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Prevalence and Factors Associated With Psychiatric Medication Use in Bariatric Surgery Candidates
Accepted Manuscript
Prevalence and Factors Associated with Psychiatric Medication Use in Bariatric Surgery Candidates Michael Hawkins MD , Andrew Lee BSc , Samantha Leung MSc , Raed Hawa MD , Susan Wnuk PhD , Richard Yanofsky MD , Sanjeev Sockalingam MDMHPE PII: DOI: Reference:
S0033-3182(18)30494-8 https://doi.org/10.1016/j.psym.2018.11.007 PSYM 948
To appear in:
Psychosomatics
Received date: Revised date: Accepted date:
6 October 2018 22 November 2018 26 November 2018
Please cite this article as: Michael Hawkins MD , Andrew Lee BSc , Samantha Leung MSc , Raed Hawa MD , Susan Wnuk PhD , Richard Yanofsky MD , Sanjeev Sockalingam MDMHPE , Prevalence and Factors Associated with Psychiatric Medication Use in Bariatric Surgery Candidates, Psychosomatics (2018), doi: https://doi.org/10.1016/j.psym.2018.11.007
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Prevalence and Factors Associated with Psychiatric Medication Use in Bariatric Surgery Candidates
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Michael Hawkins, MDa, Andrew Lee, BScb, Samantha Leung, MSc b,c, Raed Hawa, MDa,b,c, Susan Wnuk, PhDc, Richard Yanofsky, MDa,b,c, Sanjeev Sockalingam, MD, MHPEa,b,c,d
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Affiliations: a - Department of Psychiatry, University of Toronto. Toronto. Ontario. Canada. b - Centre for Mental Health, University Health Network. Toronto. Ontario. Canada. c - Toronto Western Hospital, Bariatric Surgery Program, University Health Network. Toronto. Ontario. Canada. d - Centre for Addiction and Mental Health. Toronto. Ontario. Canada.
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Corresponding Author: Dr. Sanjeev Sockalingam Director, TWH Bariatric Surgery Psychosocial Program University Health Network VP Education, Centre for Addiction and Mental Health Associate Professor, Department of Psychiatry University of Toronto Tel.: 416 535-8501 ext. 32178 Fax: 416 532-1306 Email: [email protected]
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Running Title: Psychiatric medications in bariatric surgery candidates Word count: 3,016 Tables: 3 Abstract’s word count: 236
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Abstract Objective: We aimed to describe the rates of psychiatric medication use in bariatric surgery candidates and factors associated with psychiatric medication use.
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Methods: Patients from the Toronto Western Hospital Bariatric Surgery Program (TWHBSP) were recruited from 2011 to 2014. Data extracted included demographics, clinical factors (e.g., mood disorder, anxiety disorder, eating disorder, Patient Health
Questionnaire-9 [PHQ-9], Generalized Anxiety Disorder 7 [GAD-7], other), and
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psychiatric medication use. Logistic regression analyses were used to examine the relationship between demographic variables, clinical factors, and psychiatric medication use. Multiple logistic regression was conducted to determine the predictors of clinical
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factors from demographic variables with psychiatric medication use.
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Results: A total of 262 (35.1%) patients were taking at least one psychiatric medication and 105 patients (14.1%) were taking more than 1 psychiatric medication.
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Antidepressants were the most common psychiatric medication reported. Majority of
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patients taking a psychiatric medication had a psychiatric illness, with 16.0% not having a lifetime diagnosis of a mental illness. Being male and being employed significantly
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predicted a lower odds of being on a psychiatric medication. Older age significantly predicted higher odds of being on a psychiatric medication. Psychiatric disorders were significantly associated with psychiatric medication use independent of demographic variables.
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Conclusion: Our study provides insights on clinical and demographic factors related to psychiatric medication use in bariatric surgery patients. The findings support careful screening and clarification of psychiatric medications, especially in patients without a
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formal psychiatric diagnosis.
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Key Words: psychiatric, antidepressant, medication, bariatric surgery
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1. Introduction Severe obesity is highly comorbid with a range of medical conditions including psychiatric illness, with high prevalence of both lifetime and a current psychiatric illness [1-5]. A recent meta-analyses identified depression (19%), binge eating disorder (17%)
conditions among patients seeking bariatric surgery [2].
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and anxiety (12%) disorders as the most common pre-operative mental health
As a result of the high rates of psychiatric comorbidities in bariatric surgery
candidates, it is not surprising that many candidates are actively treated with psychiatric
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medications [6,7]. Though this is intuitive, a large bariatric surgery registry study in Ontario showed that 13.3% of the patients taking a psychiatric medication had no
documented psychiatric history [7]. In the general population, it has been previously
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reported that about 13% to 52% of people without a psychiatric diagnosis are prescribed a psychiatric medication [8-10]. To date there is scarce research investigating /
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describing reasons for the prescription of psychiatric medications when there is no clear indication or the presence of a psychiatric disorder. Anxiety and depressive symptoms,
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poor sleep, and subthreshold psychiatric disorder has been reported as common
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reasons for psychiatric medication use in the absence of a psychiatric disorder diagnosis [8]. Though it is possible that the increased prescription rate of some
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antidepressants is related to the approval for their use in the management of conditions such as pain [11]. Factors associated with psychiatric medication use have been examined in the
general population and in people without psychiatric diagnosis. Female sex, older age and unemployment, among other factors have been associated with psychiatric
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medication use/prescription in the general population and in people without a psychiatric diagnosis [8,9,12-17]. People age 50 to 64 without a psychiatric diagnosis have been found to have a 3-fold increased risk of being prescribed a psychiatric medication compared to younger people without a psychiatric diagnosis [17]. This association
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remained significant even after adjusting for medical condition and severity of general medical condition, which raises the possibility of additional off-label use of these
psychotropic medications. It is unclear if psychiatric medication use in bariatric surgery candidates is mainly associated with depression and anxiety symptoms or associated
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with demographic factors. Therefore, more rigorous studies are needed to more clearly elucidate variables associated with psychiatric medication use in pre-bariatric surgery candidates.
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This study aims to build on previous literature describing rates of psychiatric medication use in bariatric surgery candidates and describe factors associated with
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psychiatric medication use in these patients. We hypothesize that psychiatric medication use rates in patients without a history of psychiatric diagnosis will be lower
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than previously reported when psychiatric illness is confirmed by structured psychiatric
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interview. Moreover, we aim to explore associations between psychiatric medication use and patient factors such as demographic and clinical factors, including the presence of
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a psychiatric diagnosis. The results of this study could provide further understanding of factors associated with psychiatric medication use and underscore the need for ongoing psychiatric medication monitoring to effectively manage psychiatric comorbidity in this population.
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2. Methods 2.1 Setting Patients from the Toronto Western Hospital Bariatric Surgery Program (TWH-BSP) were recruited from 2011 to 2014. Patients are referred to the TWH-BSP if they have a
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body mass index (BMI) ≥ 40 kg/m2 or a BMI ≥ 35 kg/m2 with one or more obesity-related co-morbidity. Patients provided informed consent permitting data collection and
extraction of all selected variables as part of a larger prospective cohort database
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[18,19].
