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M. Al Hadad158
in measuring the success. This continuous process needs a team of health care
providers that can support the patient throughout the weight loss journey. The
team consists of various specialties: Medical, allied health, and ancillary health
practitioners.
Multidisciplinary bariatric surgery care is defined as the integrated collabora-
tive care between medical, allied health workers and ancillary practitioners to
personalize the treatment plans for the patient with obesity. The need for multi-
disciplinary care was first mentioned in the National Institute of Health criteria
for bariatric surgery on March 1991, [3] candidates for bariatric surgery should be
selected carefully after evaluation by a multidisciplinary care team with medical,
surgical, psychiatry and nutritional expertise. Nowadays the core multidisciplinary
bariatric team includes a bariatric/obesity specialist, bariatric psychologist, bariatric dietitian, bariatric coordinator, and bariatric surgeon. Many other specialties
might be involved in the care team in certain cases, including but not limited to
cardiology, pulmonology, gastroenterology, and plastic surgery.
Many studies evaluated the implementation of multidisciplinary care in bariatric surgery. Among those “The peri-operative bariatric surgery care in the Middle
East region” [4]. The authors sent a questionnaire to bariatric surgeons in the
Middle East region and they found that before surgery; 65% of bariatric surgeons
referred their patients to a dietitian, 22.6% referred their patients to a psychologist, 78.3% referred their patients for smoking cessation clinic and 30% of surgeons screened for OSA. The authors of that study concluded that there is a wide
variation in the preoperative care in the Middle East region. Similar findings were
reported in Santry HP and his colleagues’ study in which a survey about multidisciplinary care was sent to practicing bariatric surgeons in the USA [5]. Although
95% of respondent surgeons reported using a multidisciplinary team; only 53%
had a general physician, nutritionist, and mental health specialist in their teams.
Only 47% of the surgeons mandated primary care, nutrition, and mental health
evaluations before the surgery (NIH-recommended evaluations).
This chapter will briefly discuss the role of the core members of the bariatric
multidisciplinary team; including the bariatric/obesity specialist, bariatric dietitian,
bariatric psychologist, and bariatric coordinator, before and after sleeve gastrectomy, which is the most commonly performed bariatric surgical operations at the
time being.
2 Bariatric/Obesity Specialist
Bariatric/Obesity specialty is one of the relatively new specialties in the management of obesity. However, the bariatric/obesity specialist has one of the most
essential and vital roles of the team. They are usually endocrinologists, internal
medicine or family medicine specialists who are specialized in obesity medical
management. In many countries around the world, obesity medical specialization
is obtained through a fellowship that certifies physicians to work in the field of
medical management of obesity.
Multidisciplinary Care Before and After Sleeve Gastrectomy
159
Preoperatively: The bariatric specialist role is unique in many aspects of the
management of obesity as they are the best source of health information for the
patients. They work as a lynchpin for the multidisciplinary team members; their
communication with the patient is usually patient-focused rather than procedure
focused. They deliver weight-related information in a simple non-technical language. Their role starts with the education of the patients and a professionally
directed lifestyle modification. It continues throughout the optimization of the
medical problems like metabolic syndrome and type 2 diabetes, hypertension and
hyperlipidemia and other weight-related diseases. Also, not to forget excluding
secondary causes of obesity before considering bariatric surgery. They are in a better position than the bariatric surgeons in making a less biased decision of the risks
versus benefits of bariatric surgery for each specific patient with obesity.
Postoperatively: The role of the bariatric/obesity specialist is significant postoperatively considering the chronicity and the progressive relapsing nature of the disease. Morbidly obese patients usually have multiple medical problems that require
proper follow-up postoperatively. Their role is to maintain the success and prevent
relapses and/or possible complications. This is done through, but not limited to,
weight management and maintenance, management of weight-related diseases,
monitoring nutritional and vitamin deficiencies, and detection of early cases of
weight recidivism. In the latter case, they will work on putting patients on back on
track programs by involving other team members like dietitian and psychologists
and possibly considering pharmacotherapy to augment and maintain the weight
loss.
