Psychological Assessment of the Patient Undergoing Bariatric Surgery Dr.Sherif Saad (M.B.B.Ch., M.Sc., M.D.) Consultant of Psychiatry International member of American Psychiatric Association (APA) International member of European Psychiatric Association (EPA
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Psychological Assessment
of the Patient Undergoing
Bariatric Surgery
Dr.Sherif Saad (M.B.B.Ch., M.Sc., M.D.)
Consultant of PsychiatryInternational member of American Psychiatric Association (APA)
International member of European Psychiatric Association (EPA
Psychological Assessment of the
patient undergoing bariatric surgery 2
After losing half her weight, can the
Egyptian Eman Ahmed walk again?
Egyptian Eman Ahmed, who weighed 500
kg when she was airlifted to India in
February this year, has managed to lose
242 kg after two months of treatment that
included surgery and a special diet.
The moot question now is – will she be
able to walk again? According to Dr
Muffazal Lakdawala, the doctor directing
the team of surgeons treating her at Saifee
Hospital in Mumbai, she is very short and
her legs have not developed at all below
her knees.
Psychological Assessment of the
patient undergoing bariatric surgery 3
Unhealthy Trends in Saudi Arabia
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patient undergoing bariatric surgery 4
Nearly half of children in Jeddah ‘at risk of obesity’!!!By Saudi Gazette Jeddah Monday, 4 May 2015
“About 40 percent of children in Jeddah, Saudi
Arabia, are overweight and at risk of becoming
obese, according to a medical survey”.
The survey, conducted by students of the college of
pediatrics at King Abdulaziz University, said a large
number of children do not play any kind of sports and
are gaining weight.
The study was conducted at a number of shopping
malls in Jeddah as part of a health awareness
campaign organized by the college.
Dr. Abdul Moien Eid Al-Agha, professor of pediatrics
and supervisor of the campaign, said excessive
weight is a warning sign of obesity and all its
associated diseases including diabetes.
Psychological Assessment of the
patient undergoing bariatric surgery 5
Obesity exposes patients to the risk of embarrassment, frustration, and
hopelessness.
It is real and poignant, and these indignities are not easily ameliorated,
especially as many of them are bolstered by opinions and comments of
individuals close to the patients, such as family members, and thus are
even more painful.
Psychological Assessment of the
patient undergoing bariatric surgery 6
Obesity surgery …….. challenges As the rates of obesity increase, so do the medical problems
caused and exacerbated by this physical state.
Traditional methods of weight loss have proven ineffective for achieving and maintaining significant weight reduction for many cases..
Bariatric surgery (ie, laparoscopic gastric banding, gastric bypass) offers these patients the opportunity to experience significant weight loss that can be maintained.
The number of obese patients seeking bariatric surgery is steadily rising. But, unlike traditional diets for which risks are low and discontinuation can occur at any time, bariatric surgery has inherent risks and requires highly restrictive, long-term behavioral changes afterwards.
Therefore, these patients typically are required to complete a thorough evaluation, including psychological assessment, to determine their appropriateness for surgery.
Psychological Assessment of the
patient undergoing bariatric surgery 7
Obesity surgery …….. multidisciplinary team
Psychological Assessment of the
patient undergoing bariatric surgery 8
Patients should be
“selected carefully after
evaluation by a
multidisciplinary team
with medical, surgical,
psychiatric, and
nutritional expertise.” Bauchowitz A., et al. Evaluation of expectations and knowledge in bariatric
surgery patients. Surg Obes Relat Dis. 2007
Pre-Operative Bariatric Surgery Psychological Evaluation
Psychological Assessment of the
patient undergoing bariatric surgery 9
Although psychological
evaluation has become
standard for most surgery
programs, no clear guidelines
exist about what that
assessment must involve. Fabricatore A. N., et al. How do mental health professionals
evaluate candidates for bariatric surgery? Survey results. Obes Surg. 2006
Obesity surgery …….. Psychological evaluation
Many patients often are hesitant and uncomfortable with the notion of seeing a psychologist before surgery.
However, the information discussed during the clinical interview is critical not only for assessing their appropriateness for surgery but also for enhancing their success during the post surgery adjustment.
Many patients report, after the interview, how valuable it was for them to examine the issues raised.
The core parts of the clinical interview include reasons for seeking surgery, weight and diet history, current eating behaviors, understanding of the surgery and its associated lifestyle changes, social supports and history, and psychiatric symptoms (current and past).
