What is The Psychiatrist’s Role in Obesity and Bariatric Surgery?
Time to read: 3 minutes
With approximately one-third of Australian adults now considered obese (BMI equal to or greater than 30), and a number of my patients considering bariatric surgery, a 2015 American Psychiatric Association (APA) course on the topic seemed ideal. Indeed given the side effects of many of our medication treatments and our increasing role in the physical health monitoring and management of our patients, we have a unique responsibility and opportunity in this area.
SHOULDN'T WE JUST RECOMMEND DIET AND EXCERCISE?
Dr. Sanjeev Sockalingham is the psychiatrist in a multidisciplinary team working in Toronto Canada, and he reminded us that obesity is now recognised as a metabolic disease that has negative effects on all organ systems. Read more about weight gain and obesity in mental health conditions.
He noted that diet and exercise plans for our patients are frequently ineffective, partially because we tend to overestimate the weight loss benefits of exercise, which might be better seen as an accompaniment to good physical and mental health rather than a weight loss strategy (it is estimated that it takes a half marathon to “run-off” a Big Mac).
Furthermore, ghrelin (a hunger hormone) is elevated and the satiety hormone leptin is suppressed following weight loss, suggesting perhaps for evolutionary reasons our body tends to defend higher weight levels once we reach them. We also have no reliable and safe pharmacological agents.
WHAT ABOUT SURGERY THEN?
Current indications for bariatric surgery are a BMI >40, or >35 with a weight loss responsive comorbidity. The gastric band has been progressively replaced by the sleeve, due to band slippage and chronic inflammation. Some Roux-en-Y gastric bypasses are still performed to add therapeutic malabsorption to food restriction, but with variation between individual treatment centres.
Funding is still broadly private, but health economic studies estimate a payback to the health system in 2-4 years. Almost all of the procedures can be performed laparoscopically, and often without the near-impossible need to lose 10kg of weight beforehand. Results for the gastric sleeve showed an average 11 point reduction in BMI for the first year and reduced all-cause mortality. The gastric bypass has the risk of a dumping syndrome and requires supplements of Vitamin D, calcium, Vitamin B12, iron, and copper indefinitely.
WHAT IS THE ROLE OF PSYCHIATRY IN BARIATRIC SURGERY?
Psychiatrists can assist throughout the process, from anxiety about the assessment process and the decision to proceed to managing pre-morbid maladaptive eating behaviours.
While most patients gain improved body image afterwards, there may be a one-year “honeymoon” after which new eating or other psychopathology can present. This can include a preoccupation with weight gain leading to restriction, self-induced vomiting or excessive exercise. Excess skin folds may also be a focus and sometimes require further surgery, at times with fear or shame about needing a further procedure.
ALCOHOL MAY BE AN ISSUE!
Interestingly alcohol overuse can emerge post-surgery, even if not evident before. This is, particularly after gastric bypass, due to more rapid absorption and intoxication. There may also be a later peak due to the re-emergence of unresolved psychological difficulties, perhaps in substitution of the addictive elements of eating onto alcohol.
For these reasons, alcohol use disorders are screened for before surgery, with a recommendation of six months of abstinence. Careful monitoring and early intervention for increasing use after the procedure is also required.
WATCH FOR SELF HARM AND SUICIDE!
There is a slightly higher rate of suicide in patients who have completed bariatric surgery, compared to both normal and obese controls. While unclear, this may relate to reduced absorption of antidepressants with emergent symptoms or struggling to manage life after body shape change, despite whether pre-surgical expectations were met or not.
THE BOTTOM LINE
As rates of obesity increase, and sometimes in our patients due to our own intervention, we can play a valuable role in managing this condition. If diet and exercise are not working, bariatric surgery in its current form is a relatively safe and effective intervention, and we are well placed to manage its complex biopsychosocial challenges longitudinally with our patients.
The above is an abbreviated version of an article written for Mindcafe Issue 12, July 2015. It comprised recollections from an APA course on the above topic.
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