Psychiatric Criteria for WLS Psych Evaluation

Feb 27, 2009

  MAYO CLINIC PROCEEDINGS

www.mayoclinicproceedings.com/content/81/10_Suppl/S11.full

Assessment and Preparation of Patients for Bariatric Surgery

  1. Maria L. Collazo-Clavell, MD,
  2. Matthew M. Clark, PhD,
  3. Donald E. McAlpine, MD and
  4. Michael D. Jensen, MD

+Author Affiliations

  1. From the Division of Endocrinology, Diabetes, Metabolism, and Nutrition (M.L.C.-C., M.D.J.) and Department of Psychiatry and Psychology (M.M.C., D.E.M.), Mayo Clinic College of Medicine, Rochester, Minn
  1. Address correspondence to Maria L. Collazo-Clavell, MD, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN 55905 (e-mail: [email protected])
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Abstract

The number of bariatric surgical procedures performed in the United States has increased steadily during the past decade. Currently accepted criteria for consideration of bariatric surgery include a body mass index (calculated as weight in kilograms divided by the square of height in meters) of 40 kg/m2 or greater (or >35 kg/m2 with obesity-related comorbidities), documented or high probability of failure of nonsurgical weight loss treatments, and assurance that the patient is well informed, motivated, and compliant. Appropriate patient selection is important in achieving optimal outcomes after bariatric surgery. In this article, we review our approach to the medical and psychological assessment of patients who want to undergo bariatric surgery. The medical evaluation is designed to identify and optimally treat medical comorbidities that may affect perioperative risks and long-term outcomes. The psychiatric and psychological assessment identifies factors that may influence long-term success in maintaining weight loss and prepares the patient for the lifestyle changes needed both before and after surgery.

BMI = body mass index; CAD = coronary artery disease; OSA = obstructive sleep apnea; RYGB = Roux-en-Y gastric bypass

The number of bariatric surgical procedures performed in the United States has increased steadily during the past decade.1,2 Several factors have contributed to this trend, including the continued increase in the prevalence of extreme (class III) obesity, the limited effectiveness of medical therapies in this patient population, and a growing body of literature supporting the positive effects of weight loss after bariatric surgery on weight-related comorbidities.3-5 As a result, patients, physicians, and third-party payers have become more receptive to this intervention.

The main incentive for considering bariatric surgery should be to improve health. This can be achieved only when the potential benefits of the surgery outweigh the risks for the individual patient. Bariatric surgery is neither completely safe nor unfailingly effective. Some patients will experience major complications or will have a poor weight-loss outcome. Discussion of both potential positive and negative outcomes is an important aspect of the assessment of patients considering bariatric surgery. Appropriate patient selection is important in achieving beneficial outcomes.6-8 The currently published criteria for consideration of bariatric surgery do not adequately address the intricacies of the assessment and preparation of these patients for surgery.9 All domains of functioning should be evaluated: physical health, activity level, nutritional intake, and psychiatric status. Health care professionals evaluating patients who want to undergo bariatric surgery should work closely with their colleagues, preferably in integrated, multidisciplinary treatment teams composed of nutritionists and medical, surgical, and psychiatric specialists. Expert consultants (cardiologists, pulmonologists, gastroenterologists) should be involved in the evaluation of the patient when clinically indicated.5

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RECOMMENDED CRITERIA FOR BARIATRIC SURGERY

In 1991, the National Institutes of Health Consensus Development Conference Panel9 outlined criteria for patients considering bariatric surgery (Table 1). A weight criterion was established using body mass index (BMI) (calculated as weight in kilograms divided by the square of height in meters). In addition, patients should have a documented or high probability of failure of nonsurgical weight-loss treatments and be well informed, motivated, and compliant.6-11 Various additional requirements are often imposed by third-party payers before authorizing coverage. Both the patient and the clinician should be well informed regarding the criteria that need to be fulfilled before planning bariatric surgery.