3 Bariatric Dietitian
Preoperatively: The bariatric dietitian is a subspecialty for dietitians and nutritionists. The role of the bariatric dietitian is essential in many aspects of the management of obesity. It starts with education and assessment of the patients eating
behaviors (frequency and type of meals per day, grazing, poor food choices,
high-calorie food). It also includes detailed history about previous weight loss
attempts, bariatric knowledge and food diaries. Their role continues with behavioral modifications like teaching the patient healthy habits, such as to eat when hungry, not to overeat, refrain from engaging in other activities while eating, and to
avoid eating quickly. In addition, to practice mindfulness eating which is achieved
through educating the patients about the satiety meter, as shown in Table 1. Before
surgery, they teach the patient about the liver shrinkage diet, which might be a
crucial step in preparing patients for surgery, especially in super and super super
obese patients.
Table 2 shows an example of the bariatric dietitian assessment parameters
before bariatric surgery.
M. Al Hadad160
Table 1 Mindful eating,
satiety meter
Table 2 Example for the bariatric dietitian assessment before bariatric surgery
Has realistic expectations for weight loss Yes
Verbalized understanding of dietary changes post surgery Yes No
Verbalized understanding of supplements needs post surgery Ye s No
Motivation to change Yes No
Verbalized understanding the plan of care and need for a major life style change Yes No
Predicted compliance on scale of 1–10
Bariatric dietitian prediction of patient success
Main factor predicting success
Satiety meter
0 Starving
1 1/4 Full
2 1/2 Full
3 3/4 Full
4 Full
5 Stuffed
6 Overstuffed
7 Sick
No
Postoperatively: The role of the bariatric dietitian is very significant. It is life
long, and it starts from the immediate post-operative period by guiding the patients
throughout the stages of diet (fluid, pureed, soft, and then regular diet). Moreover,
it continues to support the patient with dietary advice in all stages of weight loss
and weight maintenance; and monitor for early signs of macro or micronutrional
deficiencies.
4 Bariatric Clinical Psychologist
Preoperatively: Bariatric surgery is partly a behavioral surgery, as the outcomes
are largely independent of the technical performance of the surgical operations. The
long term maintenance of weight loss “one surrogate of success” is dependent on
the patient's ability/willingness to make significant changes in their eating habits,
exercise habits, and emotional relationships to food. The role of the bariatric clinical psychologists is not to decide which patient is fit for bariatric surgery and which
patient is not. Rather it is guiding and providing psychological support for the patient
throughout the journey of weight loss. All patients with obesity would need proper
evaluation and support before undergoing bariatric surgery. This includes, but not
limited to, the evaluation of their eating styles, relationship between mood and eating
Multidisciplinary Care Before and After Sleeve Gastrectomy
161
behavior, substance abuse, impulsive behavior, coping skills, motivation and expectations, mental health and current life situation and social support. The majority of
patients would need minimal psychological support before the surgery. However,
few patients may require extensive psychological support before bariatric surgery.
That might be done throughout many sessions. Table 3 shows an example of an
objective assessment for patients with obesity before undergoing bariatric surgery.
Postoperatively: A small percentage of patients would need psychological support
as they realize that obesity was not the only problem in their lives and they were
hiding their psychological/life problems behind obesity. Other psychological issues
may appear as they get rid of the obesity; and start facing difficulties in dealing with
life without obesity. This is seen in many people who previously found some sort
of comfort in binge eating, which they can no longer do after the surgery. Proper
evaluation before surgery and early identification and intervention after surgery for
those patients is essential in preventing the progression into more severe psychological problems that would complicate their course of the obesity treatment.
5 Bariatric Coordinator
Morbidly obese patients have multiple unique challenges; one of those challenges is the coordination of their care between many medical/surgical specialties, allied health and ancillary care providers. All patients with morbid obesity
who qualify for bariatric surgery would need evaluation from psychology, dietary,
and a bariatric surgeon before surgery and some would need bariatric/obesity specialist. Many patients require evaluation of multiple other specialties like; cardiology, pulmonology, gastroenterology, etc. The bariatric coordinator has a vital
role in coordinating the management plan and communicating properly with the
patients. In addition to getting necessary insurance approval, maintaining proper
follow up, coordinating the multidisciplinary team weekly meetings, participating
in data collections and certification and audits. The bariatric coordinator is the real
Table 3 Example for the bariatric psychology assessment before bariatric surgery
Any psychological issues Yes
Any eating disorders Yes No
Is the patient taking well informed consent (risk Versus benefit)? Ye s No
Patient is putting things in perspectives Yes No
Patient is ready for the surgery and the big change Yes No
Patient has enough social and family support Yes No
Patient has realistic expectations Yes No
Patient can cope with stressors Yes No
No
M. Al Hadad162
link between all the specialties that manage obesity and also the link between the
patient and the management team.
