Psychiatric illnesses in bariatric surgical patients: a common problem in the surgical world

Objective: To study the presence of pre-operative and post-operative psychiatric problems in bariatric surgery patients. Method: A literature search in different data bases and journal was performed. Results: Some bariatric patients have an underlying psychiatric illness like eating disorder as the cause of their obesity and can also have other preexisting psychiatric illnesses. However, same patients or sometimes other surgery candidates who do not have any psychiatric illness can acquire post-surgical psychiatric illnesses later. Surgery residents must be educated about pre and post-operative psychiatric problems, which will not only help them detect and diagnose the problem but will also help the patient by providing them will timely treatment or referral to a psychiatrist or psychologist. Conclusion: Appropriate measures must be taken in order to deal with the pre and post-operative psychiatric comorbidities in bariatric surgical candidates. The measures to prevent or decrease the effect of the preexisting psychiatric problem or post-operative psychiatric illnesses must be taken. The measures include preoperative interviews, assessments, follow up, education etc. More research is needed to find out more ways to reduce the psychiatric burden in surgical wards. Correspondence to: Tohid H, Center for Mind & Brain, University of California, Davis (UC Davis), USA, Tel: 707-999-1268; E-mail: hassaantohid@hotmail.com Received: January 08, 2016; Accepted: February 04, 2016; Published: February 08, 2016 Introduction Bariatric surgery also known as weight loss surgery is a term for the surgery to reduce weight in obese patients. The procedure is done by decreasing the size of the stomach with a gastric band or through removal of a portion of the stomach or re-routing the small intestine to a small stomach pouch. Research evidence shows that the procedures can cause significant weight loss, diabetic recovery, cardiovascular risk factors reduction, and a reduction in mortality to 23% from 40% [1]. The candidates for the bariatric surgery are morbidly obese, thus it is natural to expect that they either have some psychiatric comorbidity like eating disorders or have a tendency to develop other psychiatric illnesses [2]. The presence of eating disorder which is by far the most commonly seen psychiatric problem in bariatric patients is associated with high rates of other psychiatric illnesses [3]. Naturally the compulsive eaters go through higher numbers of obesity treatments. Moreover they also have increased prevalence of major depression, and the worse scores in the SF-36 scale [4]. In fact it is also studied that psychiatric comorbidity is commonly seen in many other surgery candidates and is not confined to bariatric surgery patients alone [5]. Psychiatric problems in surgical patients irrespective of the nature and the extent of the surgery is a serious issue to deal with, not only because many surgical patients have a preexisting psychiatric problem, but also because many patients later on can develop new or continue to carry on their psychiatric complications known as post-operative psychiatric complications. A recent study in Japan shows that the presence of psychiatric illnesses increase the risk of complications associated with surgery [6]. Another major problem that psychiatric problems bring is the expense and the total hospital cost. The total cost associated with surgery in patients with schizophrenia and mood disorders is found to be higher than the patients with neurotic comorbidity. Similarly the presence of psychiatric illnesses also has a direct relation with the length of the hospital stay [6]. It is well known that besides eating disorder, obesity is associated with an increased risk of psychosocial complications, including depression, and low life quality [7] probably due to the stigma associated with obesity or just by the psychological feeling of being unattractive. These psychiatric symptoms can be occasionally improved after a successful bariatric surgery in some patients. However the data is not consistent and shows that the psychiatric comorbidity persists in many patients despite a successful bariatric surgery [8,9]. Many a times this leads to post-operative psychiatric problems. Some commonly found post-surgical psychiatric problems are alcohol dependence [10], delirium [11], and post-traumatic stress disorder (PTSD) [12]. Surgery is a totally different field than psychiatry. Therefore, it is very difficult for the surgery residents and attending surgeons to correctly be able to diagnose, prevent and treat psychiatric problems that are commonly seen in the surgical arena. Thus, I attempt to write this mini review which addresses the issue of the presence of psychiatric illnesses in surgical patient’s especially bariatric surgery patients. I believe more research should be conducted and more reviews like this should be published to help and educate young surgeons to take appropriate measures to prevent, diagnose and treat the comorbid psychiatric conditions in bariatric and general psychiatric patients. Tohid H (2015) Psychiatric illnesses in bariatric surgical patients: a common problem in the surgical world Volume 2(1): 155-157 Glob Anesth Perioper Med, 2016 doi: 10.15761/GAPM.1000141 Method To write this review I reviewed published literature in PubMed, Embase, MEDLINE, MEDICINENET, Science Citation Index, Neuropsychology Review, Somatosensory and Motor Research, Sleep Medicine Reviews, British Journal of Psychiatry, Canadian Journal of Psychiatry, Archives of general psychiatry, American Journal of Psychiatry, Journal of Psychiatric research, Psych Info, the Cochrane Library Controlled Trial Registry Databases and various newspapers. No date restrictions were used. Articles relevant to psychogenic non epileptic seizures were included.


