Too Overweight for Mental Health Care

Bret Stetka, MD

Disclosures

June 13, 2019

The societal stigmas attached to being overweight and obese are well known, but might they also be an impediment to receiving adequate psychiatric care? This was the question posed in a study[1] by Katherine Elise Camfield, MD, MPH, from the Department of Psychiatry at the Los Angeles County/University of Southern California Medical Center, the results of which were presented at this year's annual conference of the American Psychiatric Association (APA).

Medscape interviewed Dr Camfield at the APA's poster session about how commonplace weight restrictions are in mental health facilities in Los Angeles Country, and what this may mean for patient care there and throughout the country.

Tell us about the objective of your study.

After noticing that some patients in our medical center weren't getting placed in psychiatric facilities because of their weight, we really wanted to explore how commonplace this problem was. This entailed reaching out to area mental health facilities regarding whether they had weight limits in place, as well as investigating the proportion of our own patients who could be adversely affected by these limits. These findings would hopefully help us shed light on the effect on the quality of mental health care our patients require, and whether discriminatory practices were in play.

What did you find?

I was surprised to find that so many psychiatric hospitals had weight restrictions in place. Almost two thirds of the 42 hospitals surveyed had either weight or BMI limitations. Most of the other hospitals said it would be on a case-by-case basis, which does not rule out patients being excluded from admission on the basis of weight.

We also found that nearly 10% of the patients on involuntary psychiatric holds on our consult service would have at least some limitations in placement options based solely on their weight (> 250 lb). Almost 3% of patients would have significant difficulties being placed in a psychiatric hospital based solely on their weight (> 350 lb).

Do your Los Angeles County findings reflect the weight restriction practices of hospitals in other parts of the country?

Thus far, we have only formally assessed what is happening in Los Angeles County, and our findings are very preliminary. However, one reason we thought it would be beneficial to have this poster at the APA is to get feedback from others as to whether this is happening at their home institutions. There was a mixture of responses, with some people being surprised by the results, whereas others have experienced something similar.

Are there justifications for these weight restrictions, or do they represent patient discrimination?

In general, multiple studies have shown that bias against obese patients is common in healthcare. However, looking at it from the perspective of these outside psychiatric hospitals, it's hard to say whether this particular situation is related to overt bias vs liability concerns, or possibly both. Could one of their staff members get injured trying to lift an overweight patient if they fall or if this obese patient becomes aggressive? Would they have to hire more staff and buy special equipment to accommodate these patients? Are there medical comorbidities that obese patients are more likely to have that could put them at risk for an adverse event?

In addition, it is unlikely insurance companies would reimburse hospitals for additional care needed, as obesity is not included in the Americans With Disabilities Act, despite patients having significant functional impairment.

Whatever the reasons are for these limitations being in place, our patients still deserve to receive quality psychiatric care. These medical-legal issues are definitely something we would like to investigate further.

Where can obese patients with mental illness go if they're turned away from inpatient care?

Unfortunately, many of our patients have to remain hospitalized in a medical/surgical setting, which is not the most appropriate milieu for someone who needs primarily psychiatric care. Along with being less therapeutic for the patient, this could also drive up hospital costs and inappropriately allocate already sparse county hospital resources.

Do you have any follow-up research planned?

It will be important to survey these outside psychiatric hospitals further regarding whether there are barriers from their standpoint that we could possibly address and find solutions for, and also whether there are any legal issues with these limitations being in place. In regard to our patient population, we would like to investigate how being overweight could affect length of stay compared with non-overweight patients. Last, although we have been able to ask conference attendees about whether they have faced similar issues in other parts of the state/country, it would be beneficial to make this comparison more formally.

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