6 Conclusion
The multidisciplinary approach in managing obesity and its related diseases is
essential for the success in the journey of managing the disease of obesity and
maintaining the success. The characteristics of a properly functioning multidisciplinary team are: having a core team of bariatric/obesity specialist, bariatric clinical psychologist, bariatric dietitian, bariatric coordinator, and bariatric surgeon. All
core members should have proper speciality training/certification in the field of
management of obesity and its complications. Ideally, all team members should be
in the same facility, where they meet regularly to discuss patients and they collect
data and perform audits to identify problems and improve outcomes.
References
1. Bray GA, Kim KK, Wilding JPH on behalf of the World Obesity Federation. Position state-
ment of the World Obesity Federation, 10 May 2017. https://doi.org/10.1111/obr.12551
2. O'Brien PE, Hindle A, Brennan L, Skinner S, Burton P, Smith A, Crosthwaite G, Brown W.
Long-term outcomes after bariatric surgery: a systematic review and meta-analysis of weight
loss at 10 or more years for all bariatric procedures and a single-centre review of 20-year out-
comes after adjustable gastric banding, meta-analysis. Obes Surg. 2019;29(1):3–14. https://
doi.org/10.1007/s11695-018-3525-0.
3. Consensus Statement, NIH Consensus Development Conference, 25–27 Mar 1991, Volume 9,
Number 1. https://consensus.nih.gov/1991/1991GISurgeryObesity084PDF.pdf4.
4. Nimeri A, Al Hadad M, Khoursheed M, Maasher A, Al Qahtani A, Al Shaban T, Fawal H,
Safadi B, Alderazi A, Abdalla E, Bashir A. The peri-operative bariatric surgery care in the
Middle East region. Obes Surg. 2017;27(6):1543–7.
5. Santry HP, et al. The use of multidisciplinary teams to evaluate bariatric surgery patients:
results from a national survey in the U.S.A. Obes Surg. 2006;16(1):59–66.
Psychiatric Evaluation: Pre and Post Sleeve
Abdullah Al-Ozairi and Husain Alshatti
1 Introduction
Mental health status of individuals should be considered prior any surgical procedure. Mental health does not only include all the psychiatric disorders but also the
spiritual, the emotional and their general state of mind.
Lately, obesity became one of the significant health issues discussed worldwide. It became a global matter, especially since it’s consideration as a disease
by the American Medical Association (AMA) in 2013 [1]. It is associated with
increased mortality and decreased quality of life [2] as well as psychiatric comorbidities, such as major depressive disorders, Anxiety disorders, eating, substance
use disorder and self-harm [3–6]. Concerns about morbidity and mortality related
to obesity are a significant concern especially in mental health populations, where
obesity prevalence rates are as high as 60% in patients with severe mental illness.
Due to the increased demand of bariatric surgery and the high prevalence of
psychiatric disorders, it is crucial to provide psychiatric evaluation to the candidates prior to the procedure and follow-up post-surgery. Such evaluation and
follow-up should be done to support the candidates, prevent the onset of new psychiatric issue, or modify their medications if presented.
In this chapter will review the association between mental illness and bariatric surgery and how having mental illness might affect the outcome of the surgery. Having bariatric surgery may affect the mental health by triggering new
A. Al-Ozairi (*)
Department of Psychiatry, Faculty of Medicine, Kuwait University, Jabriya, Hawally, Kuwait
e-mail: alozairi@gmail.com
H. Alshatti
Neuropsychiatry Department, Al Amiri Hospital, Sharq, Bin Misbah Street, Al-Asima, Kuwait
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer
Nature Switzerland AG 2021
S. Al-Sabah et al. (eds.), Laparoscopic Sleeve Gastrectomy,
https://doi.org/10.1007/978-3-030-57373-7_19
163
A. Al-Ozairi and H. Alshatti164
onset of a psychiatric disorder or suicidality. We will then review how the surgery
affects psychotropic medications. We will also discuss the importance of psychiatric assessment prior the surgery, what aspects must be considered, and when it
is contraindicated to do such surgery. Furthermore, we will review the tools to
evaluate certain mental disorders (such as depression, psychosis, eating disorders,
self-harm) as they have significant impact of the outcome of the surgery. Finally,
it is important to talk about the post-surgery evaluation, management plan and
follow-up from psychiatric point of view.