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MEDICAL ASSESSMENT OF THE PATIENT CONSIDERING BARIATRIC SURGERY

Ideally, the medical assessment of the patient considering bariatric surgery should be completed by a multidisciplinary team representing the fields of nutrition, psychiatry, medicine, and surgery.5 The assessment should have 3 main goals: (1) determine that the patient meets the recommended criteria for bariatric surgery, (2) identify issues that increase the patient's operative risk and intervene to reduce risk when possible, and (3) identify and modify, if possible, the factors that may reduce the probability of long-term successful weight loss and put the patient at risk for long-term complications.

View this table: TABLE 1.

Criteria for Consideration of Bariatric Surgery10

Creating a welcoming and patient-friendly environment is essential for obese patients. This includes handicap parking access, armless chairs in the patient waiting area, scales capable of weighing obese patients in a private setting, and examination offices that accommodate patients with special needs (eg, doors and furniture wide enough for patients, space for wheelchairs, low-height hydraulic tables, oversized gowns, and large blood pressure cuffs).

A comprehensive nutritional and weight history should be obtained, including weight trends (lowest, highest, actively gaining), current dietary habits, and current physical activity and/or exercise habits. Previous weight-loss efforts, especially those under medical supervision, should be reviewed. Factors such as the amount of weight loss achieved, the duration of weight-loss maintenance, those contributing to weight regain, and perceived obstacles to successful weight management (stress, time constraints, motivation, medical comorbidities, etc) should be documented.5,10 A detailed nutritional history may provide insight into the efficacy of specific bariatric procedures in achieving desired weight-loss outcomes. Several investigators have reported improved weight-loss outcomes with Roux-en-Y gastric bypass (RYGB) compared to gastroplasty in individuals with high intakes of sugar and sugar-containing foods.12,13 Education regarding expected dietary habits after surgery represents a key component of informed consent.

Identification of weight-related comorbidities and medical comorbidities that may increase surgical risk or potentially worsen after surgery (Table 2) is important. Although secondary causes of obesity are rare, they should be pursued when clinically suspected. Screening for hypothyroidism is recommended. Individuals at high risk for hypothyroidism include older women, those with a family history of thyroid disease, and patients with clinical findings suggestive of a

View this table: TABLE 2.

Factors That May Increase Surgical Risk or Worsen Postoperatively14,15

thyroid disorder.16 Cushing syndrome is a rare condition, and screening should be initiated if there is strong clinical suspicion of this disorder. Numerous medications promote weight gain, and alternative treatments should be considered. The social history should document current smoking, alcohol or substance abuse, and stability of the patient's social environment.7,8,17 A family history of obesity or weight-related comorbidities should be noted, although a strong family history in the absence of a personal history of weight-related comorbidities will not fulfill the medical criteria for surgery.

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PHYSICAL EXAMINATION AND ROUTINE LABORATORY TESTING

At physical examination, pulse rate, blood pressure, height, weight, and BMI should be recorded. Measurement of waist circumference provides additional information regarding health risk; a circumference greater than 102 cm in men and 88 cm in women is associated with higher risk of metabolic complications.10 However, measurement of waist circumference is a cumbersome and less useful tool in patients whose BMI values are greater than 40 kg/m2. Physical findings suggestive of weight-related metabolic or cardiopulmonary disorders should be noted, as well as signs of secondary causes of obesity such as Cushing syndrome.

Recommended laboratory tests are outlined in Table 3. These tests may reveal potential secondary causes of obesity, metabolic complications of obesity, and/or unrecognized nutritional deficiencies that may worsen after surgery. Additional testing should be guided by the clinical situation and the surgical procedure being contemplated.7,8,17 Preoperative laboratory testing is outlined in the article by McGlinch et al18 elsewhere in this supplement.

