Psychiatric Aspects of Obesity and Bariatric Surgery

1. Psychiatric Aspects of Obesity and Bariatric Surgery Daniel Anzia, MD Chairman, Psychiatry Advocate Lutheran General Hospital

2. Presentation Outline • Psychiatric Disorders and Obesity • Obesity and Common Psychiatric Disorders • Primary Eating Disorders • Psychiatric Treatments and Weight Gain • Behavioral and Psychological Factors in Obesity Treatment • Obesity: Neurobiology and Addiction Models • Questions and Discussion

3. Obesity and Psychiatry • Obesity in Psychiatric Disorders • Primary Eating Disorders • Psychiatric Treatments and Obesity

4. Obesity and Psychiatric Disorders Depression Meta-analysis of cross-sectional co-morbidity (DeWit et al): Odds of being depressed 18% higher in obese persons Gender effect: Men OR 1.00, Women OR 1.32 Severity of obesity influences the strength of the relationship Evidence (including meta-analysis) supports both temporal pathways: Obesity as risk factor for Depression Depression as risk factor for Obesity

5. Binge-Eating Disorder (Research Criteria) • Recurrent episodes of binge eating, characterized by both: • Eating, in a discrete period of time, an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances • A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating) • Binge eating episodes associated with 3 (or more) of: • Eating much more rapidly than normal • Eating until feeling uncomfortably full • Eating large amounts of food when not feeling physically hungry • Eating alone because of being embarrassed by how much one is eating • Feeling disgusted with oneself, depressed, or very guilty after overeating From DSM-IV-TR, American Psychiatric Association

6. Marked distress regarding binge eating is present. • The binge eating occurs, on average, at least 2 days a week for 6 months. • Binge eating is not associated with the regular use of inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise) and does not occur exclusively during the course of Anorexia Nervosa or Bulimia Nervosa. • From DSM-IV-TR, American Psychiatric Association

7. Psychotropic Medications, Weight, and Obesity • Bipolar Disorder, Mood Stabilizers, and Weight Gain • Likelihood of being overweight or obese correlated with number of previous depressive episodes • Lithium, valproate, some antidepressants associated with weight gain • Lithium: ¼ to ½ of patients – 5 to 10 % weight gain • Valproate: As frequent as with lithium • Mirtazepine, paroxetine, tricyclics, trazodone

8. Weight gain and Antipsychotics • Meta-analysis: Mean weight gain Clozapine 9.8 # Olanzapine 9.1 # Risperidone 4.6 # Haloperidol 2.4 # • CATIE study: Greater than 7 % weight gain Olanzapine 30% Quetiapine 16 % Risperidone 14 % Perphenazine 12 % Ziprasidone 7 %

9. Risks for weight gain and diabetes • Greatest effect on weight, increased risk of diabetes • Clozapine • Olanzapine • Effect on weight, unclear risk for diabetes • Quetiapine • Risperidone • Small to no effect on weight, without risk for diabetes • Ziprasidone • Aripiprazole

10. Metabolic Syndrome • Three or more of the following: • Waist circumference > 102 cm for men and > 88 cm for women • Fasting triglycerides > 150 mg/dL • HDL cholesterol < 40 mg/dL for men and < 50 mg/dL for women • Blood pressure > 130 mm Hg systolic, or > 85 mm Hg diastolic • Fasting blood glucose > 100 mg/dL

11. Baseline in CATIE study: • > 40 % had metabolic syndrome • Men 138 % more likely than matched controls • Women 251 % more likely than matched controls Weight gain propensity highest the higher the H-1 and 5HT-2C blockade Irony that unique effectiveness of clozapine must be balanced with greatest risks

12. Behavioral and Psychological Factors in Obesity Treatment • Eating is a Behavior • Readiness for Change is a Balance between Motivation and Resistance • Change-predisposing attributes (Whitlock et al) • Strongly want and intend to change for clear, personal reasons • Face a minimum of obstacles to change • Have the requisite skills and self-confidence to make a change • Feel positively about change and believe it will result in meaningful benefit • Perceive the change as congruent with self-image and social group norms • Receive encouragement and support to change from valued persons