2 Preoperative Mental Health State of Bariatric Surgery
Participants
Among the participants of bariatric surgery, the presence of psychiatric disorders
is frequent. Around 25% of the participants reported that they are currently receiving pharmacological treatment from a mental health professional during the period
of the surgery, and previously, up to 20% of the surgery candidates were excluded
from the surgery due to the psychiatric complications that interfere with the surgery or their condition is contraindicated to undergo a surgery [7–9]. However,
by incorporating psychiatric care into the multidisciplinary team, there have been
centers which have successfully reduced this exclusion number to only 2%, especially in context of gastric sleeve surgery.
The most common conditions presented were mood disorders 23%, including major depressive disorders (19%) and dysthymia [7, 10, 11]. 12% of the participants had an anxiety disorder, mainly generalized anxiety disorder and social
phobia [7, 10, 11]. The current estimation of eating disorders among candidates
is 17%. Furthermore, 9% of the participants had a history of suicidal ideation and
3% suffered from substance use disorders [10].
In the following section, we will discuss the status of certain psychopathologies that are present among participants and may have an impact on the surgical
outcome.
3 Depression
Major depressive disorder is considered the most prevalent psychopathology among
the participants. It was also found that there are several associated factors between
preoperative depression and the bariatric surgery. For instance, there is a positive
relation between the severity of the depressive symptoms and obesity [12, 13].
It is well known that the relation between obesity and depression is
bi-directional. Depression causes behavioural changes, such as social isolation,
lower physical activity, increase in appetite or emotional eating, and feeling of
guilt, which may facilitate further severity of obesity. On the other hand, obese
individuals suffer from issues with body image, self-esteem, lower physical activity, and other behaviours that worsen the existence of depressive symptoms [12,
Psychiatric Evaluation: Pre and Post Sleeve
165
13]. The association between the two disorders goes further into polygenic genetic
factors [14–16]. Such as the FTO (fat mass and obesity-associated) gene, which is
linked with both depression and the severity of obesity [17, 18].
During the early stage after the surgery, there is significant improvement of
depressive symptoms. The association between postoperative weight loss and
improved depression symptoms, reduced severity, and lower prevalence can be
explained by improvement in the body image and interpersonal relationships [19].
On the other hand, this improvement gradually decreases on a long-term basis [20].
4 Eating Disorders
As for eating disorder, the preoperative presentation of eating disorders among
bariatric candidates usually is grouped as follows:
• Binge Eating Disorders (BED): is experiencing binge eating without compen-
satory behavior such as induced vomiting, misuse of laxative, or excessive exercise, which is the main difference between BED and Bulimia nervosa. “Binge
eating” is characterized as having two main points [21]:
I. consumption of a relatively large amount of food in a discrete amount of
time.
II. the experience of loss of control.
It is considered the most common type of eating disorders among the candidates
and is secondary only to depression. Several studies showed a wide range of
prevalence of BED from 4–49%. This wide range can be explained by the fact
that the diagnostic criteria of BED have only been formalized with the release
of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013.
Studies have produced mixed findings, with some studies linking BED with poorer
postoperative weight loss while others suggesting no relation between BED and
weight loss post-surgery. The tendency to eat in response to negative emotions is
related to poorer postoperative weight loss.
• Bulimia nervosa: is characterized as experiencing recurrent binge eating with
the compensatory behavior such as purging and misuse of laxative use, diuret-
ics, enemas or other medications to prevent weight gain. Due to the inappropri-
ate eating behavior of bulimia, it is considered contraindicated for a bariatric
surgery. However, the prevalence among participants remains not well known,
probably due to under-reporting by the candidates to avoid delaying or cancel-
ling the surgery [22].
• Anorexia nervosa: is characterized by restriction of energy intake leading to
a significant low body weight due to fear of gaining weight with the associa-
tion of disturbed body image, despite the very low weight. The prevalence of
A. Al-Ozairi and H. Alshatti166
anorexia among the participants is not well known because of the insufficient
data. However, there are reports of “Anorexia-like presentation” experienced
postoperatively. Those behaviors include, dietary restriction, fear of weight gain
and disturbances in body image [23].