2.2 Data Assessment & Measures
Patients underwent a comprehensive pre-surgery psychosocial assessment. All patients
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in the TWH-BSP undergo an assessment by an interprofessional team including at least one assessment by a psychiatrist or psychologist. Psychiatric medication use was
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assessed by psychiatrists in the program during the psychosocial visit or during presurgery team rounds. Full details of the pre-surgery assessment have been previously
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described [20-22].
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Data extracted from patients charts included demographics, clinical factors and psychiatric medication use. Demographic data and anthropometric measures were
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collected by clinicians within the program. Relationship status was defined as either in a relationship (which included married or common-law) or not in relationship (which included divorced, separated, single or widowed individuals). Employment was defined as either full-time, part-time employment or unemployment (which included those who
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were unemployed, retired, on social assistance, and individuals receiving disability payment). Clinical factors included lifetime psychiatric diagnoses and self-reported measures of anxiety and depression symptoms and HRQOL. Lifetime diagnoses of
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mental illness was defined as a past history of or current mental illness determined by using the Mini International Neuropsychiatric Interview (M.I.N.I.), which used DSM-IV diagnostic criteria. For the purpose of our analysis, M.I.N.I. was modified to reflect DSM 5 diagnoses. Psychiatric diagnoses were categorized into any psychiatric disorder
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(excluding personality disorders), anxiety disorders, mood disorders, eating disorders, substance disorders and trauma and stressor related disorders. Additional measures for depression, anxiety and HRQOL were administered to patients in this study. Depressive
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symptoms were assessed using the Patient Health Questionnaire 9-item scale (PHQ9) which yields a score ranging from 0 to 27 [23]. The PHQ9 severity cut-point scores are
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5 for mild, 10 for moderate, 15 for moderately severe and 20 for severe depressive symptoms. The PHQ9 has been previously validated in bariatric surgery patient
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populations [24]. Anxiety symptoms were assessed using the Generalized Anxiety
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Disorder 7-item scale (GAD7), which is an anxiety assessment scale ranging from 0 to 21. The GAD7 severity cut-points are 5 for mild, 10 for moderate and 15 for severe
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anxiety [25]. This scale has been widely used in bariatric surgery candidates [18,19,26,27]. HRQOL was measured using the Medical Outcomes Study Short-Form 36 Health Status Survey (SF-36) [28]. The SF-36 yields a physical component score (SF36-PCS) and mental component score (SF36-MCS) ranging from 0 (lowest or worst possible level of functioning) to 100 (highest or best possible level of functioning). SF-36
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component scores are calculated from aggregate measure of 8 health domains: bodily pain, general health, emotional role, mental health, physical functioning, physical role, social functioning and vitality. The SF-36 has been used previously as a measure of HRQOL in bariatric surgery populations [18,19,29,30].
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During the baseline assessment of pre-surgery candidates, all psychiatric medications were recorded by a nurse practitioner and/or physician. Psychiatric
medication use was indicated as yes/no and number of medications. Medications
recorded and analyzed in this study were those the patient was taking at their initial
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assessment at the TWH-BSP. We did not include in our analyses any new medications recommended by the psychiatrist at our clinic. Psychiatric medications were grouped by class including antidepressant, benzodiazepine, non-benzodiazepine hypnotic,
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2.3 Data Analysis
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antipsychotic, mood stabilizer, stimulant, opioid and other psychiatric medication.
Descriptive statistics were conducted for demographic data and medication classes. We
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also examined psychiatric medication use among those with a lifetime diagnosis of
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mental illness. Bivariate logistic regression analyses were conducted with demographic variables, clinical factors and psychiatric diagnoses as covariates and psychiatric
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medication use as the outcome variable. A multiple logistic regression was conducted to assess whether demographic factors (i.e., age, gender, relationship status, marital status, education, employment status) were predictors of psychiatric medication use. An unadjusted logistic regression model was performed for each of the following disorders: any axis 1 disorder, anxiety disorder, mood disorder, eating disorder, substance abuse
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and trauma disorder, as well as symptom and quality of life measures (GAD7, PHQ9, SF36-PSC and SF36-MCS). The purpose of the unadjusted logistic regression analyses was to assess how diagnosis of a disorder as well as scores on psychopathology selfreported measures predicted psychotropic medication use.
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Lastly, a logistic regression adjusted for demographic variables and symptoms scales, specifically the PHQ9, GAD7, SF-PCS and SF-MCS, was run individually for each of the disorders as well as symptom and HRQOL measures to assess whether these individual variables were predictors of psychotropic medication use. Data
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analyses were conducted in SPSS version 22.0.
3. Results
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Complete data were available for 746 patients. Patients‟ average age was 44.7 years (SD = 10.6), with the majority being female (78.8%). At baseline psychiatric
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assessment, 430 (57.6%) patients had at least one lifetime diagnosis of mental illness and 188 (25.2%) had more than one mental illness diagnosis. Of those with a lifetime
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diagnosis of mental illness, the most common diagnosis was a mood disorder (n = 284,
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66.0%) and the second most common diagnosis was an anxiety disorder (n = 120, 27.9%). Compared to mood and anxiety disorders, other mental illnesses were
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identified at a lower proportion in these patients (eating disorder [n = 105, 14.1%], substance abuse [n = 105, 14.1%], trauma and stressor-related disorder [n= 76, 10.1%]). The average scores on the self-reported measures of anxiety and depression symptoms and HRQOL was as follows: PHQ9, 10.6 (SD = 6.4); GAD7, 6.4 (SD = 5.6); SF36-MCS, 46.8 (SD = 12.1); and SF36-PCS, 31.5 (SD = 10.4).
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A total of 262 (35.1%) patients were taking at least one psychiatric medication and 105 (14.1%) were taking more than 1 psychiatric medication. The most common type of medication reported was an antidepressant (n = 240, 32.2%) (Table 1). The majority of patients taking a psychiatric medication (220/262; 84.0%) had a lifetime
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diagnosis of a mental illness, although 42 (16.0%) did not have a lifetime diagnosis of a mental illness. Of the patients taking a psychiatric medication without a psychiatric illness, 64.3% of those patients were on antidepressants, 16.7% were on
benzodiazepines and 9.5% were on hypnotics. Candidates using psychiatric
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medications at baseline were significantly older compared to those candidates not using psychiatric medications [47.4 years (SD = 10.2) vs. 43.2 years (SD = 10.5), p < 0.0001]. Based on logistic regression analysis of demographic variables, being male and being
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employed significantly predicted lower odds of being on a psychiatric medication compared to their counterparts. Age, being female and unemployed significantly
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predicted higher odds of being on a psychiatric medication (Table 2). A secondary logistic regression analysis of demographic variables adjusted for psychiatric illness
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demonstrated the same significant demographic predictors. Linear regression analysis
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of the association of age with psychiatric medication use showed that higher age was significantly associated with psychiatric medication use (B = 0.038, p < 0.001). The
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crude model showed that those diagnosed with a mood disorder, anxiety disorder, eating disorder, trauma and stressor-related disorder and any axis I disorder were significantly associated with higher odds of being on a psychiatric medication (Table 3). Higher PHQ9 scores were significantly associated with psychiatric medication use and higher scores on the SF36-MCS were significantly associated with lower odds of being
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on a psychiatric medication. A diagnosis of a mood disorder was associated with the highest odds of being on a psychiatric medication compared with not having a mood disorder diagnosis (OR 7.56 [5.39 - 10.59]). Similar high odds for psychiatric medication
compared to those without an anxiety disorder.
