Résumé
Background: Morbid obesity has multiple negative consequences for psychological health. These patients are described as depressed, anxious, and impulsive, with low self-esteem and impaired quality of life. The severity of these psychological disorders has been related to the degree of obesity Abiles et al, [1]. In addition, emotional eating is a driver of weight gain in the obese, and depression is linked to disrupted eating patterns. Therefore, an effective weight loss program should include psychological management of these patients. The Specialist Weight Management Service (SWMS) offers clinical psychology intervention, alongside diet and exercise, with the hope that improving psychological health, leads to improved clinical outcomes for patients. Aim: This service evaluation aims to investigate if specialist psychological intervention of patients with moderate to high depression and/or anxiety scores; enrolled in the specialist weight management service is improved during their treatment in the service, and if clinical outcomes (specifically weight) are therefore improved. Methods: All patients assessed by the SWMS team were asked to complete an anxiety and depression measurement score (GAD7 and PHQ9) Spitzer et al, [2] before coming to their assessment appointment with the dietitian. The PHQ9 (Patient Health Questionnaire) is a multiplechoice self-report inventory, used as a screening and diagnostic tool for mental health disorders of depression, anxiety, alcohol, eating, and somatoform. It was designed for use in the primary care setting. The GAD7 (Generalized Anxiety Disorder 7) is a self-reported questionnaire for screening and severity measuring of generalized anxiety disorder. A score above 10 in either questionnaire indicated there may be a need for psychological input, and patients were referred to the SWMS clinical psychologist for further assessment. Patients were then assessed by the psychologist to see if further psychological intervention was required. Psychological interventions and treatments included motivational interviewing, brief solution focused therapy, cognitive behavioural therapy, and acceptance and commitment therapy. Treatment was tailored to each individual patient and their personal treatment needs. The number of sessions each patient received was between 2 and 10. With most patients having an average of 6 one-hour sessions on a fortnightly basis. The same questionnaires were then repeated at the 3 month point. As this project was a service evaluation, ethics were not required. All data was anonymised before being evaluated. Results: N= 297 patients were assessed by the SWMS team dietitian during the review period (2010 to 2012). A further psychological assessment was indicated for n=119 patients, n=67 of these required psychological intervention as described above. The mean BMI in cohort was 42.7kg/m2. The mean PHQ9 score at baseline was 14 and GAD7 9. Table 1 shows the basic demographic data of the cohort. Table 1 Shows the demographic details the cohort. Table 2 shows the mean PHQ9 scores at baseline and 3 months, mean change after 3 months, range of change in scores and % of patients who improved their scores in the treatment and nontreatment group. Fisher’s exact test was used to compare the changes in PHQ9 scores in the two groups over 3 months: p=0.72. Chi squared test used to see if there is a significant difference between the numbers of those that improved their PHQ9 scores between the two groups: p=0.47. Therefore the change was not statistically significant. Table 3 shows the % of patients in the treatment and non-treatment group that gained weight, lost ≤5% of their initial body weight or >5%. Using chi squared test to see if there is a significant difference between the intervention and non-intervention group in terms weight change. Non of the weight changes were statistically significant. Table 4 shows the mean GAD7 score at baseline and after 3 months, the mean change in scores between the two groups, the range of change and the of % patients who improved their scores amongst the two groups. Fisher’s exact test was used to compare the changes in scores of the treatment and non-treatment group: p=1. Chi squared test was used to compare the numbers of those that improved their GAD7 scores between the two groups: p=0.64. The results were not statistically significant. Discussion: This evaluation looked at the effect of psychology intervention on weight loss and self-reported anxiety and depression using patient questionnaires in a community SWMS. It was observed that the intervention group had a higher proportion of patients who gained weight. Possible explanations for this from anecdotal observation may be due to the complex relationships these patients have with food and emotional eating, however, without further research it is difficult to ascertain the reason for is. Therefore, further long-term research into this area is required. Although not statistically significant, the results suggest that depression scores did improve with intervention after 3 months. However, there was no indication that the intervention had any effect on anxiety scores. Conclusions: The results suggest that psychological intervention helps improve patients depression scores, although in this evaluation this did not translate into weight loss. Further long term research in needed to see if weight loss increases with increased length of intervention in SWMS.
Résumé
Background: The aim of a tier 3 specialist weight management service (SWMS) is to encourage patients to lose and maintain clinically significant levels (5-10%) of weight, NICE CG43 [1], through a holistic, patient centred multidisciplinary approach. The service consists of specialist dietitians, clinical psychologist, physiotherapist and consultant endocrinologist. As levels of obesity worldwide increase, bariatric surgery is not a viable and long-term, population wide treatment option (secondary to the associated costs and patient risk). The aim of this service evaluation was to identify the cost effectiveness of a community based specialist weight management service. Methods: Using SWMS outcome database, patients were identified within this retrospective study if they had attended at least one 3 month review and had available anthropometric information. Weight changes were analysed using SPSS 20 statistical software and compared with costs identified in the literature search. Costs associated with providing the service were obtained via the service's finance department which accounts for the salaries of the healthcare professionals, room hire, and other overhead costs. A literature search was performed and manual identification within references, to determine weight loss and associated cost savings of type 2 diabetes mellitus (T2DM) diagnosis occurrence and bariatric surgery costs. This retrospective analysis was logged with the service's Trust clinical governance and did not require ethical approval. Results: Of the 249 patients within the database, 128 patients were included in this evaluation with a mean starting BMI of 42.4 kg/m2 (SD±5.6). Patients within this study had been within the service for different lengths of time ranging from 3-15 months. The mean weight loss of the cohort was 3.5% of their starting body weight, with 37 (28.9%) of patients achieving >5% weight loss. The average BMI reduction for males and females were 1.2 and 1.6 units respectively. The literature search found bariatric surgery costs ranging from £5,500 to £17,900 (depending on surgical costs, pre and post-operative appointments and complications) per person. Projected costs using UK literature of T2DM occurrence and associated treatment costs were £6411.76/ year/patient. The possibility of diagnosis of T2DM for patients of high risk was 11% diagnosis/ year. The cost of the SWMS service was £242, 000 per year. Discussion: It has been estimated that the direct cost of treating obesity and associated co-morbidities is £480m to the national health service (NHS) expenditure in England NationalAudit Office [2]. If the above findings were applied to the SWMS weight loss results, 15% of patients would no long qualify for bariatric surgery which equates to a saving of £71500-232000/ year. For patients that achieved a 5% weight loss reduction, 1.86 of these patients are less likely to develop T2DM with a potential saving of £11925.87. Savings identified in this evaluation sample total to £83,425.87-£243,925.87. Further savings associated with the reduction in obesity would be recommended for future investigations including cardiovascular disease treatments, prescription drug utilisation and other health care costs. Conclusions: There is an indication that the SWMS has the potential to be a cost neutral weight loss provider. Further research is required to gain a greater understanding of it's broader cost savings