR. DAVID SARWER:

No, and again and for a variety of different reasons, programs are often times very reluctant to say the patients - no, absolutely not, and that is actually one of the fascinating issues from me working in this area is that it really is looking at the phycological issues as they interface with a very significant medical disease and that we really need to balance any reservations that I or my colleagues may have about a person's mood or level of anxiety with the severity of their obesity, realizing that if this individual does not have bariatric surgery, you know, their hope is going to be significantly compromised and they may, in fact, experience a premature mortality because of their weight.

DR. LESLIE LUNDT:

So, should we be doing more from a psychological standpoint before surgery in these patients?

DR. DAVID SARWER:

One of the things that has clearly happened in the last couple of years is that more and more patients and again I think this is a result of the media coverage around bariatric surgery, are coming in for surgery and really thinking that it is all about the surgical procedure, and it is not about changing their behavior and it is not about adhering to this rigorous diet, and unfortunately as a result we are seeing an increasing number of patients who are doing well after surgery, who are either struggling to keep the weight off, or struggling with emotional issues, and so organizations such as the American Society of Metabolic and Bariatric surgery and other professionals who work in this area are really focusing more both on how can we do a better job to educate these patients for surgery, but then what types of programs need to be in place for these patients postoperatively to help them maximize their outcomes, not only in terms of how much weight that they lose and keep off, but also in terms of improvements in psychosocial status and quality of life.

DR. LESLIE LUNDT:

So, what should we be doing?

DR. DAVID SARWER:

Well, again, I think that many programs now use multidisciplinary teams, both pre and postoperatively, but I think programs themselves from the surgeon on down need to do a better job of convincing patients the postoperative care and continued contact with the team is critically important to success. We know from the behavioral weight control literature that the continued contact with the dietitian, with a mental health professional or a physician help people maintain their weight more effectively long term and surgeons are used to operating on patients and curing the problem and sending them on their way and for bariatric surgeons it is really a new school of thought realizing that to effectively treat severe obesity really is going to require chronic care beyond just a surgical procedure.

DR. LESLIE LUNDT:

So, we have to do a better job of addressing, almost really the magical thinking that these patients have that surgery is it, and they do not have to do any work.

DR. DAVID SARWER:

Right, and that is a significant problem because patients do like to think and often because the surgery is in fact so powerful, but again from many patients what we are seeing is that a year or two after surgery after they have lost the weight, they are really struggling to keep it up, or they are really struggling with some of the psychosocial sequelae related to the changes in body image, the change in the dynamics of their marital and social relationships when obviously we would like to see these patients be as successful as possible, and I think every member of the bariatric surgery team from the dietitians to the surgeons, to the mental health professionals can do a better job of that.

DR. LESLIE LUNDT:

So, in terms of proper workup preop in these patients and evaluation it sounds like the very minimum thing and to do more intensive work preop can help postop outcome.

DR. DAVID SARWER:

Absolutely, and about one-third to 40% of all patients who present for bariatric surgery are actually engaged in some form of psychiatric treatment at the time of surgery. The most common form of treatment is the use of a low-dose antidepressant, that is actually being prescribed by a primary care physician and not a psychiatrist, and so in those situations, it is really important that the mental health professionals who know about bariatric surgery close the loop if you will, contact the treating professionals in the community and really make sure that patients are appropriate for surgery at a given point in time. What often gets lost in the shuffle with these patients is that this is still an elective procedure and obviously we would like to see patients elect to pursue this from a position of strength and at times of relative stability in their lives and not out of a sense of desperation or at a time when things are particularly chaotic or stressful.

DR. LESLIE LUNDT:

It makes a great sense. Well, thank you so much for being on our show today.

DR. DAVID SARWER:

Sure, thanks Dr. Lundt. It was a pleasure.

We have been speaking with Dr. David Sarwer from the University of Pennsylvania School of Medicine, Center for Weight and Eating Disorders about the psychological workup prior to bariatric surgery. I am Dr. Leslie Lundt. You are listening to ReachMD.com on XM160, the Channel for Medical Professionals. Please visit our web site at ReachMD.com which features our entire library through on-demand podcasts. Call us toll-free with your comments and suggestions at 888-639-6157. Thank you for listening.

You are listening to ReachMD XM160, The Channel for Medical Professionals.