Introduction
Bariatric surgery also known as weight loss surgery is a term for the surgery to reduce weight in obese patients. The procedure is done by decreasing the size of the stomach with a gastric band or through removal of a portion of the stomach or re-routing the small intestine to a small stomach pouch. Research evidence shows that the procedures can cause significant weight loss, diabetic recovery, cardiovascular risk factors reduction, and a reduction in mortality to 23% from 40% [1].
The candidates for the bariatric surgery are morbidly obese, thus it is natural to expect that they either have some psychiatric comorbidity like eating disorders or have a tendency to develop other psychiatric illnesses [2]. The presence of eating disorder which is by far the most commonly seen psychiatric problem in bariatric patients is associated with high rates of other psychiatric illnesses [3]. Naturally the compulsive eaters go through higher numbers of obesity treatments. Moreover they also have increased prevalence of major depression, and the worse scores in the SF-36 scale [4].
In fact it is also studied that psychiatric comorbidity is commonly seen in many other surgery candidates and is not confined to bariatric surgery patients alone [5]. Psychiatric problems in surgical patients irrespective of the nature and the extent of the surgery is a serious issue to deal with, not only because many surgical patients have a preexisting psychiatric problem, but also because many patients later on can develop new or continue to carry on their psychiatric complications known as post-operative psychiatric complications.
A recent study in Japan shows that the presence of psychiatric illnesses increase the risk of complications associated with surgery [6]. Another major problem that psychiatric problems bring is the expense and the total hospital cost. The total cost associated with surgery in patients with schizophrenia and mood disorders is found to be higher than the patients with neurotic comorbidity. Similarly the presence of psychiatric illnesses also has a direct relation with the length of the hospital stay [6].
It is well known that besides eating disorder, obesity is associated with an increased risk of psychosocial complications, including depression, and low life quality [7] probably due to the stigma associated with obesity or just by the psychological feeling of being unattractive. These psychiatric symptoms can be occasionally improved after a successful bariatric surgery in some patients. However the data is not consistent and shows that the psychiatric comorbidity persists in many patients despite a successful bariatric surgery [8,9]. Many a times this leads to post-operative psychiatric problems. Some commonly found post-surgical psychiatric problems are alcohol dependence [10], delirium [11], and post-traumatic stress disorder (PTSD) [12].
Surgery is a totally different field than psychiatry. Therefore, it is very difficult for the surgery residents and attending surgeons to correctly be able to diagnose, prevent and treat psychiatric problems that are commonly seen in the surgical arena. Thus, I attempt to write this mini review which addresses the issue of the presence of psychiatric illnesses in surgical patient's especially bariatric surgery patients. I believe more research should be conducted and more reviews like this should be published to help and educate young surgeons to take appropriate measures to prevent, diagnose and treat the comorbid psychiatric conditions in bariatric and general psychiatric patients.

Method
To write this review I reviewed published literature in PubMed, Embase, MEDLINE, MEDICINENET, Science Citation Index, Neuropsychology Review, Somatosensory and Motor Research, Sleep Medicine Reviews, British Journal of Psychiatry, Canadian Journal of Psychiatry, Archives of general psychiatry, American Journal of Psychiatry, Journal of Psychiatric research, Psych Info, the Cochrane Library Controlled Trial Registry Databases and various newspapers. No date restrictions were used. Articles relevant to psychogenic non epileptic seizures were included. Keywords included but not limited to bariatric surgery, pre-operative psychiatry, post-operative psychiatry, pre-surgical psychiatric, post-surgical psychiatric etc. I reviewed reference section for additional relevant articles. Article titles and abstracts were reviewed to ascertain if they were applicable to the theme of psychiatric disorders in bariatric surgery patients. Data on surgery and psychiatry appears in a wide range of studies, case series, project descriptions and program evaluations to more formal research trials. Selected articles were reviewed to identify additional articles that may have been missed by the keyword search. In total, over 400 articles were initially reviewed, with 379 excluded because of little information data on the subject.

