Bariatric procedures: Managing patients after surgery

David B. Sarwer, PhD, Associate Professor of Psychology, Departments of Psychiatry and Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA

Lucy F. Faulconbridge, PhD, Assistant Professor of Psychology, Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA

Kristine J. Steffen, PharmD, PhD, Research Scientist, Neuropsychiatric Research Institute, Fargo, ND

James L. Roerig, PharmD, BCPP, Associate Professor, Department of Clinical, Neuroscience, University of North Dakota School of Medicine and Health Sciences, Fargo, ND

James E. Mitchell, MD, President and Scientific Director, Neuropsychiatric Research Institute, Christoferson Professor and Chair, Department of Clinical Neuroscience, University of North Dakota School of Medicine and Health Sciences, Fargo, ND

Bariatric surgery is the most effective treatment for obesity (defined as a body mass index [BMI] >30 kg/m²) and is recommended for extremely obese individuals (BMI >40 kg/m²) age >18. Most patients experience significant weight loss accompanied by improvements in mood, physical comorbidities, and quality of life. Despite these favorable outcomes, several aspects of postoperative care—such as management of mental health issues—remain unclear. Bariatric surgery candidates show high rates of preoperative psychopathology, particularly depression and dysphoria. Little is known about how bariatric surgery affects absorption of psychiatric medications, leaving prescribing clinicians with minimal guidance when a postoperative patient reports changes in mood symptoms.

This article discusses the psychosocial status of bariatric surgery candidates and presents a rationale for increased medication monitoring after surgery.

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Atypical antipsychotics for delirium: A reasonable alternative to haloperidol?

David R. Spiegel, MD, Associate Professor of Clinical Psychiatry and Behavioral Sciences, Director of Consultation-Liaison Services, Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, Norfolk, VA

David Ahlers, MD, Psychiatry Resident, Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, Norfolk, VA

Grant Yoder, DO, Psychiatry Resident, Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, Norfolk, VA

Nabeel Qureshi, MD, Psychiatry Resident, Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, Norfolk, VA

Ms. B, age 48, is admitted to our hospital after overdosing on unknown amounts of amitriptyline, diphenhydramine, and laxatives. Three days after admission, the psychiatry service is consulted to assess her for “bipolar disorder.” Although Ms. B does not have a psychiatric history, her internist believes her pressured speech and psychomotor agitation warrant investigation.

During the initial psychiatric interview, Ms. B is disoriented, with fluctuating alertness and cognition. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is positive for delirium. We perform a delirium workup while we start Ms. B on olanzapine, 5 mg/d orally and 5 mg intramuscular (IM) every 8 hours as needed.

Ms. B’s laboratory results (complete blood count, complete metabolic profile, urinalysis, chest roentgenogram, vitamin B12 level, blood alcohol level, urine drug screen, arterial blood gas, and head CT) are unremarkable except for her amitriptyline/nortriptyline level, which is in the toxic range. On physical examination, Ms. B’s heart rate and temperature are elevated, her pupils are dilated and sluggish, and her skin is hot and dry. Based on these findings, we determine that Ms. B’s delirium most likely is an anticholinergic syndrome from amitriptyline/diphenhydramine toxicity. We discontinue olanzapine after only 2 doses because of its potential anticholinergic effects.

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Shattering dogmas

Henry A. Nasrallah, MD
Editor-in-Chief

Like all other medical specialties, psychiatry has its share of dogmas that are perpetuated via the clinical apprenticeship model from one generation of physicians to the next, despite the lack of hard evidence. They become “articles of faith” that go unchallenged by trainees who acquire them from their supervisors. A dogma masquerades as a truism and eventually becomes a sacred feature of the “clinical lore.”

Sooner or later, however, the bright light of scientific evidence will reveal the ersatz nature of a dogma and it will come crashing down. Similar to a revolution to depose a dictator, the demise of a dogma will have a salutary effect on medical practice and a liberating effect on practitioners.

Here are examples of psychiatric dogmas that were part of my training but have been/or are in the process of being taken to the slaughterhouse of obsolete tenets:

Psychiatrists should not touch their patients. Really! How can we be practicing physicians if we don’t? This dogma arbitrarily sexualized the physical exam, including drawing blood, measuring blood pressure or waist circumference, assessing neuroleptic-induced cogwheeling, or checking the body for a drug-induced rash. This dogma is the antithesis of good medical care for psychiatric patients, who frequently suffer from serious physical ailments and often do not have a primary care provider. It was created during the primordial phase of psychiatry (aka psychoanalysis) and is irrelevant in modern-era psychiatry.

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