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PSYCHIATRIC AND PSYCHOLOGICAL ASSESSMENT OF THE PATIENT CONSIDERING BARIATRIC SURGERY

Currently, no evidenced-based models or consensus guidelines are available to identify patients whose psychological profile and motivation make them appropriate candidates for bariatric surgery.19,20 Many individuals considering weight-loss surgery have a psychiatric disorder or are experiencing psychological difficulties. Fifty percent or more of patients referred for bariatric surgery are reported to have a psychiatric Axis I disorder, an Axis II personality disorder, or doubtful motivation for surgery.21-26 Approximately half are taking psychotropic medications when they present for evaluation.27 Common diagnoses include somatization, social phobia, obsessive-compulsive disorder, substance abuse/dependence, binge-eating disorder, night eating syndrome, posttraumatic stress disorder, generalized anxiety disorder, and depression.28 In the United States, 15% to 30% of patients with psychosocial difficulties are referred for additional treatment, and 0% to 10% are not recommended for surgery.19,27,29,30

Although consensus for a standardized protocol for the psychiatric and psychological evaluation of bariatric surgical candidates is lacking, many centers use a structured interview. Examples include the Boston interview for gastric bypass,31 the structured clinical interview with the Weight and Lifestyle Inventory from the University of Pennsylvania,32 and guidelines from Montefiore Medical Center/Albert Einstein College of Medicine.33 Because many bariatric centers use a number of mental health professionals to conduct their assessments, a structured clinical interview allows the treatment team to identify key psychosocial areas that may need further evaluation. Psychological testing is often part of this assessment, and many clinicians use the Beck Depression Inventory or the Minnesota Multiphasic Personality Inventory.30 Key areas to identify include current depressive symptoms, personality disorders, trauma history, substance abuse, or purging.

In general, the influence of psychological factors on long-term outcome in bariatric surgical patients is not well understood.31 A 2005 review of the published literature examining the psychological evaluation of bariatric candidates confirmed that the presence of binge-eating disorder, a personality disorder, or an untreated Axis I disorder, particularly a depressive disorder, warrants additional attention.34 These factors were found to be highly prevalent in presurgical patients and have been proposed to contribute to poor long-term outcome. In a review of 29 studies that assessed possible psychosocial predictors of weight loss, serious psychiatric disorders that required inpatient hospitalization and personality disorders were found to predict suboptimal weight loss after surgery.22 Further research is needed to provide a better understanding of how an untreated psychiatric condition such as major depression can impact weight loss and other outcomes of bariatric surgery.

Some bariatric surgical candidates are denied surgery on the basis of their psychiatric status, and others have surgery postponed until their psychological difficulties have improved.33 A survey of 81 bariatric surgery programs found that the most commonly ranked potential psychosocial contraindications for surgery were current illicit drug abuse, active uncontrolled symptoms of schizophrenia, severe mental retardation (IQ <50), heavy alcohol use, and lack of knowledge about surgery.30 Although empirical evidence does not demonstrate how problematic psychosocial issues will influence outcome, in our clinical practice, bariatric surgery is postponed until the following criteria are

View this table: TABLE 3.

Recommended Laboratory Evaluation of Candidates for Bariatric Surgery

fulfilled: no psychiatric hospitalization for 12 months, professional treatment and demonstrated 12 months of abstinence for patients with substance abuse, and treatment by a licensed mental health professional for patients with ongoing psychological issues (personality disorders, trauma survivorship difficulties, low-grade depression). In addition, the mental health professional should support the patient's desire to have surgery and agree to provide postoperative follow-up care.

Another area that should be assessed is the perception of positive aspects of being overweight. Being overweight prevents some individuals from addressing painful issues. In our clinical experience, surgery and major weight loss can produce sudden onset of symptoms of posttraumatic stress disorder in some survivors of sexual abuse or trauma. Even after these patients have successfully managed horrific memories for many years, substantial weight loss seems to trigger frequent flashbacks, daily intrusive memories, and nightmares. A history of childhood trauma is distressingly common in those considering bariatric surgery. In a sample of 340 consecutive patients studied by Grilo et al,35 32% reported being sexually abused. These same investigators also examined the effect of childhood sexual abuse on 1-year outcome. Although no difference in weight loss was noted at 1-year follow-up, the sexual abuse survivors had higher levels of depression on the Beck Depression Inventory compared with those who had not been abused.36 We believe that a history of trauma is insufficient for excluding an individual from bariatric surgery. However, patients with a history of trauma, those who have experienced psychiatric difficulties when they lost weight in the past, and individuals who perceive being overweight as protective warrant special attention. After preoperative assessment, these patients should initiate mental health care to address these issues. Although a history of sexual abuse has reportedly been related to poor weight-loss outcome after a low-energy diet program,37 weight-loss outcomes after bariatric surgery have not differed significantly between sexual abuse survivors and those with no history of abuse.38,39