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use was seen for patients diagnosed with an anxiety disorder (OR 4.88 [3.22 - 7.40])
In the adjusted regression model (Table 3), after controlling for demographic factors it was found that mood disorders, any axis I disorder, eating disorders, trauma and stressor-related disorders and anxiety disorders remained significant predictors of
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psychiatric medication use. Only the SF36-PCS became non-significant in the adjusted model. All measures decreased in their effect size except for anxiety disorders (OR 5.12 [3.29 - 7.98]), which was associated with higher odds for psychiatric medication use in
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the adjusted model. Tests for multicollinearity indicated a very low level of multicollinearity among the regression models with VIF values were less than 2 and
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4. Discussion
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tolerance values approaching 1.
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Our data adds to the existing literature on psychiatric medication prescribing in bariatric surgery candidates and identified several associated factors for psychiatric
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medication use. We found that being male and employed was associated with a lesser likelihood of being on a psychiatric medication. In addition, higher age (besides being female and unemployed) was also significantly associated with a higher likelihood of being on a psychiatric medication. Our findings appear to be similar to that of other studies from the general population [8,12-16], suggesting that the association between
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demographic factors and psychiatric medication prescription are also generalize to bariatric surgery candidates. Furthermore, our regression model suggested that patients in our sample with any axis I disorder, mood disorder, anxiety disorder, eating disorder and trauma and
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stressor-relater disorder had higher odds of being on a psychiatric medication
independent of demographic factors. In addition, psychiatric medication use was
associated with higher PHQ9 scores, remaining significant even after adjusting for demographic factors. Though a small odds ratio, better SF36-MCS scores were
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associated with lower odds of psychiatric medication use in our sample. These findings suggest that patients who have a history of a psychiatric disorder and more severe symptoms, as indicated by higher PHQ9 scores and lower mental HRQOL, were more
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likely to be using a psychiatric medication. Our study‟s analysis of demographic, clinical, and measurement-based factors associated with psychiatric medication use in a
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bariatric surgery sample adds to the literature and provides clarification on clinical
candidates.
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factors related to the prescription of psychiatric medications in bariatric surgery
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Of the patients assessed in our sample, more than one third reported using a psychiatric medication. Our reported rate of psychiatric medication use is similar to
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previously reported rates of psychiatric medication use in bariatric surgery patients from our province, which has been estimated to be 37.9% [7]. Compared to other psychiatric medications, antidepressants were used at a higher rate by patients in our sample. This is not a surprising finding, considering that mood disorders and anxiety disorders were among the most common lifetime psychiatric diagnoses identified. In addition to
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antidepressants, nearly one third of patients prescribed psychiatric medications were taking a sedative or hypnotic medications (benzodiazepine or non-benzodiazepine hypnotic). The high proportion of anxiety disorders in our sample could explain, in part, the use of sedatives or hypnotics in these patients. High frequency of sedative and
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hypnotic use could also be explained by the reported high rates of insomnia symptoms in bariatric surgery candidates [31] and individuals with higher BMI and obesity [32]. This finding raises an important issue around the prescription of sedatives and
hypnotics. Although these medications can be helpful in the treatment of anxiety
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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 [33,34]. The continued use of
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sedatives carry significant risks (e.g., tolerance, rebound insomnia after discontinuation and delirium post-operatively, among other risks) [33,35]. Clinicians should be more
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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 [36].
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Given that 35% of patients were taking psychiatric medications pre-bariatric
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surgery, it is important for clinicians to be aware of potential changes to the bioavailability of psychotropic medications after bariatric surgery, specifically Roux-en-Y
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gastric bypass. After bariatric surgery, the anatomy of the gastrointestinal tract is significantly altered and variations in absorption of medications could be expected [37,38]. Though this holds true, recent research has shown that changes in drug dissolution and absorption are drug-specific and difficult to predict [39]. Drugs that are intrinsically poorly absorbed, highly lipophilic and/or undergo enterohepatic recirculation
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exhibited the greatest potential for malabsorption in these patients [40]. Specific to antidepressants, a recent study showed that patients, although in a small number (n = 12), taking selective serotonin reuptake inhibitors and serotonin and norepinephrine reuptake inhibitors experienced reduced bioavailability one month post Roux-en-Y
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gastric bypass surgery [41], with some improvement over time. However, case
controlled studies examining antidepressant plasma concentration at approximately 1year post-bariatric surgery, specifically sertraline (n = 5) and duloxetine (n = 10),
showed significant reductions in plasma levels of both agents in Roux-en-Y gastric
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bypass patients[42,43]. In the absence of clear guidelines, expert opinion suggests that patient taking psychotropic medications to manage psychiatric conditions pre-surgery be switched from extended formulations of medications to immediate release when
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possible due to issues with absorption [38]. Further, patients expected to take psychiatric medications immediately post-surgery should be monitored post-surgery for
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potential relapse of psychiatric symptoms and an increased in dose should be considered to optimize plasma concentrations if relapse of psychiatric symptom occurs
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[38,41]. Further evidence is needed to inform more conclusive guidelines including
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longitudinal studies on psychotropic bioavailability post-bariatric surgery. We found a similar proportion to previously reported studies of patients without a
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formal psychiatric diagnosis taking psychiatric medications (16% vs.13%) from samples where psychiatric diagnosis was self-reported [7]. Moreover, our reported rate of psychiatric medication use in patients without a psychiatric diagnosis is similar to the previously reported psychiatric medication use in the general population without a psychiatric diagnosis [8,10]. It is possible that the rates were comparable based on
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patients‟ social desirability bias when undergoing psychiatric assessment for bariatric surgery, specifically due to concerns of being “rejected” for surgery based on the presence of psychiatric illness. Nonetheless, prescription of psychiatric medications in the absence of a clear psychiatric diagnosis could be explained by several potential
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factors. First, it is well documented that the prescription of antidepressants in individuals without a psychiatric condition is on the rise [44] and in part, perhaps, explaining this phenomenon. To this point, some antidepressants have been approved for the
treatment of conditions other than psychiatric illnesses, such as pain [11,45], which is a
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common comorbidity in patients with obesity [46]. Alternatively, antidepressants may be used off-label to manage insomnia and headaches [47,48], even when the evidence is limited for their effectiveness in these contexts [49]. Further, people with multiple
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medical conditions, in the context of severe obesity may be at risk of being overdiagnosed with depression due to the overlap of some symptoms of depression and
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chronic medical conditions, which may result in an increased likelihood of prescribing antidepressants despite not meeting criteria for mood and anxiety disorders [44,50].