Psychological Assessment of the
patient undergoing bariatric surgery 10
Pre-Operative Bariatric Surgery Psychological Evaluation : WHY?
When a surgeon assesses patients for bariatric surgery, he/she
ascertains their general health, to assess the degree of risk.
Behavioral health specialists can no more “predict” a particular
psychological outcome than the physician can “predict” a surgical or
medical complication.
However, via the pre-operative behavioral health assessment,
identify psychosocial risk factors and make recommendations to
both the client and surgical group that are aimed at facilitating the
best possible outcome for the patient.
Psychological Assessment of the
patient undergoing bariatric surgery 11
Pre-Operative Bariatric Surgery Psychological Evaluation : WHY?
Patients are typically faced with initial dietary restrictions, permanent changes in eating and dietary habits, altered body sensations and experiences, shifting body image and self care behaviors, new cognitions and feelings, and an emerging and different lifestyle.
Patients may realize sometimes unexpected and significant changes in relationships that may result in marked stress.
Bariatric surgery is a highly effective procedure that not only reconfigures and/or restricts a patient’s stomach, but significantly affects their psyche as well.
Generally patients will need a secure identity, sound psychological resources, resiliency, effective coping strategies, and willingness to access meaningful support from others.
Psychological Assessment of the
patient undergoing bariatric surgery 12
Pre-Operative Bariatric Surgery Psychological Evaluation : WHY?
When problematic pre-surgery psychosocial factors are identified, the clinician is able to alert the treatment team and the patient, and make appropriate recommendations.
Recommendations may include:
• pharmacological interventions,
• psycho-education,
• psychotherapy to address potential post surgery stumbling blocks,
• nutritional consultation,
• close aftercare monitoring, and/or
• bariatric surgery support group attendance.
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patient undergoing bariatric surgery 13
Pre-Operative Bariatric Surgery Psychological Evaluation
Common categories of assessment include:
Behavioral.
Cognitive/Emotional.
Developmental history.
Current life situation.
Motivation and expectations.
Psychological Assessment of the
patient undergoing bariatric surgery 14
Pre-Operative Bariatric Surgery Psychological Evaluation
Behavioral Aspects
Previous Attempts at Weight Management
Eating and Dietary Styles: Maladaptive eating behaviors:
personality disorders, alcohol or substance use disorders in
remission
History of an isolated suicide attempt in the distant past
Psychological Assessment of the
patient undergoing bariatric surgery 25
Good candidate for bariatric surgery
If there are no risks or any of past criteria.
Psychological Assessment of the
patient undergoing bariatric surgery 26
Recommendations:
Mild depression after surgery is not uncommon, especially
if there are complications and hospital readmissions.
Severe depression is much less common.
Suicidal ideation is a serious red-flag that should be
immediately addressed.
All patients should receive education before surgery as to
the possibility of depression, and the higher rates of suicide in
this population.
They should also be given education on the symptoms of
depression, and concrete steps to follow to get help if they
notice they are becoming depressed.
Most bariatric programs have many patients, and it is
unrealistic to monitor the ongoing mental health of every
patient. At Cleveland Clinic, we give patients education about
the possibility of depression after bariatric surgery, and
they are strongly encouraged to call if there is a problem or
question.Psychological Assessment of the
patient undergoing bariatric surgery 27
ConclusionMost patients will not become depressed
after surgery, but the possibility is present.
Therefore it is strongly recommended that each
patient receive education about postoperative
depression, including the recent study showing
the elevated rate of suicide.
It is important that patients do not make the
illogical assumption that suicide is a side
effect of bariatric surgery. At this point, we do
know that there is a potential vulnerability that
should be addressed, but we do not yet know all
of the facts concerning this finding.
Preoperative education should be provided for
all patients, along with steps to take if they do
become depressed.
With adequate education and support,
hopefully postoperative depression may be
reduced.Psychological Assessment of the
patient undergoing bariatric surgery 28
Dopamine Hypothesis of Reward
Postulates that the actions of drugs of
abuse are rewarding as a consequence of
activation of dopamine in the mesolimbic
dopamine system.
A similar mechanism occurs with
amphetamine, cocaine, nicotine and food.
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patient undergoing bariatric surgery 29
30
Obesity and Brain Reward
Human dopamine projections: (1) The nigrostriatal projection, which is concerned with movement .(2) and (3) The mesolimbic dopamine projection, which is involved in reward-related functions.