A history of psychological difficulties or the presence of a psychiatric disorder that is well managed is not a contraindication to bariatric surgery. Clark et al40 reported that a history of treatment for mental illness or substance abuse was predictive of acceptable weight-loss outcomes at 2-year follow-up in patients who had undergone bariatric surgery.

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ASSESSING PREOPERATIVE RISK

Mortality rates after bariatric surgery have been commonly reported at less than 1%.41 Recently, higher mortality rates were reported among Medicare recipients.42 The highest mortality rates were seen in older patients (due to age and comorbidities) and patients whose operations were performed by less experienced surgeons. The article by McGlinch et al18 elsewhere in this supplement reviews perioperative risks and management in detail. Thus, this article briefly discusses preoperative risk assessment.

When appropriately evaluated, patients with known coronary artery disease (CAD) can safely undergo bariatric procedures without increased morbidity or mortality.43 The risks of perioperative complications are increased in men, in patients older than 45 years, and in those with high blood pressure, diabetes mellitus, BMI greater than 50 kg/m2, obstructive sleep apnea (OSA), asthma, and risk factors for pulmonary embolus and cirrhosis.14,44,45 Portenier et al46 have proposed a simple scoring system that uses 5 patient characteristics—age, hypertension, BMI, sex, and pulmonary embolus risk—to predict perioperative mortality risk. The Obesity Surgery Mortality Risk Score was developed after the authors retrospectively reviewed more than 2000 medical records of patients who had undergone bariatric surgery at Virginia Commonwealth University between 1995 and 2004. Scores define a patient's 90-day mortality risk as low (<1%), medium (<2%), or high (>5%). Although this scoring system has not been validated in prospective studies, it promises to be a useful tool for the assessment of patients contemplating bariatric surgery. Thus, preoperative and perioperative assessment and care should focus on modifiable risk factors that may increase mortality risk (eg, optimizing glycemic control, asthma management).47,48

Although the impact of unrecognized or inadequately treated OSA on perioperative risk remains controversial,49,50 we routinely screen our patients for OSA. Overnight oximetry can be a useful screening tool but is not highly sensitive. Proceeding directly to overnight polysomnography is appropriate when clinical suspicion for this disorder is high.47 Patients in whom clinically important OSA is identified are advised to initiate recommended therapy with continuous or bilevel positive airway pressure before surgery, and therapy is continued throughout the perioperative period.

Symptomatic gallbladder disease can occur after substantial weight loss, particularly in patients with preexisting gallbladder abnormalities. As a result, imaging of the gallbladder is frequently performed in preparing for surgery. Prophylactic cholecystectomy may be recommended during open procedures for RYGB and biliopancreatic diversion. However, this practice has not been vigorously studied.15,51 Alternatively, therapy with ursodiol has been shown to decrease the incidence of symptomatic gallbladder disease.11,52

The most common cause of abnormal liver function in bariatric surgical candidates is nonalcoholic fatty liver disease, which can progress to cirrhosis. When liver function studies show elevated levels, imaging of the liver with either ultrasonography or computed tomography is recommended.53 Liver biopsy remains the gold standard for determining the extent of disease. Steatosis frequently improves with weight loss, but the presence of inflammation and fibrosis suggests more advanced disease with less predictable outcomes.54 Although several investigators have noted favorable changes in liver histology after bariatric surgery,55-57 a careful examination of these and other reports44 reveals incomplete histologic data to allow definitive conclusions. Determining the extent of liver disease is recommended to assess perioperative risks and postoperative outcomes. In many centers, cirrhotic liver disease with portal hypertension is considered a contraindication to bariatric surgery due to the risk of deterioration in liver function.