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Second, at least one study have suggested that antidepressants are being prescribed
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for subthreshold depression or patients with minor depression, even when there are no guidelines or evidence of the effectiveness of pharmacological treatment in these
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conditions [8,51]. Finally, ongoing fears of depression recurrence from patients, the fact that these medications are generally safe, and the lack of proactive medication review from physicians, are all factors potentially contributing to psychiatric medication continued use even in the absence of a current psychiatric illness [52].
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There are several potential risks for bariatric surgery patients taking psychiatric medications in the absence of clear psychiatric illness. Provided that these medications are not treating comorbid physical health comorbidities in obesity, patients may be at unnecessary risk of polypharmacy and drug-drug interactions, which is a concern given
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the multiple medical comorbidities in the context of obesity. Of significant concern is the risk of many psychotropic medications causing weight gain post-surgery and potentially impacting bariatric surgery weight loss outcomes (53-57). Based on these potential concerns, clinicians should continue to reassess the need for ongoing psychotropic
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medications post-surgery especially in cases where psychotropic medications 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
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unnecessary medications if clinically indicated. However, if psychiatric medications are needed for long-term psychiatric illness stabilization, consideration of psychiatric
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medications with lower metabolic risk should be considered before and after bariatric surgery based on patient preference, tolerability and response.
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Although one of the strengths of our study was the use of a structured clinical
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assessment to obtain psychiatric diagnoses, there are several limitations to our findings. First, this study was a cross-sectional study and future studies are needed to examine
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longitudinal predictors of long-term psychiatric medication use after bariatric surgery Second, we did not collect data from prescribers thus limiting the interpretation of our results, especially in those participants taking psychiatric medication without a mental disorder diagnosis. Indeed, it has been reported that psychiatric diagnoses made by general practitioners have only partial concordance with diagnoses made using a
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structured interview [58,59]. Similar to this, we do not have the reasons (e.g., medical diagnosis/conditions) for prescribing a psychiatric medication in patients without a mental illness diagnosis in our sample. Third, this study was of patients from a single bariatric surgery center and our sample may not be a full representation of the whole
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Canadian population, although our results are consistent with past studies from Canada and the United States.
Conclusion
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Our study adds to the literature and provides insights on clinical and
demographic factors related to the prescription of psychiatric medications in bariatric surgery candidates. Although our results are reassuring in that psychiatric medication
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use was related to a psychiatric diagnosis for most patients, our study highlights that approximately 16% of patients were taking psychiatric medications despite the absence
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of a lifetime psychiatric diagnosis. This finding underscores the importance of screening patients that are using psychiatric medications without a formal psychiatric diagnosis,
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including sedatives and hypnotic medications given the concerns in bariatric patient
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populations (e.g., substance use, weight gain, drug-drug interaction, other). Therefore, clinicians should consider ongoing monitoring and assessment of psychiatric
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medications before and after surgery to further mitigate risks related to post-surgical complications (e.g., delirium), weight loss outcomes and psychiatric stability.
Sources of Funding: None
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Potential Conflicts of Interest: The authors report no financial or other relationships relevant to the subject of this article.
Authors’ contributions: Authors A.L, M.H, S.S contributed to the conception and
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design of the paper. A.L and S.L performed the analyses of the data. All authors
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contributed equally to the interpretation of the data and the writing of this manuscript.
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Table 1. Prevalence of Psychiatric Medication Use by Medication Class in Bariatric Surgery Candidates. Toronto Western Hospital Bariatric Surgery Program (TWH-BSP). 2011-2014. Toronto, Ontario. Canada. (N = 746) Class of Medication n % Antidepressant 240 32.2% Benzodiazepine 59 8.0% Mood stabilizer 32 4.3% Antipsychotic 25 3.4% Non-benzodiazepine hypnotic 15 2.0% Stimulant 13 1.7% Other 10 1.3% Percent expressed as percent of total sample
Table 2. Crude Model of Demographic Variables Associated with Psychiatric Medication Use. Toronto Western Hospital Bariatric Surgery Program (TWH-BSP). 2011-2014. Toronto, Ontario. Canada. (N = 746) P-value Variable OR (95% CI) Gender (Male)a*
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0.54 (0.36 - 0.80)
In a relationshipb High School Educationc
1.04 (1.02 - 1.05)
< 0.0001
0.79 (0.58 - 1.08)
0.14
0.78 (0.56 - 1.09)
0.14
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Age*
0.002
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Employedd* 0.39 (0.28 - 0.54) < 0.0001 a. Females is the reference group chosen b. Not in relationship (divorced, separated, widowed, or single) is the reference group chosen c. Education less than a high school diploma is the reference group chosen d. Unemployed (unemployed, social assistance, disability, retired) is the reference group chosen *Statistical significance p < 0.05
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Table 3. Crude Model and Adjusted Regression Model of Non-Demographic Variables Associated with Psychiatric Medication Use. Toronto Western Hospital Bariatric Surgery Program (TWH-BSP). 2011-2014. Toronto, Ontario. Canada. (N = 746) Crude Model Adjusted Modelk P-value P-value Variable OR (95% CI) OR (95% CI) a < 0.0001 < 0.0001 Axis 1 Disorder 6.95 (4.77 – 10.12)* 6.38 (4.32 – 9.40)* Anxiety Disorderb 4.88 (3.22 - 7.40)* < 0.0001 5.12 (3.29 - 7.98)* < 0.0001 c < 0.0001 Mood Disorder 7.56 (5.39 - 10.59)* 7.06 (4.96 – 10.06)* < 0.0001 d 0.002 0.01 Eating Disorder 1.92 (1.27 - 2.92)* 1.79 (1.16 - 2.76)* Substance Abusee 1.46 (0.96 - 2.23) 0.07 1.38 (0.88 - 2.16) 0.16 Trauma Disorderf 2.24 (1.39 - 3.62)* 0.001 1.79 (1.10 – 3.05)* 0.02 g 0.06 0.09 GAD7 1.03 (1.00 - 1.05) 1.02 (1.00 - 1.05) h 0.001 0.01 PHQ9 1.04 (1.02 - 1.06)* 1.03 (1.01 - 1.06)* i 0.001 0.40 SF36-PCS 0.98 (0.96 - 0.99)* 0.99 (0.98 - 1.01) j < 0.0001 < 0.0001 SF36-MCS 0.98 (0.96 - 0.99)* 0.98 (0.96 - 0.99)* a. Individuals without axis 1 disorder diagnosis is reference group chosen b. Individuals without anxiety disorder diagnosis is reference group chosen. c. Individuals without mood disorder diagnosis is reference group chosen d. Individuals without eating disorder diagnosis is reference group chosen e. Individuals without substance abuse diagnosis is reference group chosen f. Refers to Trauma and Stressor-Related Disorder. Individuals without trauma disorder diagnosis is reference group chosen g. Generalized Anxiety Disorder 7-item scale (GAD 7) h. Patient Health Questionnaire-9 (PHQ9) i. Short-Form 36 Health Status Survey physical component score (SF36-PCS). j. Short-Form 36 Health Status Survey mental component score (SF36-MCS) k. Adjusted model controlled for socio-economic factors * Statistical significance p < 0.05
Prevalence and Factors Associated with Psychiatric Medication Use in Bariatric Surgery Candidates Michael Hawkins MD , Andrew Lee BSc , Samantha Leung MSc , Raed Hawa MD , Susan Wnuk PhD , Richard Yanofsky MD , Sanjeev Sockalingam MDMHPE PII: DOI: Reference:
S0033-3182(18)30494-8 https://doi.org/10.1016/j.psym.2018.11.007 PSYM 948
To appear in:
Psychosomatics
Received date: Revised date: Accepted date:
6 October 2018 22 November 2018 26 November 2018
Please cite this article as: Michael Hawkins MD , Andrew Lee BSc , Samantha Leung MSc , Raed Hawa MD , Susan Wnuk PhD , Richard Yanofsky MD , Sanjeev Sockalingam MDMHPE , Prevalence and Factors Associated with Psychiatric Medication Use in Bariatric Surgery Candidates, Psychosomatics (2018), doi: https://doi.org/10.1016/j.psym.2018.11.007
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Prevalence and Factors Associated with Psychiatric Medication Use in Bariatric Surgery Candidates
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Michael Hawkins, MDa, Andrew Lee, BScb, Samantha Leung, MSc b,c, Raed Hawa, MDa,b,c, Susan Wnuk, PhDc, Richard Yanofsky, MDa,b,c, Sanjeev Sockalingam, MD, MHPEa,b,c,d
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Affiliations: a - Department of Psychiatry, University of Toronto. Toronto. Ontario. Canada. b - Centre for Mental Health, University Health Network. Toronto. Ontario. Canada. c - Toronto Western Hospital, Bariatric Surgery Program, University Health Network. Toronto. Ontario. Canada. d - Centre for Addiction and Mental Health. Toronto. Ontario. Canada.