Discussion
Preoperative psychiatric comorbidity has a risk of poor outcome in bariatric surgery patients of its own. However, the post-operative psychiatric problems are also extremely dangerous and an important problem to address in the 21 st century. Effects of anesthetics may be altered if the patient develops alcohol use disorder [10]. In addition to this, alcohol is also associated with a long list of heart problems and nutritional deficiencies. Moreover it can drastically increase the postsurgical morbidity and mortality [13]. Similar if the patient develops delirium or PTSD, both conditions can affect the postoperative outcomes if not treated.
I believe surgical residents should be aware about the dosage and the frequency of the administration of psychotropic drugs for the surgical patients with comorbid psychiatric condition. Besides drug therapy attending surgeons and residents must be educated about the need of psychotherapy by a certified professional i.e. licensed psychiatrist or psychologist. Procedures commonly used to help treat post-operative psychiatric problems are group therapy, educational groups, internet based and mentorship programs [14]. Evidence suggests that group psychotherapy and individual therapy are helpful in reducing the post-surgical psychiatric complications, with individual therapy more beneficial than the group therapy [15]. Furthermore, it is also studied that telephone support and cognitive behavior therapy (CBT) improve the quality of life of the patients [16]. These psychotherapeutic techniques are complicated and need a psychiatric expert, thus patients must be referred to a specialist licensed psychiatrist or psychologist. Ignorance of not referring the patients in time could be detrimental to both, the patient's physical as well as the mental health.
Considering the ample range of comorbid psychiatric illnesses in surgical patients it is imperative to improve the diagnosis and detection of these disorders to manage the problem in a timely and efficient manner. It is also clear that the surgical candidates can have an already existed psychiatric comorbidity or they develop comorbidity after the surgery. Therefore, in order to tackle the problem in the best way, as the first approach a prolonged preoperative evaluation must be done [17]. Psychometric testing is commonly done by various multidisciplinary teams in different hospitals throughout the US and also across the world. These psychometric testing is used to screen for any possible psychiatric problem. This is imperative because an unaddressed mental problem affects the overall post-surgical recovery.
Some common methods for pre-surgical evaluation include Minnesota Multiphasic Personality Inventory-2 Restructed Form (MMPI-2-RF) scales. Marek et al. [18] concluded that The MMPI-2-RF assists in detecting much psychiatric comorbidity in the patients ready for bariatric surgery. This kind of scales with pre-surgical psychiatric interviews can be useful in assessing the factors leading to psychiatric problems and can also be helpful in predicting the chances of the patient of developing a post-operative psychiatric issue as well.
In contrast to screening some authors are of the view that the psychiatric problems should be treated preoperatively in order to enhance the surgical outcomes and decrease the risk of complications [19]. The pre-operative assessment is also highly important in bariatric patients, because obese patients are more likely to be suffering from eating disorders as their main psychiatric problem. Moreover, the presence of eating disorders could point toward a possibility of higher rates of other psychiatric illnesses. Thus, ignoring the pre-operative psychiatric assessment could be deleterious for the patient's wellbeing [3].
These interventions are necessary because they do not only help the patient psychologically but also enhance the overall post-operative prognosis. In addition to pre-operative psychological assessment, a post-operative follow up and education regarding the psychotropic medication compliance, nutrition and psychological aspects can be helpful and play an integral role in the overall recovery of the patients [20]. Accurate pre and post-operative screening, education of the patient and the clinicians about the psychotropic drugs, drug compliance, when to taper, discontinue or change the medication, is a necessary measure [21].
Although this review is mostly focused on bariatric surgery patients, the pre-operative assessment and post-operative follow up suggestion is not only valid for bariatric patients alone. Research suggests that other surgical patients like post epileptic surgery patients are also equally benefitted by this approach [22].

Conclusion
The review concludes that many bariatric surgery candidates either have a pre-existing psychiatric illness or are prone to psychiatric illnesses post operatively. Eating disorder is highly prevalent among these patients and is mostly the cause of their obesity. The presence of eating disorder can further increase the rate of other comorbid psychiatric conditions. These psychiatric problems become challenging for the doctors as well as the patients. Association of any psychiatric comorbidity including or excluding eating disorder can not only affect the mental health of the patients but also has disastrous effect on the overall prognosis and recovery of these patients. Therefore, it is recommended that appropriate measures must be taken as soon the patient is admitted for the surgery in a surgical ward. These measures include but not limited to pre-operative psychological interviews, screening tools and various modes of assessment of psychiatric illnesses, regular follow up, proper patient and doctor education. The same measures can also be helpful for the patients with post-operative psychiatric problems. Moreover, the surgery residents should be aware about the dosage of psychotropic drugs and should also be educated about the importance of proper referral of the surgical candidates with psychiatric comorbidity to a licensed psychiatrist or psychologist rather than handling complicated matters on their own. What other measures could be useful in helping the patients and improving their quality of life is still a topic of debate and the answers to these key of questions will be brought to surface in a decade to follow by more extensive research on the subject.