8. The role of mental health in obesity management

Question 1

The mechanisms underlying the association between mental illness
and early onset and sustained weight gain are multi-faceted and
involve both biological and psychological factors, superimposed
on the background of social health determinants, and medication and metabolic side effects.

This association is supported
by clinical and epidemiological research reporting prevalence rates of overweight and obesity of how much % for bipolar disorder, x% for schizophrenia and x% for depression.

Answer 1

25-60% bipolar
30-70% schiz
20-50% depression

Question 2

Links have also been made between overweight and obesity and what other mental illnesses?

Answer 2

binge eating disorder (BED), attention deficit disorder (ADHD) and
post-traumatic stress disorder (PTSD)

Question 3

Research has indicated that individuals with mental health issues
often fall through the cracks; this outcome can be prevented with what?

Answer 3

standardized screening approach

Question 4

While second-generation anti-psychotics have been argued to
have a lower propensity for causing extrapyramidal side effects
as compared to their first-generation counterparts when used
on-label, they are indisputably associated with significant metabolic sequelae, including weight gain, glucose dysregulation and
dyslipidemia - T/F

Answer 4

T

Question 5

In elderly patients with dementia, use of anti-psychotics has been associated with increased risk of what?

Answer 5

mortality and cardiovascular events

Question 6

significant occurrence of metabolic adverse
effects in the context of off-label anti-psychotic use, including ?

Answer 6

increased appetite and weight gain, increased triglyceride abnormalities and increased risk of precipitating diabetes

Question 7

Three randomized controlled trials have examined GLP-1 RAs
(liraglutide or exenatide) in people living with overweight or obesity
with schizophrenia spectrum disorders taking anti-psychotic medications - what were the results?

Answer 7

Endpoint
weight for GLP-1 RAs was 3.61 kg lower than for controls. Body
mass index (BMI), HbA1C, fasting glucose and visceral adiposity
were all lower for the GLP-1 RA group. Weight loss in the GLP-1
RA group appeared to be greater for participants on clozapine
or olanzapine, and for longer study endpoints. GLP-1 RAs were
well tolerated, with no safety concerns aside from more common
reports of nausea in the treatment group

Question 8

Naltrexone/bupropion was examined in males with obesity and
schizophrenia who were smokers - what were the results?

Answer 8

showed no differences in
weight change or smoking cessation rates as compared to placebo

Question 9

In patients with schizophrenia using olanzapine, naltrexone alone (a
component of naltrexone/bupropion), when compared to placebo in
a small double-blind randomized clinical trial - result?

Answer 9

did not find differences
in BMI over a 12-week treatment period

Question 10

In women with obesity and MDD, naltrexone/bupropion - result?

Answer 10

modestly reduce
both weight and depression scores

Question 11

Orlistat was examined in a
double-blind randomized clinical trial in patients with schizophrenia
spectrum or bipolar disorder taking anti-psychotics - result?

Answer 11

not show a significant difference in body weight between groups

Question 12

in patients with schizophrenia spectrum disorders, what medication consistently emerges as an effective and safe intervention resulting in modest weight loss as compared to placebo (average of
3.5 kg), as well as improvements in lipid and insulin sensitivity
parameters?

also with mood disorders receiving mood stabilizers?

Answer 12

metformin

Question 13

A recent meta-analysis of randomized control trials examined the
use of topiramate in patients with schizophrenia spectrum disorders - results?

Answer 13

superiority of topiramate as compared to placebo on
weight (3.76 kg) and BMI (1.62 kg/m2
) reduction

Overall, the side
effect profile was comparable to control groups, with the exception of paresthesia, which was more common in topiramate-treated patients

The topiramate group also had small improvements
in psychopathology

Similarly, a meta-analysis examining randomized control trials conducted in mixed populations of schizophrenia
spectrum and mood disorders (bipolar disorder) found topiramate
to be associated with weight loss as compared to placebo (3.95 kg),
with no safety concerns reported

Question 14

what have been linked with topiramate use (particularly in epilepsy
populations)?