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Corresponding Author: Dr. Sanjeev Sockalingam Director, TWH Bariatric Surgery Psychosocial Program University Health Network VP Education, Centre for Addiction and Mental Health Associate Professor, Department of Psychiatry University of Toronto Tel.: 416 535-8501 ext. 32178 Fax: 416 532-1306 Email: [email protected]
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Running Title: Psychiatric medications in bariatric surgery candidates Word count: 3,016 Tables: 3 Abstract’s word count: 236
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Abstract Objective: We aimed to describe the rates of psychiatric medication use in bariatric surgery candidates and factors associated with psychiatric medication use.
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Methods: Patients from the Toronto Western Hospital Bariatric Surgery Program (TWHBSP) were recruited from 2011 to 2014. Data extracted included demographics, clinical factors (e.g., mood disorder, anxiety disorder, eating disorder, Patient Health
Questionnaire-9 [PHQ-9], Generalized Anxiety Disorder 7 [GAD-7], other), and
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psychiatric medication use. Logistic regression analyses were used to examine the relationship between demographic variables, clinical factors, and psychiatric medication use. Multiple logistic regression was conducted to determine the predictors of clinical
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factors from demographic variables with psychiatric medication use.
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Results: A total of 262 (35.1%) patients were taking at least one psychiatric medication and 105 patients (14.1%) were taking more than 1 psychiatric medication.
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Antidepressants were the most common psychiatric medication reported. Majority of
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patients taking a psychiatric medication had a psychiatric illness, with 16.0% not having a lifetime diagnosis of a mental illness. Being male and being employed significantly
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predicted a lower odds of being on a psychiatric medication. Older age significantly predicted higher odds of being on a psychiatric medication. Psychiatric disorders were significantly associated with psychiatric medication use independent of demographic variables.
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Conclusion: Our study provides insights on clinical and demographic factors related to psychiatric medication use in bariatric surgery patients. The findings support careful screening and clarification of psychiatric medications, especially in patients without a
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formal psychiatric diagnosis.
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Key Words: psychiatric, antidepressant, medication, bariatric surgery
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1. Introduction Severe obesity is highly comorbid with a range of medical conditions including psychiatric illness, with high prevalence of both lifetime and a current psychiatric illness [1-5]. A recent meta-analyses identified depression (19%), binge eating disorder (17%)
conditions among patients seeking bariatric surgery [2].
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and anxiety (12%) disorders as the most common pre-operative mental health
As a result of the high rates of psychiatric comorbidities in bariatric surgery
candidates, it is not surprising that many candidates are actively treated with psychiatric
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medications [6,7]. Though this is intuitive, a large bariatric surgery registry study in Ontario showed that 13.3% of the patients taking a psychiatric medication had no
documented psychiatric history [7]. In the general population, it has been previously
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reported that about 13% to 52% of people without a psychiatric diagnosis are prescribed a psychiatric medication [8-10]. To date there is scarce research investigating /
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describing reasons for the prescription of psychiatric medications when there is no clear indication or the presence of a psychiatric disorder. Anxiety and depressive symptoms,
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poor sleep, and subthreshold psychiatric disorder has been reported as common
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reasons for psychiatric medication use in the absence of a psychiatric disorder diagnosis [8]. Though it is possible that the increased prescription rate of some
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antidepressants is related to the approval for their use in the management of conditions such as pain [11]. Factors associated with psychiatric medication use have been examined in the
general population and in people without psychiatric diagnosis. Female sex, older age and unemployment, among other factors have been associated with psychiatric
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medication use/prescription in the general population and in people without a psychiatric diagnosis [8,9,12-17]. People age 50 to 64 without a psychiatric diagnosis have been found to have a 3-fold increased risk of being prescribed a psychiatric medication compared to younger people without a psychiatric diagnosis [17]. This association
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remained significant even after adjusting for medical condition and severity of general medical condition, which raises the possibility of additional off-label use of these
psychotropic medications. It is unclear if psychiatric medication use in bariatric surgery candidates is mainly associated with depression and anxiety symptoms or associated
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with demographic factors. Therefore, more rigorous studies are needed to more clearly elucidate variables associated with psychiatric medication use in pre-bariatric surgery candidates.
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This study aims to build on previous literature describing rates of psychiatric medication use in bariatric surgery candidates and describe factors associated with
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psychiatric medication use in these patients. We hypothesize that psychiatric medication use rates in patients without a history of psychiatric diagnosis will be lower
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than previously reported when psychiatric illness is confirmed by structured psychiatric
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interview. Moreover, we aim to explore associations between psychiatric medication use and patient factors such as demographic and clinical factors, including the presence of
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a psychiatric diagnosis. The results of this study could provide further understanding of factors associated with psychiatric medication use and underscore the need for ongoing psychiatric medication monitoring to effectively manage psychiatric comorbidity in this population.
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2. Methods 2.1 Setting Patients from the Toronto Western Hospital Bariatric Surgery Program (TWH-BSP) were recruited from 2011 to 2014. Patients are referred to the TWH-BSP if they have a
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body mass index (BMI) ≥ 40 kg/m2 or a BMI ≥ 35 kg/m2 with one or more obesity-related co-morbidity. Patients provided informed consent permitting data collection and
extraction of all selected variables as part of a larger prospective cohort database
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[18,19].
