C-L Psychiatry Vital in Assessing Patients Before, After Bariatric Surgery

Bariatric surgery is an effective treatment for severe obesity (BMI ≥40 or BMI ≥35 with medical comorbidities), and 200,000 such procedures are performed in the United States annually. Surgical guidelines recommend that candidates for surgery undergo a psychosocial evaluation prior to bariatric surgery, and many insurance companies in this country will not authorize the surgery without approval from a behavioral health professional.

Up to 70% of patients seeking bariatric surgery have a history of psychiatric illness, which underscores the importance of supporting psychiatric stability before bariatric surgery and monitoring for psychiatric relapse after bariatric surgery. The following case outlines the role of consultation-liaison (C-L) psychiatrists in bariatric surgery for obesity management.

Case Study

Ms. S, a 42-year-old woman, had several obesity-related medical conditions, including hypertension, dyslipidemia, and obstructive sleep apnea. Her BMI was 39.9 kg/m2. She had had multiple depressive episodes, the most recent of which occurred three years ago when she was hospitalized due to suicidal ideation. She did not have a history of alcohol or drug use.

She reported eating when under stress but denied binge eating. She was assessed by the C-L psychiatry (CLP)team prior to gastric bypass surgery because of concerns regarding her psychiatric history and current use of psychiatric and other medications because gastric bypass surgery can alter medication absorption.

Her medications at the time of presurgical evaluation included quetiapine XR 300 mg once daily at bedtime, sertraline 100 mg once daily, atorvastatin 20 mg once daily at bedtime, and amlodipine 5 mg once daily. She used her CPAP machine nightly for obstructive sleep apnea.

iStock/Katarzyna Bialasiewicz

The CLP team determined that her psychiatric symptoms were stable. The team provided the patient with education on the potential for reduced antidepressant bioavailability after gastric bypass surgery and the need to be alert for any signs and symptoms of reduced antidepressant absorption (such as reemergent depressive symptoms). It was recommended that quetiapine XR be changed to an immediate-release formulation to guard against the reduced bioavailability associated with extended-release medications. She was told that regular adherence to her CPAP treatment was important since it minimizes perioperative cardiovascular complications.

Nine months after having Roux-en-Y gastric bypass surgery, Ms. S was seen by the bariatric surgery social worker who was concerned that she was depressed. During her assessment, Ms. S reported that she did well in the first six months after bariatric surgery but had been having difficulties with her mood over the previous two months. She was feeling more down, tearful, and fatigued and had reduced concentration. She had thoughts of dying, but she had no suicidal intent or plan. Her eating patterns had been erratic as she had been missing meals and was not adhering to her vitamin regimen or her CPAP treatment. Further exploration revealed Ms. S was experiencing marital difficulties and her husband had not been supportive of her surgery.

Discussion

As is evident in the case of Ms. S, psychiatrists play an important role in assessing patient readiness for bariatric surgery. The presurgical evaluation can be an opportunity to assess and treat the patient for psychiatric comorbidities ahead of bariatric surgery. In cases of surgical contraindications such as uncontrolled substance use or suicidality, the psychiatrist can help guide a treatment plan that addresses these concerns so that the patient may develop into a suitable surgical candidate. As the case of Ms. S also makes clear, postsurgical psychiatric and psychological complications are not uncommon. Patients often struggle with their new eating restrictions, disordered eating behaviors, bodily changes (excess skin), increased impulsive behaviors, mood and anxiety symptoms, and suicide attempts with increased risk of completed suicide.

There is no consensus about psychiatric monitoring and treatment after bariatric surgery, but given the high rates of psychiatric illness in this population, C-L psychiatrists are often involved in the longitudinal care of postsurgical patients. Patients with existing psychiatric illness may experience a remission in their symptoms after surgery, with symptoms often returning one to two years postoperatively. Changes in medication absorption and metabolism after surgery deserve particular attention as this can precipitate drug toxicity or subtherapeutic dosing leading to relapse. These changes are not always predictable, particularly in the first year after surgery, and psychiatrists should carefully assess patients’ symptoms and any side effects they may be experiencing.

After bariatric surgery, some patients experience worsening or new onset of psychiatric symptoms or problematic substance use. There is also an increased incidence of self-injurious and suicidal behaviors, including completed suicide. All patients should receive a comprehensive evaluation of suicide risk or self-harm prior to surgery, with modifiable risk factors addressed at that time. New-onset alcohol use disorders occur in 7% to 8% of patients, and patients should be made aware of these risks prior to surgery, especially with the Roux-en-Y gastric bypass. More recent data also suggest that rates of opioid and benzodiazepine misuse are higher among bariatric surgery cohorts than those who have not had the surgery.

Wernicke encephalopathy and other clinically significant nutritional deficiencies do occur after bariatric surgery and may present with psychiatric symptoms. C-L psychiatrists may encounter these patients in the hospital and should keep in mind the possible contribution of nutritional deficiency in patients’ presentation.

Clearly, C-L psychiatrists play an important role in assessing and treating patients at all stages of bariatric surgery. Behavioral health services embedded in subspecialty clinics providing bariatric surgery could result in improved clinical outcomes and reduced costs. ■