1. Dr. Samantha Scholtz, MRCPsych
Consultant Liaison Psychiatrist
Imperial Weight Centre
West London Mental Health Trust
Wellcome Trust Research Training Fellow
MRC Clinical Sciences Centre
Imperial College London
Psychological assessment of
obese patients

2. OBESITY AND SERIOUS
MENTAL ILLNESS

3. Rates of obesity in serious
mental illness
• 30-40% men, 50-60% women
• Association with depression is bi-
directional
• Bipolar disorder doubles risk of
obesity
• Obese bipolar patients have longer
episodes, poorer physical and
mental health
Lopresti et al, 2013 Prog Neurospychopharm

4. Common mediators
• Poor diet
• Sedentary lifestyle
• Early life trauma
• Sleep disorder
• Cardiovascular and metabolic
disease
• ? Difficulty with affect regulation
Lopresti et al, 2013 Prog Neurospychopharm

5. Psychotropic medication
• Worst offenders: Amitriptyline,
Mirtazepine, Paroxetine, Olanzapine,
Clozapine
• Influenced by genetics (eg. 759 T/C
SNP in 5HT2C gene)
• But medication naïve patients have
higher risk of obesity
Lopresti et al, 2013 Prog Neurospychopharm

6. Das et al. 2012, Annals Clinical Psychiatry

7. Psychiatric co-morbidity of
bariatric surgery patients
Kaarchian et al, Am J Psychiatry 2007
•Obesity is associated
with mental disorder
•Major depressive
disorder (42.0%
lifetime and 10.4%
current)
•Binge eating
disorder (27.1%
lifetime and 16.0%
current)
Obesity
surgery
candidate
%
Population
sample
%
Mood
disorders
45.5 20.8
Anxiety
disorders
37.5 28.8
Substance
disorders
32.6 14.6

8. Binge eating disorder
• Average person’s daily intake in short period of time
• Subjective sense of lack of control
• At least 2 days a week for 6 months
• No associated purging – laxatives, vomiting or
excessive exercise
• Binge episodes associated with:
eating rapidly
eating until uncomfortably full
eating when not hungry
eating alone or in secret
disgust, depression, guilt

9. WHAT DRIVES OBESITY?

10. Having 2 obese parents increases risk of obesity 5 times

11. Clustering of obesity (yellow circles) in a social network (Christakis & Fowler, 2007)
http://www.nejm.org/doi/full/10.1056/NEJMsa066082

12. Eating behaviour
Hormones
Autonomic
nervous system
External cues
Gut
Fat tissue
Food Reward Systems
BMI
Nutritional state
Food type
Internal cues
Food intake
Sensory
system
Psychological
cues
Fasted Fed Gender
Hypothalamus
Midbrain (VTA)
Nuc. solitary tract
Eating behaviour, reward sensitivity

13. PYY
GLP-1
GLP-1
PYY
GLP-1
Vagus Nerve
Midbrain
Brainstem
Hypothalamus
Courtesy of Gao, Annu Rev Neruosci 2007

14. Brain Regions Activated in Response to
Palatable Food or Food-Associated Cues
Kenny et al. Neuron 69:664-679, 2011

15. Fig.?2 Obesity and its influence on pathways associated with psychiatric disorders. Obesity influences several biological pathways
associated with psychiatric disorders including immuno-inflammatory processes, oxidative stress, neuroprogression, mitochondr...
Adrian L. Lopresti , Peter D. Drummond
Obesity and psychiatric disorders: Commonalities in dysregulated biological pathways and their implications for treatment
Progress in Neuro-Psychopharmacology and Biological Psychiatry null 2013 null
http://dx.doi.org/10.1016/j.pnpbp.2013.05.005

16. TREATMENT FOR OBESITY

17. Sjostrom Int J Obesity 2008
Long term weight loss after surgery

18. Psychological treatment obesity
No. studies Mean weight
change
(kg)
No treatment -2.8 to +1.8
Behavioural Therapy (BT) 10 -0.6 to -5.5
Intensive BT 17 -1.4 to -8.4
BT plus Diet/Exercise 8 -2.4 to-7.3
Cognitive Behavioural Therapy 2 -0.6 to -10
Shaw, 2009: Cochrane review