Answer 14

cognitive disturbances

Question 15

An open-label trial in patients with anxiety disorders who experienced weight gain with selective serotonin
reuptake inhibitors (SSRIs) also found which med to be associated
with weight loss and reported no safety concerns

Answer 15

topiramate

Question 16

adjunctive off-label use of which med appears to be modestly effective
to mitigate weight gain in the context of schizophrenia spectrum illnesses?

However, larger studies of extended treatment, and
more detailed examination of potential adverse effects on cognition
are required prior to advocating for routine use in the management
of obesity in severe mental illness

Answer 16

topiramate

Question 17

Other off-label obesity interventions that may be effective in the
treatment of anti-psychotic-associated weight gain and obesity
include which meds?

However, the quality of the evidence for these interventions is low, making
the effects uncertain

Answer 17

aripiprazole and H2 agonists, such as nizatidine

A published meta-analysis investigating
H2 receptor agonists in anti-psychotic-induced weight gain failed to
find differences in weight reduction as compared to placebo

Question 18

How effective are behavioural interventions for
obesity in patients with mental illness?

Answer 18

Two randomized controlled trials comparing behavioural obesity therapy in combination with an additional psychological treatment, namely a behavioural intervention or CBT,
resulted in comparable weight loss between groups and showed
no advantage of combination treatment

Question 19

Significant research exists on the efficacy of behavioural treatments for obesity in individuals with severe mental illness, including patients with psychotic illness and severe mood disorders.

Interventions focused primarily on physical activity - result?

Answer 19

inconclusive results related to weight loss

Question 20

A comprehensive meta-analysis, conducted by Caemmerer et al., evaluated the effectiveness of non-pharmacological
interventions for obesity management in patients with severe
mental illness across 17 included studies.

CBT had a smaller effect
than which intervention?

Answer 20

nutrition and/or exercise programs

Question 21

behavioural interventions, including lifestyle, nutrition and physical
activity changes, in severe mental illness patients - results in ?

Answer 21

an average weight loss of 3 kg and a BMI
reduction of 0.9 to 1 kg/m2

Question 22

A recent
meta-analysis of placebo-controlled randomized control trials reported a significantly greater reduction in binge eating and related
psychopathology for which medications?

which meds reduced weight?

Answer 22

second-generation anti-depressants (bupropion, SSRIs and duloxetine), lisdexamfetamine (a central nervous
system stimulant originally marketed for ADHD) and topiramate
(an anti-convulsant).

Only topiramate and lisdexamfetamine (but not anti-depressants)
reduced weight compared to placebo in patients.

Question 23

which med is approved for treatment of binge eating disorder in Canada?

what is the concern of this treatment?

Answer 23

vyvanse;

Thus, efficacy and safety may not be generalizable to patients with a history of substance use disorders, suicidal attempts, bipolar disorder and psychosis, as these populations
could be more susceptible to abuse or mental deterioration.

Question 24

Possible factors associated
with poor post-operative appointment attendance include ?

Answer 24

higher
pre-operative weight, younger age, family-related problems, work
problems or unemployment, lack of insurance coverage, avoidant
attachment (relationship) style and longer distance to travel

Question 25

Patients who stopped attending post-surgery follow-up appointments:

Answer 25

1. Had greater confidence in their primary care physician’s ability
   to manage their bariatric surgery care;
2. Had challenges with travel distance in terms of time and financial
   implications;
3. Felt that they failed to achieve weight-loss goals; and
4. Perceived that follow-up had limited utility to their current care.

Question 26

what have been associated with
poor adherence to post-operative vitamins?

Answer 26

higher attachment (relationship) anxiety and
younger age (i.e., adolescents)

Question 27

After biatric surgery, Poor dietary adherence has been associated with ?

Answer 27

baseline depressive symptoms and the presence of binge eating disorder

Question 28

What is the evidence for psychosocial
interventions to support weight loss after bariatric surgery? short-term and long-term

Answer 28

short term - cognitive behavioural therapy (in-person or remotely delivered via telephone),119,120 acceptance commitment therapy,121
mindfulness-based therapies122 and other psychological modalities that have improved eating pathology and psychological distress
post-bariatric surgery in the short term

long-term - psychological treatments have not translated to
long-term post-surgery improvements in weight-loss outcomes.