Preexisting gastrointestinal symptoms are often evaluated to identify undiagnosed pathology that may affect surgical outcome. Preoperative screening for Helicobacter pylori in patients with dyspepsia who are considering bariatric surgery has been proposed but not universally practiced.58 When identified, H pylori is treated empirically with currently accepted medical regimens.

The literature is sparse regarding the impact of bariatric surgery on many common medical conditions and the effect of these conditions on surgical outcomes. Information regarding the effect of bariatric surgery on inflammatory bowel disease, renal stone disease, and autoimmune disorders is restricted to case reports. Although these conditions do not represent absolute contraindications to bariatric surgery, appropriate treatment and monitoring are essential.

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MEDICAL CONTRAINDICATIONS TO BARIATRIC SURGERY

Few preexisting medical conditions represent absolute contraindications to bariatric surgery. Notable exceptions in our practice include the presence of mental/cognitive impairment that limits the individual's ability to understand the proposed therapy and advanced liver disease with portal hypertension. Occasionally, we do not recommend surgery because of unacceptable operative risks due to multiple preexisting medical comorbidities such as unstable CAD, uncontrolled severe OSA, or an uncontrolled psychiatric disorder. However, in most situations, preoperative management of medical comorbidities will reduce operative risks to acceptable levels. Age is not an absolute contraindication to bariatric surgery,10 although the combination of older age and preexisting medical conditions may be associated with unacceptable risks. The presence or history of cancer is considered a contraindication when the prognosis for 5-year survival is poor.

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PATIENT PREPARATION: MAXIMIZING SUCCESS

A successful weight-loss outcome after bariatric surgery has been defined as a loss of at least 50% of excess weight.9 Variations in how weight-loss outcomes are reported make comparisons of studies difficult. Reported rates of weight loss associated with currently offered bariatric procedures are discussed in the article by Kendrick and Dakin59 elsewhere in this supplement. However, success should not be measured solely in pounds lost but also in health benefits. Reviewing with the patient anticipated weight-loss outcomes, potential health benefits, and surgical risks associated with the planned procedure is important to avoid unrealistic expectations.

Failure to maintain weight loss at 10 years after bariatric surgery has been reported in 10% to 25% of patients who undergo this intervention.4,11 Factors contributing to weight regain are complex, vary with the surgical procedure performed, and are not fully understood. Evidence consistent with our clinical experience suggests that nonadherence to dietary and activity recommendations contributes to poor long-term outcome.60

To assess motivation and predict adherence to postsurgical recommendations, some programs mandate that the patient achieve some weight loss before surgery. Two published studies have examined presurgical weight loss and its association with short-term outcome (1 year). One study reported no effect,61 whereas the other reported that presurgical weight loss was related to greater postoperative weight loss.62 Several multidisciplinary programs have focused on a more comprehensive approach, namely, the benefits of behavioral therapy in medically supervised weight-loss programs designed to improve weight-loss outcomes.63-66 To our knowledge, no published randomized controlled trial has examined the potential benefits of receiving behavioral therapy before bariatric surgery in regard to weight-loss outcomes. Nonetheless, on the basis of our clinical experience, we recommend and often require that patients receive behavioral therapy for lifestyle changes (eating, exercise, social support, and stress management) from a licensed mental health professional before surgery. The goal of behavioral therapy is to provide guidance and support as individuals pursue lifestyle changes before and after bariatric surgery. Their efforts at behavioral change will aid in fulfilling our preoperative requirements of no weight gain and adherence to lifestyle changes in diet and physical activity.

Little data are available in the medical literature regarding the physical activity requirements imposed by various bariatric programs, the physical activity habits of those considering bariatric surgery, and how to help obese, sedentary individuals increase their activity level. In preparation for surgery, we encourage our patients to initiate physical activities that they are able to perform comfortably with their physical limitations. The American College of Cardiology and American Heart Association practice guidelines recommend screening for CAD in individuals with multiple risk factors before initiation of an exercise program.67 The challenge often lies in which functional cardiac assessment study to pursue in view of the weight limitations imposed by the available technologies and the patient's limitations for exercise. Ultimately, the study performed will depend on which one is deemed most appropriate at each institution.

