Psychiatry Newsletter - Bariatric surgery
Date: March 30, 2011
A case of mind over matter
You pull yourself up from bed with your cane one morning, your wife ties your shoes and you inch to the recliner, catching your breath. Then comes surgery, and some months later you awake, not sure which is more astonishing: that you’ve lost the weight equivalent of an 8-year-old or that it’s your body that’s taking dance lessons.
“The ability of bariatric surgery to alter patients’ lives is incredible,” says psychologist Janelle Coughlin, and scenarios like this continue to draw prospective patients to hospitals. “Yet though it’s generally a positive step,” she adds, “many people discount the idea that they could end up in a worse place after surgery if they don’t comply with the proper regimen.”
Instilling a realistic mind set and a right attitude is part of Coughlin’s role as head of a behavioral medicine program at Hopkins, one that offers services for patients with a variety of weight-related issues. Most patients, so far, come seeking surgery: They can’t be accepted for it without a psychological signoff. Last year, for example, Coughlin screened more than 250 patients.
Taking a psychiatric history and evaluating mental status are, not surprisingly, part of the screening, since two-thirds of severely obese patients have at some time suffered a psychiatric illness, mostly major depression. Yet it’s not so much the presence or absence of illness that’s a concern for the surgery, Coughlin says, as how well it’s managed. “So untreated or unstable major depression are a concern,” she says. “If someone had a major event in the last year, like attempting suicide, surgery should wait.”
Likewise, she also screens for activities that could derail postsurgery success. “I look for patterns or clusters of behaviors,” Coughlin explains. “I wouldn’t necessarily deny patients, say, who binge-eat once a month. That would likely be helped by the surgery. If it’s more frequent, however, or if patients also eat from an emotional need, then they need to understand their relationship between mood state and food. We help raise awareness of both internal and environmental triggers for their eating.”
Coughlin does reality checks, starting with the surgical informed consent. The belief that the surgery is both simple and a cure-all isn’t unusual. But the operations—there are several types—are complex. The most-performed “Roux-en-Y” procedure, for example, bypasses much of the stomach and upper small intestine and fashions new connections. And afterward, the joyful anticipation of losing roughly 50 percent of excess weight can be tempered by an inability to eat and drink simultaneously or to eat a favorite cheesesteak. For many, their most reliable comfort in life has gone.
“So we help patients identify these challenges before surgery,” Coughlin says, “emphasizing the positive outcomes while honestly describing the work that can lie ahead.” Because it’s impractical for Coughlin to treat every patient she could clear for surgery, she refers those needing ongoing therapy to the program’s psychiatrist Hochang Lee or psychotherapists Jill Varelli and Maura Murphy.
Because Coughlin also researches maintaining weight lost through lifestyle changes—she’s an investigator on several national trials—she’s well aware of the struggles of some bariatric patients several years after surgery. She’s now working to apply the lessons learned to them.
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