• Atypical Eating Disorders (AED): This is usually used for the two eating
behaviors:
I. “grazing” defined as continuous eating.
II. “night eating syndrome”(NES) characterized by hyperphagia at night.
5 Anxiety
The prevalence of anxiety disorders among the candidates of the surgery vary
from 12% and up to 24%. With a lifetime prevalence of up to 37% for a history of
lifetime diagnosis of anxiety disorders [24]. Although the rate of anxiety disorders
among the bariatric population is evident, there is no reported relation between
anxiety and the post-surgical outcome [20]. This is supported by the prevalence of
anxiety disorders after surgery, where the rates are the same as prior surgery [20].
6 Substance Use Disorders
Substance use disorder is prevalent among bariatric candidates, around 30% have
a lifetime history prevalence of alcohol use disorder [25]. It is also found that the
rate of alcohol use disorder and alcohol consumption increases even after the surgery, notably sleeve gastrectomy surgery. The reason for such increased rate was
explained by multiple suggestions, such as changes in pharmacokinetics of alcohol from accelerated absorption and the long duration of elimination [10]. The
effect of substance use disorder on the surgery outcome varies. The increased use
of substances may contribute to further progression of the individual depression
and may result in suicide [10]. Another possible effect is that individuals who are
unable to change their substance use behavior are at risk of achieving only suboptimal weight change after the surgery, because they may fail to change their eating
behavior to accommodate their new life style.
Toxicology screening is recommended by several studies for the preoperative
evaluation, as the surgery should be delayed until the issue of substance use disorders is resolved, if present [26, 27].
7 Self-harm and Suicidal Ideation
Self-harm and suicidal ideation are important aspects to be assessed pre-surgery.
The rate of suicidal behavior among individuals who had bariatric surgery is four
times higher than the general population. In addition, during the first 3 years after
the surgery showed an increased rate of reported self-harm behaviors among
Psychiatric Evaluation: Pre and Post Sleeve
individuals after bariatric surgery [28]. Also, the prevalence of past suicidal
attempts among the participants is 73 times higher than the normal population!
This increased suicidal rate among this particular population could be affected by
several circumstances, such as:
• difficulty adjusting to a new lifestyle which may lead to depression.
• not achieving the expected weight loss or experiencing weight regain, which
may cause the feeling of disappointment.
• increased substance use, such as alcohol.
Screening for suicidal ideation preoperatively is as important as postoperatively.
The presence of suicidal ideation can be a contraindication or a reason to delay the
surgery [29].
167
8 Psychotropic Medications
As previously mentioned, up to 60% of the participants reported to have psychiatric disorder at the time of the preoperative evaluation, and around 25% receive
psychotropic medication from a mental health provider [7–10]. By and large, the
most common psychotropic medications used are antidepressants (87%), anxiolytics 9%, and 2% on mood stabilizers [30].
The change in drug absorption and pharmacokinetics of the psychotropics in
bariatric surgery differs depending on the type of the procedure. Furthermore, this
change affects the level of the medication in the body, thus, affecting its therapeutic effects and side effects. As an example, Hamad et al. in 2010 [31] measured
the level of antidepressants in individuals immediately after bypass surgery. It was
found that the level of antidepressants was reduced, and the reduction remained, in
some individuals, up to 1 year after the surgery. The decreased level of antidepressant immediately after the surgery in those individuals can lead to discontinuation
syndrome, which is causes discomfort to the patient and can be rarely fatal.
History of receiving psychotropic treatments is not contraindicated for bariatric
surgery. However, it is highly recommended to be evaluated by a mental health
provider, prior the surgery, and to follow up with a psychiatrist after the surgery on
a regular basis. The post-operative follows up is essential to observe the course of
the psychopathology and possibility of modification the treatment.
9 Psychological Predictors of Post-Surgical Weight
Loss
Some studies found a relation between preoperative psychiatric history and reports
of dietary noncompliance and medical complication postoperatively, these reports
were not associated with weight loss [32, 33]. When analyzing this further, some
studies that severity of the psychiatric disorders such as severe depression and