Is there a role for mental health nurses within bariatric services? Sonya Chelvanayagam Lecturer in Mental Health Nursing

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1 Is there a role for mental health nurses within bariatric services? Sonya Chelvanayagam Lecturer in Mental Health Nursing

2 Background Prevalence of obesity in UK is between 24-26% for men and women (HSCIC, 2014, NICE, 2014) Many people with obesity have significant mental health issues and/or eating disorders (NICE, 2014). Bariatric surgery most effective treatment to reduce obesity Mental health issues can negatively impact on the outcome of surgery and/or further psychological distress can occur postoperatively(yen et al, 2014, NCEPOD, 2012).

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4 Route to bariatric surgery (BOMSS, 2014 p.2)

5 NICE Guidelines (2014) Indications for bariatric surgery BMI > 40 or BMI > 35 for people with significant health problems Non-surgical methods have been tried but ineffective Will have received input in Tier 3 service Fit for anaesthesia & surgery Person commits to long term follow up MDT with specialist dietetic, nursing and surgical support Psychological support pre and post op

6 Types of bariatric surgery Approximately 8,000 operations in UK annually (NBSR, 2014, McCarthy, 2015) Main procedures Adjustable gastric banding Sleeve Gastrectomy Gastric Bypass

7 Adjustable gastric banding Inflatable silicone ring placed around the top part of the stomach. Weight loss expected - 50% of excess weight in 2 years post op Mortality 1:1000 will not survive the surgery

8 Sleeve Gastrectomy Stomach is reduced to 25% of its original size Approximately 60% excess weight loss can be achieved at 1 year post op Mortality rates 1:400 people will not survive the surgery

9 Gastric Bypass creates a small gastric pouch about the size of a golf ball Food enters the small bowel about a metre lower Weight loss is achieved through reduced volume of food & an element of malabsorption Approximately 70% excess weight loss expected at 1 year post op Mortality rates 1:300 people will not survive the surgery

10 Mental Health Issues Patients presenting for surgery more likely to have psychopathology than other surgical patients or those with obesity living within the community Effect of chronic illness on mental health 2/3 of patients presenting for bariatric surgery - lifetime history of at least one psychiatric disorder Increased likelihood of substance misuse More likely to have attempted suicide & increased risk of suicide 18/12 post operatively?reduced ghrelin levels can increase suicide risk 55% of people with severe mental illness are obese

11 Mental Health Issues Sexual & physical abuse - rates from 15 69%. Dependent on how this is assessed & when Fear of surgical rejection More likely to disclose suicidal ideation Impact of weight loss on mental health Eating disorders particularly BED (rates from 5-50%) Treatment preoperatively Improves BED for up to 2 years Post operatively can develop eating disorder

12 Psychosocial Issues Stigma & discrimination Effect on self and relationships of altered body image Lifestyle changes post operatively

13 NICE Guidelines (2014 p.30) Carry out a comprehensive preoperative assessment of any psychological or clinical factors that may affect adherence to postoperative care requirements (such as changes to diet) before performing surgery

14 Too Lean a Service? A review of the care of patients who underwent bariatric surgery (NCEPOD, 2012) Principle recommendations All patients must have access to full range of specialist professionals in line with NICE guidelines Greater emphasis on psychological assessment and support & should occur at an earlier stage in the care pathway Clear continuous long term follow up plan which includes surgical, dietetic and nursing input. Also assessment of psychological or psychiatric input

15 Psychological Input Despite the fact that psychological disorders are known to be common in obese patients seeking bariatric surgery, in only 91/309 (29%) of patients was there evidence to demonstrate that they had received any psychological input into their care, and in the majority of those, this input occurred following referral for bariatric surgery (NCEPOD, 2014 : 51)

16 Outcomes are enhanced when multidisciplinary teams, that include psychiatric nurses, work collaboratively to meet patients medical, educational, nutritional, and psychological needs (Grimaldi & Etten, 2010 p.25)

17 Role of Mental Health Nurse Review referral letters Assessment & therapeutic engagement throughout patient journey Interventions including facilitation of support groups Long term follow up (beyond 2 years) Collaboration Staff education and clinical supervision Audit and research

18 References British Obesity and Metabolic Surgery Society (BOMSS) (2014) Commissioning guide: Weight assessment and management clinics (tier 3). London: Royal College of Surgeons Grimaldi, D., Van Etten, D Psychosocial adjustments to weight loss surgery Journal Of Psychosocial Nursing And Mental Health Services 48 (3) Health & Social Care Information Centre (hscie) (2014) Health Survey for England [NS] &q=title%3a%22health+survey+for+england%22&sort=relevan ce&size=10&page=1#top National Confidential Enquiry into Patient Outcome and Death (NCEPOD) (2012) Too Lean a Service? A review of the care of patients who underwent bariatric surgery port.pdf

19 References National Institute of Health and Care Excellence (2014) Obesity: identification, assessment and management of overweight and obesity in children, young peopleand adults Parker, K. and Brennan, L Measurement of disordered eating in bariatric surgery candidates: A systematic review of the literature Obesity Research and Clinical Practice Wsoker, A. (2005) The lived experience of choosing bariatric surgery to lose weight Journal of the American Psychiatric Nurses Association Yen, Y.C., Chih-Kuan H. and Tai, C.M. (2014) Psychiatric aspects of bariatric surgery Current Opinion in Psychiatry