13. First-Line Obesity Treatment is Behavioral • Structure: Weekly, 4-6 months, usually in group • Goal Setting • Objective, easily-measured • Self-Monitoring • Food records, weight • Highly correlated with successful weight loss • Stimulus Control • Change internal and external cues associated with eating and activity behaviors • Longer-term treatment: weight loss maintenance skills • Profound environmental influences to counter

14. Best Practices in Behavioral and Psychological Care in Weight Loss Surgery • Pre-surgical psychosocial evaluation • 20-60% have current Axis I disorders, mood and anxiety disorders most common; substance use disorders • Mental Disorders not necessarily contraindication • Focused on safety and efficacy of WLS • In more severe disorders, deferral; compliance with recommendations as predictor of better outcome • Behavioralist for psychosocial evaluation and pre- and postoperative support • Credentials for specialization not fully formalized

15. Best Practices (Continued) • Binge-Eating Disorder: Assessment, address as potential complication to promote best outcomes • Night-eating syndrome, emotional eating should be addressed in similar way to BED • Substance abuse: While prior lifetime prevalence may be high, current abuse prevalence low • Exclusion of current abuse/dependence • Further research • Psychotropic medications: 70+% lifetime history • Further research needed on effects of surgery • Research opportunities: Psychosocial factors, treatments, and surgical outcomes From I Greenberg et al, Obesity, 2009

16. Criteria for Substance Dependence • Tolerance (Need for more to get same effect) • Withdrawal (Characteristic syndrome or consumption to avoid withdrawal symptoms) • Substance used more or longer than intended • Persistent desire or unsuccessful attempts to cut down • Great amount of time to obtain, use, or recover from effects • Important social, occupational, or recreational activities given up or reduced because of use • Use continued despite knowledge of having a persistent or recurrent physical or psychological problem likely caused or exacerbated by use Adapted from DSM-IV-TR, American Psychiatric Association

17. Eating and Obesity: Neurobiology • Homeostatic Mechanisms: Hypothalamus • Ventromedial hypothalamus: Satiety • Lateral hypothalamus: Feeding • Connected both through neuronal projections and neuroendocrine mediators • Leptin and Insulin inhibit feeding • Reward-based Mechanisms • Reactive or Immediate reward: Limbic cortex, amygdala, ventral striatum; Dopamine and the Nucleus Accumbens • Reflective or Delayed reward: Prefrontal and lateral orbitofrontal cortex, central striatum • Eating is driven by both homeostatic and reward-based mechanisms, in some balance

18. Reward Systems, Addiction, and Tolerance • Dopamine neurons of midbrain ventral tegmentum project to ventral striatum, nucleus accumbens, and also to the amygdala, limbic cortex (Mesolimbic Dopamine pathway) • Brain centers of reward, pleasure, “fun,” and reinforcement • Many natural triggers: Food • Many drugs of abuse trigger more explosive (and initially pleasurable) release of dopamine • Sensitivity, potentiation, reinforcement • Tolerance: down-regulation of dopamine receptors in NA occurs in opiate, alcohol, cocaine addictions; also occurs in overeaters, correlated with increased BMI

19. Pros and Cons of an Addiction Model for Obesity Pros • Neurobiological and Behavioral Similarities • Perception (by self and others) as Illness, NOT Weakness • Possible Reduction of Stigma • Treatment Models (E.g., 12-step model, future pharmacology, Deep Brain Stimulation) • Recognition of Role of Environment • Possible Public Policy Changes, Resource Allocation Cons • Food, unlike substances of abuse, is necessary for survival. • Possible Increase in Stigma • One size does not fit all. Obesity has diverse causes (Genetic, medical, environmental, infectious?).