Treating Obesity In The Mentally Ill

Valerie Taylor, MD, PhD, Psychiatrist-in-Chief, Women’s College Hospital Associate Professor of Psychiatry, and Head, Division of Women's Mental Health, University of Toronto

Valerie Taylor, MD, PhD, Psychiatrist-in-Chief, Women’s College Hospital and Head, Division of Women's Mental Health, University of Toronto

Now that we’ve discussed some of the links between obesity and mental illness, we turn to another article by Valerie Taylor and colleagues from the January issue of the Canadian Journal of Psychiatry, which looks at the treatment options for obesity management in those with mental health problems.

The article begins with a discussion of various psychological interventions to assist with behaviour change – many of which have also been shown to be effective in individuals without mental illness.

These include, Cognitive behavioral therapy (CBT), well researched and empirically effective approach to address dysfunctional, negativistic thinking characteristic of depressive disorders. In relationship to better managing obesity, short-term effects have been consistently positive, however, long-term success has been variable.

The strongest evidence for the use of CBT in weight management probably exists for binge eating disorder (BED), where CBT consistently results in greater treatment effects than do other interventions after both short- and long-term follow-up.

Components of successful CBT for obesity treatment include: 1) identifying readiness for change and goodness of fit between patient and treatment, 2) self-monitoring by tracking weight and food behaviours, 3) cognitive restructuring via challenging maladaptive cognitions and 4) problem solving by developing system of alternate food behaviours.

Other forms of psychological interventions with promising results include Mindfulness Therapy, Dialectical Behavioural Therapy, Interpersonal Psychotherapy, and Motivational Interviewing. As with CBT, all these interventions require trained and experienced practitioners and may therefore not be readily available to most patients.

The paper then briefly discusses the rather limited options for pharmacological obesity treatments, noting that many agents that act centrally are currently under investigation as obesity drugs.

Finally, the Taylor and colleagues look the outcomes of bariatric surgery on patients with co-morbid mental health issues. As noted before, a large proportion of patients seeking surgical obesity treatment have concomitant mental illness, with Axis 1 disorders ranging from 20-60%, with mood and anxiety disorders being most common, and with Axis II disorders in approximately 25% of surgical candidates.

How these underlying mental health issues affect post-surgical outcomes remains a matter of debate with studies (largely consisting of case series) showing mixed results. In fact, there is currently no accepted consensus as to appropriate mental health screening that should be utilized prior to bariatric surgery, although most weight loss surgery programs require some type of mental health evaluation prior to surgery.

“A primary objective of mental health screening is to identify and exclude patients with a significant, poorly controlled psychiatric illness or active substance dependence. Mental health evaluation may also identify addressable barriers to weight management.

Contraindications to bariatric surgery include current drug or alcohol abuse, severe uncontrolled psychiatric illness, and lack of comprehension of risks, benefits, expected outcomes, alternative, and lifestyle changes required with bariatric surgery.”

Importantly, the authors note that:

“Bariatric surgery is not a treatment for depression and is not a panacea to improve dysfunctional interpersonal relationships or psychosocial stress. It is important that patients clearly understand what can be altered with this procedure and what requires different types of treatment, preferably prior to engaging in a life changing surgical procedure.”

Also, there are consistent reports of increased risk of suicidality and ‘accidental’ deaths following bariatric surgery, a relationship that remains poorly understood both in its aetiology and incidence.

Finally, the article discusses some of the challenges of pharmacological treatment post bariatric surgery, which potentially affects the absorption of psychiatric medications.

Thus, while many patients seeking obesity treatments may also have mental health problems (but by no means everyone), these can and should be addressed through multidisciplinary interventions utilizing the full spectrum of available psychological, pharmacological and (if necessary) surgical treatments.

Lethbridge, Alberta