2.2 Data Assessment & Measures
Patients underwent a comprehensive pre-surgery psychosocial assessment. All patients
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in the TWH-BSP undergo an assessment by an interprofessional team including at least one assessment by a psychiatrist or psychologist. Psychiatric medication use was
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assessed by psychiatrists in the program during the psychosocial visit or during presurgery team rounds. Full details of the pre-surgery assessment have been previously
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described [20-22].
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Data extracted from patients charts included demographics, clinical factors and psychiatric medication use. Demographic data and anthropometric measures were
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collected by clinicians within the program. Relationship status was defined as either in a relationship (which included married or common-law) or not in relationship (which included divorced, separated, single or widowed individuals). Employment was defined as either full-time, part-time employment or unemployment (which included those who
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were unemployed, retired, on social assistance, and individuals receiving disability payment). Clinical factors included lifetime psychiatric diagnoses and self-reported measures of anxiety and depression symptoms and HRQOL. Lifetime diagnoses of
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mental illness was defined as a past history of or current mental illness determined by using the Mini International Neuropsychiatric Interview (M.I.N.I.), which used DSM-IV diagnostic criteria. For the purpose of our analysis, M.I.N.I. was modified to reflect DSM 5 diagnoses. Psychiatric diagnoses were categorized into any psychiatric disorder
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(excluding personality disorders), anxiety disorders, mood disorders, eating disorders, substance disorders and trauma and stressor related disorders. Additional measures for depression, anxiety and HRQOL were administered to patients in this study. Depressive
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symptoms were assessed using the Patient Health Questionnaire 9-item scale (PHQ9) which yields a score ranging from 0 to 27 [23]. The PHQ9 severity cut-point scores are
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5 for mild, 10 for moderate, 15 for moderately severe and 20 for severe depressive symptoms. The PHQ9 has been previously validated in bariatric surgery patient
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populations [24]. Anxiety symptoms were assessed using the Generalized Anxiety
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Disorder 7-item scale (GAD7), which is an anxiety assessment scale ranging from 0 to 21. The GAD7 severity cut-points are 5 for mild, 10 for moderate and 15 for severe
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anxiety [25]. This scale has been widely used in bariatric surgery candidates [18,19,26,27]. HRQOL was measured using the Medical Outcomes Study Short-Form 36 Health Status Survey (SF-36) [28]. The SF-36 yields a physical component score (SF36-PCS) and mental component score (SF36-MCS) ranging from 0 (lowest or worst possible level of functioning) to 100 (highest or best possible level of functioning). SF-36
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component scores are calculated from aggregate measure of 8 health domains: bodily pain, general health, emotional role, mental health, physical functioning, physical role, social functioning and vitality. The SF-36 has been used previously as a measure of HRQOL in bariatric surgery populations [18,19,29,30].
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During the baseline assessment of pre-surgery candidates, all psychiatric medications were recorded by a nurse practitioner and/or physician. Psychiatric
medication use was indicated as yes/no and number of medications. Medications
recorded and analyzed in this study were those the patient was taking at their initial
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assessment at the TWH-BSP. We did not include in our analyses any new medications recommended by the psychiatrist at our clinic. Psychiatric medications were grouped by class including antidepressant, benzodiazepine, non-benzodiazepine hypnotic,
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2.3 Data Analysis
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antipsychotic, mood stabilizer, stimulant, opioid and other psychiatric medication.
Descriptive statistics were conducted for demographic data and medication classes. We
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also examined psychiatric medication use among those with a lifetime diagnosis of
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mental illness. Bivariate logistic regression analyses were conducted with demographic variables, clinical factors and psychiatric diagnoses as covariates and psychiatric
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medication use as the outcome variable. A multiple logistic regression was conducted to assess whether demographic factors (i.e., age, gender, relationship status, marital status, education, employment status) were predictors of psychiatric medication use. An unadjusted logistic regression model was performed for each of the following disorders: any axis 1 disorder, anxiety disorder, mood disorder, eating disorder, substance abuse
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and trauma disorder, as well as symptom and quality of life measures (GAD7, PHQ9, SF36-PSC and SF36-MCS). The purpose of the unadjusted logistic regression analyses was to assess how diagnosis of a disorder as well as scores on psychopathology selfreported measures predicted psychotropic medication use.
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Lastly, a logistic regression adjusted for demographic variables and symptoms scales, specifically the PHQ9, GAD7, SF-PCS and SF-MCS, was run individually for each of the disorders as well as symptom and HRQOL measures to assess whether these individual variables were predictors of psychotropic medication use. Data
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analyses were conducted in SPSS version 22.0.
3. Results
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Complete data were available for 746 patients. Patients‟ average age was 44.7 years (SD = 10.6), with the majority being female (78.8%). At baseline psychiatric
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assessment, 430 (57.6%) patients had at least one lifetime diagnosis of mental illness and 188 (25.2%) had more than one mental illness diagnosis. Of those with a lifetime
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diagnosis of mental illness, the most common diagnosis was a mood disorder (n = 284,
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66.0%) and the second most common diagnosis was an anxiety disorder (n = 120, 27.9%). Compared to mood and anxiety disorders, other mental illnesses were
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identified at a lower proportion in these patients (eating disorder [n = 105, 14.1%], substance abuse [n = 105, 14.1%], trauma and stressor-related disorder [n= 76, 10.1%]). The average scores on the self-reported measures of anxiety and depression symptoms and HRQOL was as follows: PHQ9, 10.6 (SD = 6.4); GAD7, 6.4 (SD = 5.6); SF36-MCS, 46.8 (SD = 12.1); and SF36-PCS, 31.5 (SD = 10.4).
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A total of 262 (35.1%) patients were taking at least one psychiatric medication and 105 (14.1%) were taking more than 1 psychiatric medication. The most common type of medication reported was an antidepressant (n = 240, 32.2%) (Table 1). The majority of patients taking a psychiatric medication (220/262; 84.0%) had a lifetime
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diagnosis of a mental illness, although 42 (16.0%) did not have a lifetime diagnosis of a mental illness. Of the patients taking a psychiatric medication without a psychiatric illness, 64.3% of those patients were on antidepressants, 16.7% were on
benzodiazepines and 9.5% were on hypnotics. Candidates using psychiatric
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medications at baseline were significantly older compared to those candidates not using psychiatric medications [47.4 years (SD = 10.2) vs. 43.2 years (SD = 10.5), p < 0.0001]. Based on logistic regression analysis of demographic variables, being male and being
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employed significantly predicted lower odds of being on a psychiatric medication compared to their counterparts. Age, being female and unemployed significantly
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predicted higher odds of being on a psychiatric medication (Table 2). A secondary logistic regression analysis of demographic variables adjusted for psychiatric illness
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demonstrated the same significant demographic predictors. Linear regression analysis
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of the association of age with psychiatric medication use showed that higher age was significantly associated with psychiatric medication use (B = 0.038, p < 0.001). The
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crude model showed that those diagnosed with a mood disorder, anxiety disorder, eating disorder, trauma and stressor-related disorder and any axis I disorder were significantly associated with higher odds of being on a psychiatric medication (Table 3). Higher PHQ9 scores were significantly associated with psychiatric medication use and higher scores on the SF36-MCS were significantly associated with lower odds of being
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on a psychiatric medication. A diagnosis of a mood disorder was associated with the highest odds of being on a psychiatric medication compared with not having a mood disorder diagnosis (OR 7.56 [5.39 - 10.59]). Similar high odds for psychiatric medication
compared to those without an anxiety disorder.