Some individuals may be able to perform only 5 to 10 minutes of aerobic activity daily. For those with serious joint limitations, water exercises are recommended; unfortunately, facilities at which such exercises can be performed are not always available to our patients. We often refer patients to physical therapists or sports medicine specialists for advice on safe activity programs. The expectation is that after surgery individuals will be able to gradually increase both the duration and the intensity of their activity program. Individuals who have undergone bariatric surgery tend to be more active than medically treated controls.4

Noncompliance to preoperative recommendations often identifies an unmotivated patient who may be a poor surgical candidate because of potential nonadherence to recommended long-term follow-up, vitamin and mineral supplementation, and lifestyle changes required for successful weight maintenance. In these patients, surgery is often postponed or not performed.

Psychotropic medications can seriously affect weight. One third of bariatric surgical candidates are taking psychotropic medications preoperatively,29 typically antidepressants. In addition, the presurgery assessment may identify mood or anxiety disorders that require initiation of psychotropic agents. Selection or modification of psychotropic regimens that favor weight loss is a useful intervention whether or not bariatric surgery is pursued.

Antidepressants considered most likely to promote weight gain include amitriptyline, mirtazapine, and imipramine. Those least likely to promote weight gain include bupropion and nefazodone. The selective serotonin reuptake inhibitors (fluoxetine, sertraline, citalopram, fluvoxamine, escitalopram, paroxetine) cause a modest initial weight loss typically followed by weight regain and in some patients a small net gain. Antidepressants with relatively neutral effects on weight include duloxetine, venlafaxine, nortriptyline, desipramine, tranylcypromine, and phenelzine.68-72

Presurgical assessment also provides an opportunity to consider the possible ramifications of surgery on psychotropic vehicle and dosage. Despite bariatric surgery's increasing popularity, no data exist to guide psychotropic dosing in patients with altered gastrointestinal environments or in those who experience massive postoperative weight loss. One novel in vitro study examined the dissolution of 22 psychotropic agents in a simulated gastrointestinal environment of control and post-RYGB states.73 Twelve agents dissolved differently in the postoperative environment than in the control state; 10 dissolved much less than expected. The effect of bariatric surgery on in vivo absorption of commonly used psychotropics has not been studied. Synthesis of the available information yields the following clinical considerations.

  • Consider using immediate-release psychotropics.

    • Time-release medications are designed to dissolve gradually within the full intestinal tract and thus may be expected to have different pharmacokinetics after RYGB.

  • Consider monitoring of psychotropic serum levels before and after surgery.

    • Some psychotropics, such as tricyclic antidepressants, have a narrow therapeutic index. A preoperative blood level obtained while the patient feels well emotionally may provide a target goal for the patient who has a postoperative relapse.

  • Anticipate effects of postoperative weight loss on dosage.

    • Many physiologic factors influence drug absorption, such as gastric emptying time and the integrity and surface area of the epithelium. The gut has an impressive ability to compensate for loss of function, and absorption after surgery may eventually normalize. However, marked weight loss may then complicate the clinical picture.

  • Obese persons have an increased proportion of adipose tissue, as well as increased total body water, lean body mass, and visceral organ mass and higher glomerular filtration rate.

    • Awareness of the volume of distribution and the importance of renal clearance is necessary.74 Increased monitoring of lithium levels is warranted during the postoperative period.

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SUMMARY

The number of individuals seeking bariatric surgery for the treatment of extreme obesity is increasing. The medical evaluation has several goals: assuring that the patient meets currently accepted criteria for consideration of bariatric surgery, identifying and optimally treating medical conditions that may affect perioperative risks, and educating and preparing patients in the hope of maximizing long-term successful weight loss and improving health. Clearly outlining characteristics of the “ideal” patient for bariatric surgery is challenging because of active investigation and evolution of the procedures being offered, their associated risks, and long-term outcomes. Most of the information in the current literature is based on retrospective studies and expert opinion. Future investigations should be designed to clarify the important aspects of the bariatric surgical evaluation to achieve optimal outcomes.

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Footnotes

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