…Especially if they have no psychiatric history
Physicians prescribe psychotropics despite the absence of a current psychiatric illness—yet, when they do so with bariatric surgery patients, there are several risks.
Patients may be put at unnecessary risk of poly-pharmacy and drug-drug interactions, which are concerns given the medical comorbidities of obesity.
Also of significant concern is that many psychotropics cause weight gain—potentially impacting weight loss from the surgery itself.
“These findings support careful screening and clarification of psychiatric medications, especially in patients without a formal psychiatric diagnosis,” say researchers.
Michael Hawkins, MD, University of Toronto, Ontario, and colleagues present their findings in a paper, Prevalence and Factors Associated with Psychiatric Medication Use in Bariatric Surgery Candidates, in the September/October issue of Psychosomatics.
“Clinicians should be more judicious about the use of sedative and hypnotics due to the potential for dependence, especially with the reported higher rates of substance use after bariatric surgery.”
Background
A previous study, quoted in the paper, shows that up to 52% of people in the general population without a psychiatric diagnosis are prescribed psychiatric medication.
In the researchers’ own bariatric surgery study—of patients from the Toronto Western Hospital Bariatric Surgery Program, recruited from 2011 to 2014— more than one-third reported using a psychotropic and 13.3% of patients had been taking a psychiatric medication despite no documented psychiatric history.
Yet, that is not surprising, say the researchers—because those with severe obesity have a high prevalence of both lifetime and current psychiatric illness. Meta-analyses identify depression (19%), binge eating (17%), and anxiety (12%) disorders as the most common preoperative mental health conditions among those seeking bariatric surgery. Prescribing a psychotropic, they say, is “intuitive.”
The risks
Prescription of psychiatric medications in the absence of a clear psychiatric diagnosis, say the researchers, could be explained by several factors:
Based on concerns about the outcome risks, clinicians should continue to reassess the need for ongoing psychotropic use post-surgery, especially in cases where psychotropics are being used off-label for non-psychiatric conditions, or for conditions, such as pain, which can improve after massive weight loss.
“Physicians should not be afraid of discontinuing unnecessary medications if clinically indicated. However, if psychotropics are needed for long-term psychiatric illness stabilization, consideration of psychiatric medications with lower metabolic risk should be considered before and after bariatric surgery based on patient preference, tolerability, and response.”
“The findings support careful screening and clarification of psychiatric medications, especially in patients without a formal psychiatric diagnosis.”
Research & findings
“We hypothesize that psychiatric medication use rates in patients without a history of psychiatric diagnosis will be lower than previously reported when psychiatric illness is confirmed by structured psychiatric interview,” say the researchers.
Of the patients assessed, more than one-third reported using a psychotropic—similar to a previously-reported rate of psychotropic use in bariatric surgery patients in Massachusetts that was estimated at 37.9%.
“Compared to other psychiatric medications, antidepressants were used at a higher rate by patients in our sample,” say the researchers. “This is not a surprising finding, considering that mood disorders and anxiety disorders were among the most common lifetime psychiatric diagnoses identified. In addition, nearly one-third of patients prescribed psychiatric medications were taking sedative-hypnotic agents (benzodiazepines or non-benzodiazepine hypnotics.)
The high proportion of anxiety disorders in the research sample could explain, in part, the use of sedative-hypnotics. The high frequency of sedative and hypnotic use could also be explained by the reported high rates of insomnia in bariatric surgery candidates and individuals with a higher BMI.
“This finding raises an important issue around the prescription of sedatives and hypnotics,” say the researchers. “Although these medications can be helpful in the treatment of anxiety disorders and insomnia for some patients, prescribers should keep in mind that hypnotic and sedative medications are not recommended as first-line pharmacological treatment for the management of sleep or anxiety disorders.The continued use of sedatives carries significant risks (e.g., tolerance, rebound insomnia after discontinuation and delirium postoperatively, among others.)”
“Clinicians should be more judicious about the use of sedatives and hypnotics due to the potential for dependence, especially with the reported higher rates of substance use after bariatric surgery.”
Given that 35% of patients were taking psychiatric medications before bariatric surgery, it is important for clinicians to be aware of potential changes to the bioavailability of psychotropics after bariatric surgery, specifically Roux-en-Y gastric bypass. After bariatric surgery, the anatomy of the gastrointestinal tract is significantly altered and variations in absorption of medications could be expected. ”Though this holds true,” say the researchers, “research has shown that changes in drug dissolution and absorption are drug-specific and difficult to predict. Drugs that are intrinsically poorly absorbed, highly lipophilic, and/or undergo enterohepatic recirculation exhibited the greatest potential for malabsorption.”
Specific to antidepressants, a study shows that patients taking selective serotonin reuptake inhibitors and serotonin and norepinephrine reuptake inhibitors experienced reduced bioavailability one month post Roux-en-Y gastric bypass surgery, with some improvement over time. However, case-controlled studies examining antidepressant plasma concentration at approximately one-year post-bariatric surgery, specifically sertraline and duloxetine, showed significant reductions in plasma levels of both agents in Roux-en-Y gastric bypass patients.
“In the absence of clear guidelines, expert opinion suggests that patients taking psychotropics to manage psychiatric conditions before surgery be switched from extended-release formulations of medications to immediate release when possible due to issues with absorption,” say the researchers. “Patients expected to take psychiatric medications immediately after surgery should be monitored after surgery for potential relapse of psychiatric symptoms, and an increased dose should be considered to optimize plasma concentrations if relapse of psychiatric symptoms occurs.”
The researchers conclude: “Clinicians should consider ongoing monitoring and assessment of psychiatric medications before and after [bariatric] surgery to further mitigate risks related to post-surgical complications (e.g., delirium), weight loss outcomes, and psychiatric stability.”
The full paper, Prevalence and Factors Associated with Psychiatric Medication Use in Bariatric Surgery Candidates, is available here.