Question 29

the optimal time to initiate adjunctive behavioural interventions is ?

Answer 29

after bariatric surgery,
but before significant weight regain has occurred.

Question 30

greater weight loss
post-bariatric surgery when surgery was combined with ?

Answer 30

h post-operative
behavioural interventions

Question 31

psychological support focused on behaviour
change and modifying cognitions pre- and post-bariatric surgery had no impact on weight loss as measured by BMI - T/F

Answer 31

T

Question 32

which meds are the most commonly prescribed psychotropic
medication in bariatric surgery candidates, with accounts of up
to 35% of a cohort of 2146 patients in the LABS-2 study

Answer 32

anti-depressant

Question 33

clinicians have to be vigilant to make sure bariatric patients do not exhibit
discontinuation symptoms or worsening of depressive symptoms, especially in the course of at least the first post-operative year, due to?

Answer 33

malabsorption of anti-depressant medication

Question 34

which medication is particularly concern after bariatric surgery ?

Answer 34

lithium - narrow therapeutic index

Question 35

which medications are a concern of inconsistent absorption due to low-calorie intake in the perioperative period?

Answer 35

ziprasidone or lurasidone

Question 36

which assessment is recommended by bariatric behavioural health clinicians with experience and specialized knowledge of the assessment and care of psychosocial issues before and after surgery?

Answer 36

pre-bariatric surgery assessment of psychiatric stability

Question 37

Recent guidelines recommend a which assessment before bariatric surgery to identify risk factors and proactive identification of potential post-operative
challenges that could be problematic post-surgery?

Answer 37

comprehensive psychosocial assessment

Question 38

Psychosocial
assessment should be conducted using clinical interview and can
be guided by such resources as ?

Answer 38

the Boston Interview for Gastric
Bypass assessment

Question 39

what is the Toronto Bariatric Interprofessional Psychosocial Assessment Suitability Scale (BIPASS)?

Answer 39

an interprofessional risk assessment tool;
provide a standardized approach to pre-surgery psychosocial assessment and can inform risk stratification pre-bariatric surgery

Question 40

a tool that assessed patients
on multiple eating behaviour domains in patients with obesity?

Answer 40

Master Questionnaire, a 56-item true/false
questionnaire

Question 41

which assessment was identified as having the most support for assessing binge eating symptoms in patients
undergoing bariatric surgery?

Answer 41

the binge eating scale

Question 42

what are other tools to assess eating psychopathology in patients undergoing bariatric surgery?

Answer 42

The Night
Eating Questionnaire and the Eating Disorder Examination Questionnaire

Question 43

which tools are recommended
for assessing depressive symptoms and alcohol use in bariatric
surgery candidates?

Answer 43

PHQ-9
the Alcohol Use Disorders Identification Test

Question 44

Evidence from animal models suggests that ingredients from highly processed foods can result in ?

Answer 44

addictive-like biological and behavioural responses, such as food craving

Question 45

In human studies, the symptoms of food addiction have mirrored which
diagnostic criteria for substance use disorder, which has led to the
use of the Yale Food Addiction Scale as a measure of food addiction?

Answer 45

Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5)

Question 46

6 Given the need for greater clarity and research regarding the diagnosis of food addiction, there is limited evidence on
effective treatments for food addiction symptoms in the context
of obesity - T/F

Answer 46

T

Question 47

Following bariatric surgery, was there a reduction in psychiatric disorder?

Answer 47

yes - at year 2, 16.8%; at year 3, 18.4% post surgery, as compared to pre-surgery rates 30.2%

Question 48

bariatric surgery can result in improvements in what function of brain?

Answer 48

cognition, most commonly memory and
attention/executive function

Question 49

what have been associated with less weight loss after bariatric
surgery in multiple studies?

Answer 49

post-surgery eating disorder
symptoms

Question 50

How does mental illness affect bariatric surgery
outcomes?

Question 51

How do psychiatric symptoms affect weight loss
after bariatric surgery?