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use was seen for patients diagnosed with an anxiety disorder (OR 4.88 [3.22 - 7.40])
In the adjusted regression model (Table 3), after controlling for demographic factors it was found that mood disorders, any axis I disorder, eating disorders, trauma and stressor-related disorders and anxiety disorders remained significant predictors of
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psychiatric medication use. Only the SF36-PCS became non-significant in the adjusted model. All measures decreased in their effect size except for anxiety disorders (OR 5.12 [3.29 - 7.98]), which was associated with higher odds for psychiatric medication use in
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the adjusted model. Tests for multicollinearity indicated a very low level of multicollinearity among the regression models with VIF values were less than 2 and
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4. Discussion
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tolerance values approaching 1.
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Our data adds to the existing literature on psychiatric medication prescribing in bariatric surgery candidates and identified several associated factors for psychiatric
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medication use. We found that being male and employed was associated with a lesser likelihood of being on a psychiatric medication. In addition, higher age (besides being female and unemployed) was also significantly associated with a higher likelihood of being on a psychiatric medication. Our findings appear to be similar to that of other studies from the general population [8,12-16], suggesting that the association between
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demographic factors and psychiatric medication prescription are also generalize to bariatric surgery candidates. Furthermore, our regression model suggested that patients in our sample with any axis I disorder, mood disorder, anxiety disorder, eating disorder and trauma and
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stressor-relater disorder had higher odds of being on a psychiatric medication
independent of demographic factors. In addition, psychiatric medication use was
associated with higher PHQ9 scores, remaining significant even after adjusting for demographic factors. Though a small odds ratio, better SF36-MCS scores were
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associated with lower odds of psychiatric medication use in our sample. These findings suggest that patients who have a history of a psychiatric disorder and more severe symptoms, as indicated by higher PHQ9 scores and lower mental HRQOL, were more
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likely to be using a psychiatric medication. Our study‟s analysis of demographic, clinical, and measurement-based factors associated with psychiatric medication use in a
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bariatric surgery sample adds to the literature and provides clarification on clinical
candidates.
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factors related to the prescription of psychiatric medications in bariatric surgery
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Of the patients assessed in our sample, more than one third reported using a psychiatric medication. Our reported rate of psychiatric medication use is similar to
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previously reported rates of psychiatric medication use in bariatric surgery patients from our province, which has been estimated to be 37.9% [7]. Compared to other psychiatric medications, antidepressants were used at a higher rate by patients in our sample. This is not a surprising finding, considering that mood disorders and anxiety disorders were among the most common lifetime psychiatric diagnoses identified. In addition to
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antidepressants, nearly one third of patients prescribed psychiatric medications were taking a sedative or hypnotic medications (benzodiazepine or non-benzodiazepine hypnotic). The high proportion of anxiety disorders in our sample could explain, in part, the use of sedatives or hypnotics in these patients. High frequency of sedative and
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hypnotic use could also be explained by the reported high rates of insomnia symptoms in bariatric surgery candidates [31] and individuals with higher BMI and obesity [32]. This finding raises an important issue around the prescription of sedatives and
hypnotics. Although these medications can be helpful in the treatment of anxiety
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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 [33,34]. The continued use of
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sedatives carry significant risks (e.g., tolerance, rebound insomnia after discontinuation and delirium post-operatively, among other risks) [33,35]. Clinicians should be more
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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 [36].
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Given that 35% of patients were taking psychiatric medications pre-bariatric
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surgery, it is important for clinicians to be aware of potential changes to the bioavailability of psychotropic medications after bariatric surgery, specifically Roux-en-Y
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gastric bypass. After bariatric surgery, the anatomy of the gastrointestinal tract is significantly altered and variations in absorption of medications could be expected [37,38]. Though this holds true, recent research has shown that changes in drug dissolution and absorption are drug-specific and difficult to predict [39]. Drugs that are intrinsically poorly absorbed, highly lipophilic and/or undergo enterohepatic recirculation
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exhibited the greatest potential for malabsorption in these patients [40]. Specific to antidepressants, a recent study showed that patients, although in a small number (n = 12), taking selective serotonin reuptake inhibitors and serotonin and norepinephrine reuptake inhibitors experienced reduced bioavailability one month post Roux-en-Y
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gastric bypass surgery [41], with some improvement over time. However, case
controlled studies examining antidepressant plasma concentration at approximately 1year post-bariatric surgery, specifically sertraline (n = 5) and duloxetine (n = 10),
showed significant reductions in plasma levels of both agents in Roux-en-Y gastric
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bypass patients[42,43]. In the absence of clear guidelines, expert opinion suggests that patient taking psychotropic medications to manage psychiatric conditions pre-surgery be switched from extended formulations of medications to immediate release when
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possible due to issues with absorption [38]. Further, patients expected to take psychiatric medications immediately post-surgery should be monitored post-surgery for
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potential relapse of psychiatric symptoms and an increased in dose should be considered to optimize plasma concentrations if relapse of psychiatric symptom occurs
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[38,41]. Further evidence is needed to inform more conclusive guidelines including
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longitudinal studies on psychotropic bioavailability post-bariatric surgery. We found a similar proportion to previously reported studies of patients without a
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formal psychiatric diagnosis taking psychiatric medications (16% vs.13%) from samples where psychiatric diagnosis was self-reported [7]. Moreover, our reported rate of psychiatric medication use in patients without a psychiatric diagnosis is similar to the previously reported psychiatric medication use in the general population without a psychiatric diagnosis [8,10]. It is possible that the rates were comparable based on
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patients‟ social desirability bias when undergoing psychiatric assessment for bariatric surgery, specifically due to concerns of being “rejected” for surgery based on the presence of psychiatric illness. Nonetheless, prescription of psychiatric medications in the absence of a clear psychiatric diagnosis could be explained by several potential
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factors. First, it is well documented that the prescription of antidepressants in individuals without a psychiatric condition is on the rise [44] and in part, perhaps, explaining this phenomenon. To this point, some antidepressants have been approved for the
treatment of conditions other than psychiatric illnesses, such as pain [11,45], which is a
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common comorbidity in patients with obesity [46]. Alternatively, antidepressants may be used off-label to manage insomnia and headaches [47,48], even when the evidence is limited for their effectiveness in these contexts [49]. Further, people with multiple
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medical conditions, in the context of severe obesity may be at risk of being overdiagnosed with depression due to the overlap of some symptoms of depression and
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chronic medical conditions, which may result in an increased likelihood of prescribing antidepressants despite not meeting criteria for mood and anxiety disorders [44,50].
