Preparing patients for life after bariatric surgery
With obesity on the rise, more people are seeking alternatives to failed diets, grueling exercise regimens, and prescription weight-loss agents with troublesome side effects.
Bariatric surgery offers hope to morbidly obese persons (defined as having a body mass index [BMI] 40 kg/m2) and to those with a BMI >34 kg/m2 who suffer hypertension, diabetes, and other comorbidities. The procedure produces significant short-term gains (diminished binge eating, weight loss, alleviation of depressed mood) and long-term benefits (improved self-image; increased HDL; lower apoprotein beta-containing lipoproteins; and lower LDL, blood pressure, and fasting blood glucose).
Too often, however, patients see bariatric surgery as a quick fix. Although hunger and stomach capacity are reduced, some patients do eat compulsively,1 and many regain weight after surgery. Patients also may not realize that they must make extensive lifestyle changes and adjust psychologically to life as a normal-weight person.
Suicide is a major cause of postoperative death, either because of poor psychosocial adjustment or the emergence of an occult personality disorder. Continued alcohol consumption and noncompliance with prescribed vitamin or mineral regimens can also be fatal.
Gauging patient readiness
A preoperative psychiatric evaluation can uncover mental disorders and other risk factors for postoperative noncompliance. Evaluate the following issues:
- What caused or contributed to the patient’s obesity? Bariatric surgery candidates have a high prevalence of psychopathology, including major depression, binge eating, and personality disorders.2,3 Untreated depression, bulimia, suicidality, and substance abuse are contraindications to bariatric surgery. Pre-existing major depression and binge-eating disorder are not, however.
- How does the patient perceive his or her body? Patients who have unrealistic perceptions about their bodies, such as those with eating disorders or psychoses, are poor surgical candidates. Such patients are unlikely to be satisfied with their postoperative body size.
- Why has the patient chosen to undergo bariatric surgery at this time? Ask whether he or she views it as a major procedure, and determine his or her level of conviction about receiving the surgery.
- Can the patient expect support from family and friends? Undue pressure from family members, such as a significant other’s dissatisfaction with the patient’s pre-operative body size, may lead to postoperative psychosocial maladjustment. A collateral history may be useful.
- Is the patient aware that postoperative behavioral changes will be needed? People will treat the patient differently and may even comment frequently about his or her new body size. Moreover, instead of eating as a coping mechanism, patients will need to find other ways to deal with unpleasant emotions.
- Does the patient understand the postoperative requirements? Reiterate that the patient must participate in group psychotherapy and follow postoperative instructions. The patient’s history of dieting, exercise, and weight-loss prescriptions may offer clues to prospective post-op compliance. Patients who have not complied with less invasive measures are not likely to be compliant after bariatric surgery.
Finally, to prevent miscommunication between patient and provider, ask the surgeon what he or she has told the patient about the procedure. A Minnesota Multiphasic Personality Inventory test can help confirm psychiatric diagnoses and determine whether the patient is being candid.
1. Saunders R. Compulsive eating and gastric bypass surgery: what does hunger have to do with it? Obes Surg 2001;11(6):757-61.
2. Wadden TA, Sarwer DB, Womble LG, et al. Psychosocial aspects of obesity and obesity surgery. Surg Clin North Am 2001;81(5):1001-24.
3. Glinski J, et al. The psychology of gastric bypass surgery. Obes Surg 2001;11:581-8.
Dr. Menaster practices psychiatry in San Francisco, CA