19. Behavioural intervention in SMI
• Tailored for executive functioning
impairment
• Group and individual sessions: diet,
exercise and self regulation
• Dietary: junk food, sugar drinks, 5
fruits, portion size
• Monitoring weight and behaviour
Daumit et al. 2013, NEJM

20. Daumit et al. 2013, NEJM

21. Gastric
Banding
Gastric
Bypass
Surgical procedures
Sleeve
Gastrectomy

22. NICE guidelines
• BMI > 35kg/m2 + co-morbidity and failed
treatment
• BMI > 40kg/m2 and failed treatment
• BMI > 50kg/m2
• Within centre with multi-disciplinary
support
• Tier 3 specialist service including
dietetics, psychology, exercise therapist
and obesity physician 6-24 months

23. PSYCHOLOGICAL EFFECTS
OF BARIATRIC SURGERY

24. Psychiatric outcomes following
obesity surgery
•Improvement in depression,
anxiety disorders diagnosed with
DSM-IV classification
•50-60% improvement in social
functioning
•BUT higher suicide rates compared
to subjects of similar BMI and
increasing reports of alcohol
dependency Herpetz et al. International Journal of Obesity (2003).

25. Increased alcohol
dependency after bariatric
surgery
•Increased alcohol use in particularly
2nd year
•Increase in alcohol dependency
from 3% to 6% at 2 years post
operatively
•More prevalent after gastric bypass,
and in younger, male, previous
alcohol use, poor social support
King, JAMA 2012, Ostlund, JAMA Surg 2013

26. Less Activation to High-Calorie Foods in Gastric Bypass
OFC
vACC
High-calorie food > Objects, Banding > Bypass, Bypass > Banding, adjusting age, gender, BMI
n=19-20, cluster threshold Z>2.1 , P<0.05
Amygdala
Ventral
striatum
Medial frontal
cortex
y 36R x 6
z -6
y -2
vACC
Ventral
striatum
Caudate

27. PSYCHOLOGICAL
ASSESSMENT FOR
BARIATRIC SURGERY

28. POSPS
• Semi-structured interview screening
• Identify binge eating disorder/other eating
disorder, depression, past or current serious
mental illness
• Social support
• Alcohol or drug misuse (AUDIT)
• Personality disorder
• Expectation management
• Motivational interviewing approach

29. 0
20
40
60
80
100
120
140
160
180
16 20 24 28 32 36 40 44 48 52
Rugby player
Knee injury
Married
Diabetes
Age
Weight
in kg
54 year old male

30. 0
20
40
60
80
100
120
140
160
180
1 5 9 13 17 21 25 29 33
Sexual abuse
Bulimia nervosa
Cutting arms
Weight
in kg
Age
34 year old woman

31. RED: full psychiatric
assessment/not suitable
(5%)
•Active psychosis or current serious mental
illness
•Personality disorder
•Suicide attempts in last 1 year
•Alcohol or drug dependency in last 1 year
•Moderate to severe learning difficulty
•Dementia
•Active bulimia nervosa
•Non-compliance

32. AMBER: Needs preparation
(30%)
•Binge eating disorder or significant
emotional eating
•Substance misuse in last 1 year
•Unrealistic expectations or motivation to
have surgery
•Untreated depression
•Mild learning difficulties
•Minimal social support

33. GREEN: OK to proceed
(65%)
•Treated binge eating disorder
•Stable depression on medication
•Ability to psychologically reflect on role of
food in life
•Access to alternative coping strategies
•Stable psychotic illness > 1yr without
symptoms and under CMHT

34. Acknowledgements
Computational, Cognitive &
Clinical Neuroimaging Lab
Christian Beckmann
David Sharp
Richard Wise
Imaging Sciences Dept.
Rita Nunes
David Larkman
Jo Hajnal
Hammersmith Hospital Trustees’
Research Committee
Imperial College Healthcare Charity
NIHR Biomedical Research Centre
UK Clinical Research Network
Metabolic & Molecular Imaging Group
Tony Goldstone
Jimmy Bell
Christina Prechtl
Shahrzad Deliran
Waaka Moni-Nwinia
Navpreet Chhina
Alex Miras
Robert Steiner MRI Unit
Giuliana Durighel
Emer Hughes
Adam Waldman
Section of Investigative
Medicine
Carel le Roux
Dept. of Bariatric Surgery
Ahmed Ahmed
Torsten Olbers
Karen O’Donnell
Jonathan Cousins
Lisa Cotter