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Second, at least one study have suggested that antidepressants are being prescribed
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for subthreshold depression or patients with minor depression, even when there are no guidelines or evidence of the effectiveness of pharmacological treatment in these
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conditions [8,51]. Finally, ongoing fears of depression recurrence from patients, the fact that these medications are generally safe, and the lack of proactive medication review from physicians, are all factors potentially contributing to psychiatric medication continued use even in the absence of a current psychiatric illness [52].
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There are several potential risks for bariatric surgery patients taking psychiatric medications in the absence of clear psychiatric illness. Provided that these medications are not treating comorbid physical health comorbidities in obesity, patients may be at unnecessary risk of polypharmacy and drug-drug interactions, which is a concern given
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the multiple medical comorbidities in the context of obesity. Of significant concern is the risk of many psychotropic medications causing weight gain post-surgery and potentially impacting bariatric surgery weight loss outcomes (53-57). Based on these potential concerns, clinicians should continue to reassess the need for ongoing psychotropic
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medications post-surgery especially in cases where psychotropic medications 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
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unnecessary medications if clinically indicated. However, if psychiatric medications are needed for long-term psychiatric illness stabilization, consideration of psychiatric
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medications with lower metabolic risk should be considered before and after bariatric surgery based on patient preference, tolerability and response.
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Although one of the strengths of our study was the use of a structured clinical
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assessment to obtain psychiatric diagnoses, there are several limitations to our findings. First, this study was a cross-sectional study and future studies are needed to examine
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longitudinal predictors of long-term psychiatric medication use after bariatric surgery Second, we did not collect data from prescribers thus limiting the interpretation of our results, especially in those participants taking psychiatric medication without a mental disorder diagnosis. Indeed, it has been reported that psychiatric diagnoses made by general practitioners have only partial concordance with diagnoses made using a
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structured interview [58,59]. Similar to this, we do not have the reasons (e.g., medical diagnosis/conditions) for prescribing a psychiatric medication in patients without a mental illness diagnosis in our sample. Third, this study was of patients from a single bariatric surgery center and our sample may not be a full representation of the whole
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Canadian population, although our results are consistent with past studies from Canada and the United States.
Conclusion
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Our study adds to the literature and provides insights on clinical and
demographic factors related to the prescription of psychiatric medications in bariatric surgery candidates. Although our results are reassuring in that psychiatric medication
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use was related to a psychiatric diagnosis for most patients, our study highlights that approximately 16% of patients were taking psychiatric medications despite the absence
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of a lifetime psychiatric diagnosis. This finding underscores the importance of screening patients that are using psychiatric medications without a formal psychiatric diagnosis,
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including sedatives and hypnotic medications given the concerns in bariatric patient
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populations (e.g., substance use, weight gain, drug-drug interaction, other). Therefore, clinicians should consider ongoing monitoring and assessment of psychiatric
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medications before and after surgery to further mitigate risks related to post-surgical complications (e.g., delirium), weight loss outcomes and psychiatric stability.
Sources of Funding: None
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Potential Conflicts of Interest: The authors report no financial or other relationships relevant to the subject of this article.
Authors’ contributions: Authors A.L, M.H, S.S contributed to the conception and
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design of the paper. A.L and S.L performed the analyses of the data. All authors
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contributed equally to the interpretation of the data and the writing of this manuscript.
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Table 1. Prevalence of Psychiatric Medication Use by Medication Class in Bariatric Surgery Candidates. Toronto Western Hospital Bariatric Surgery Program (TWH-BSP). 2011-2014. Toronto, Ontario. Canada. (N = 746) Class of Medication n % Antidepressant 240 32.2% Benzodiazepine 59 8.0% Mood stabilizer 32 4.3% Antipsychotic 25 3.4% Non-benzodiazepine hypnotic 15 2.0% Stimulant 13 1.7% Other 10 1.3% Percent expressed as percent of total sample
Table 2. Crude Model of Demographic Variables Associated with Psychiatric Medication Use. Toronto Western Hospital Bariatric Surgery Program (TWH-BSP). 2011-2014. Toronto, Ontario. Canada. (N = 746) P-value Variable OR (95% CI) Gender (Male)a*
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0.54 (0.36 - 0.80)
In a relationshipb High School Educationc
1.04 (1.02 - 1.05)
< 0.0001
0.79 (0.58 - 1.08)
0.14
0.78 (0.56 - 1.09)
0.14
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Age*
0.002
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Employedd* 0.39 (0.28 - 0.54) < 0.0001 a. Females is the reference group chosen b. Not in relationship (divorced, separated, widowed, or single) is the reference group chosen c. Education less than a high school diploma is the reference group chosen d. Unemployed (unemployed, social assistance, disability, retired) is the reference group chosen *Statistical significance p < 0.05
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Table 3. Crude Model and Adjusted Regression Model of Non-Demographic Variables Associated with Psychiatric Medication Use. Toronto Western Hospital Bariatric Surgery Program (TWH-BSP). 2011-2014. Toronto, Ontario. Canada. (N = 746) Crude Model Adjusted Modelk P-value P-value Variable OR (95% CI) OR (95% CI) a < 0.0001 < 0.0001 Axis 1 Disorder 6.95 (4.77 – 10.12)* 6.38 (4.32 – 9.40)* Anxiety Disorderb 4.88 (3.22 - 7.40)* < 0.0001 5.12 (3.29 - 7.98)* < 0.0001 c < 0.0001 Mood Disorder 7.56 (5.39 - 10.59)* 7.06 (4.96 – 10.06)* < 0.0001 d 0.002 0.01 Eating Disorder 1.92 (1.27 - 2.92)* 1.79 (1.16 - 2.76)* Substance Abusee 1.46 (0.96 - 2.23) 0.07 1.38 (0.88 - 2.16) 0.16 Trauma Disorderf 2.24 (1.39 - 3.62)* 0.001 1.79 (1.10 – 3.05)* 0.02 g 0.06 0.09 GAD7 1.03 (1.00 - 1.05) 1.02 (1.00 - 1.05) h 0.001 0.01 PHQ9 1.04 (1.02 - 1.06)* 1.03 (1.01 - 1.06)* i 0.001 0.40 SF36-PCS 0.98 (0.96 - 0.99)* 0.99 (0.98 - 1.01) j < 0.0001 < 0.0001 SF36-MCS 0.98 (0.96 - 0.99)* 0.98 (0.96 - 0.99)* a. Individuals without axis 1 disorder diagnosis is reference group chosen b. Individuals without anxiety disorder diagnosis is reference group chosen. c. Individuals without mood disorder diagnosis is reference group chosen d. Individuals without eating disorder diagnosis is reference group chosen e. Individuals without substance abuse diagnosis is reference group chosen f. Refers to Trauma and Stressor-Related Disorder. Individuals without trauma disorder diagnosis is reference group chosen g. Generalized Anxiety Disorder 7-item scale (GAD 7) h. Patient Health Questionnaire-9 (PHQ9) i. Short-Form 36 Health Status Survey physical component score (SF36-PCS). j. Short-Form 36 Health Status Survey mental component score (SF36-MCS) k. Adjusted model controlled for socio-economic factors * Statistical significance p < 0.05