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ORIGINAL ARTICLES |
From the University of Virginia Health System Departments of Psychiatric Medicine (A.U.B., L.A.G.-F., L.A., M.-Y.R., M.W.) and Surgery (A.M., B.S.), Charlottesville, Virginia; and the Virginia Commonwealth University, Departments of Psychiatry and Surgery, Richmond, Virginia (M-E.O.).
Address correspondence and reprint requests to Andrea Bauchowitz, PhD, Behavioral Medicine Center, Department of Psychiatric Medicine, University of Virginia Health System, Box 800223, Charlottesville, VA 22908. E-mail: ab4sc{at}virginia.edu
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ABSTRACT |
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Methods: Surveys about psychological evaluation practices were mailed to 188 bariatric surgery programs. Eighty-one surveys were returned.
Results: Eighty-eight percent of programs require patients to undergo a psychological evaluation and almost half require formal standardized psychological assessment. Current illicit drug use, active symptoms of schizophrenia, severe mental retardation, and lack of knowledge about the surgery were the most commonly cited contraindications, preventing patients from gaining approval for surgery.
Discussion: The majority of programs use psychological evaluations; however, the exclusion criteria for surgery vary greatly. Establishing uniform guidelines for the screening of bariatric surgery candidates is necessary. Suggestions on how to begin this process are provided. More research about behavioral and cognitive predictors of postsurgical success is needed.
Key Words: bariatric surgery • gastric bypass • psychological evaluation
Abbreviations: OCD = obsessive compulsive disorder.
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INTRODUCTION |
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30) has more than doubled since 1980, and it is likely to increase over the next decade, especially considering today’s overweight children and adolescents (2). By 2005 the obesity epidemic is expected to outpace smoking and become the number one source of preventable illness in the United States, with sleep apnea, cardiovascular disease, diabetes, osteoarthritis, and cancer being some of the most common medical comorbidities (3). A rise in the prevalence of obesity, failure of conventional treatments to produce lasting weight loss in the severely obese, along with the development of laparoscopic surgical techniques, have led to an increase of bariatric surgery over the past decade. Bariatric surgery was first developed in 1950. Today’s most commonly used surgical technique, the Roux-en-Y gastric bypass, involves reduction of the stomach to a pouch with a capacity to hold about 2 to 3 oz., combined with partial bypass of the intestinal tract to reduce caloric absorption. The number of surgeries performed annually has risen more than 500% over the last 10 years (4). Because alternative treatments for obesity have not shown lasting effects for the severely obese, bariatric surgery is currently considered a viable and effective option to lower the risk of comorbid medical problems and improve a sense of quality of life and productivity (5). Despite these benefits, it also comes at a cost to society. Obesity accounts for about 6% of all national health expenditures (6). At present the cost of the operation averages $25,000 not including additional costs following potential postoperative complications. Given that more than 100,000 of these surgeries are being performed in the United States per year, this cost quickly becomes a burden to the health care industry and consequently society. Thus, it is imperative that patient selection and treatment is guided by scientifically sound principles.
In spite of the considerable anatomical alterations described above, long-term successful weight loss after surgery is not a guaranteed outcome (7). Surgical success also requires significant behavioral changes and is largely dependent on an individual’s ability to implement permanent lifestyle changes, such as adhering to a strict nutritional and exercise regimen, as well as acquiring new coping skills to decrease reliance on food for addressing emotional needs (8). Our clinical experience shows that for people with difficulties implementing these lifestyle changes, surgical outcome may be less than optimal and even detrimental, with negative results including regaining lost weight, malnutrition, and clinical depression. Therefore, the National Institutes of Health recommends monitoring and addressing psychological and behavioral factors pre and postsurgery (9,10). Consequently, psychological evaluation of bariatric surgery candidates has become the norm, and in many cases insurance companies require assessment by mental health professionals to approve coverage for this procedure.
Despite the great demand for bariatric surgery and the rising involvement of mental health professionals in the patient preparation process, little data exists on how to best evaluate these individuals, and there are no uniform guidelines for the psychological assessment of surgery candidates. Even in the 1991 National Institutes of Health consensus statement no specific guidelines for psychological screening were developed, although involvement of mental health professionals in the presurgical evaluation process was encouraged (9). Unfortunately, very few studies have systematically investigated psychosocial and behavioral variables as negative or positive prognostic indicators for surgery outcome.
Obese patients seeking treatment tend to have a greater prevalence of psychopathology than the general population (11). Several studies have been conducted examining psychopathology among the severely obese and bariatric population. It seems that depression and binge eating are more common in these individuals (12–16). Variables other than psychopathology deserve attention during the presurgical evaluation because they may affect postoperative outcome. These include social support, interpersonal sensitivity, marital satisfaction, past diet attempts, evidence of successful lifestyle changes, and knowledge about surgery, its risks, and the behavioral changes required for successful postoperative weight loss. It is beyond the scope of this paper to review literature related to each of the above mentioned variables. The interested reader is directed to the excellent review articles by Bocchieri, Meana, and Fisher as well as by Herpertz et al. (17,18).
Thus, only assessing psychopathology may be insufficient. For example, an early study showed a link between compromised socio-environmental and psychological factors and increased medical complications during the first year after surgery (19). These authors suggested that, in addition to the assessment of psychopathology, assessment of stressful life events, socio-economic status, marital satisfaction, and social support should also be incorporated into presurgical screenings. Other studies support that binge eating is a significant problem in the severely obese. Rates of binge eating disorder range from 25 to 50% in this population (20,21). Untreated eating disorders, including binge eating, could have detrimental effects on surgery outcome (22,23).
Cognitive and behavioral factors should also be assessed preoperatively. Many overweight and obese patients have unrealistic expectations about weight loss. Foster et al. (24,25) found that people entering behavioral weight-loss programs do so with unrealistically high expectations about degree of weight loss. A study of 32 bariatric surgery patients showed that preoperative expectations for weight loss far exceeded expectations for weight loss after patients had actually undergone surgery (26), suggesting a process in which patients adjust their expectations after experiencing the behavioral rigor inherent in postoperative weight management. Data from our own patient database shows that 27% of patients overestimate the expected postoperative weight-loss.
To summarize, several studies suggest that standard psychiatric interviews may be insufficient and that a detailed behavioral assessment is needed to determine patients’ readiness for surgery and the required postoperative lifestyle changes. These studies imply that assessment of psychopathology alone may not be enough to identify those at greatest risk for postoperative medical and psychological complications. Eating habits, stress levels, the presence of a stable and supportive environment, as well as expectations for surgery, are equally important in this population and distinguish a bariatric surgery evaluation from standard psychological assessments. Although the evidence points in the direction that special guidelines are needed to inform assessment of these patients, psychosocial evaluations continue to be performed without these in place. Consequently, surgery programs typically develop their own screening procedures, and mental health professionals struggle with the task of formulating recommendations about patients’ appropriateness for this life-altering procedure without a clear consensus on how to determine suitability. A first step toward consensus is to identify current practices in the evaluation of surgery candidates. Toward this goal, we conducted a survey of bariatric surgery programs in the United States to examine current guidelines for patient selection and screening and to determine the role of mental health professionals in these programs.
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METHODS |
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The survey contained a total of 57 items, and inquired about criteria for requiring psychosocial evaluations, the type of health care professional conducting evaluations, the format of the evaluation, practices regarding follow-up, and the overall perceived value of the psychosocial evaluation. The survey also included 37 behavioral, psychiatric, and medical symptoms that may be contraindications for surgery, and respondents were asked to indicate whether a given symptom would be a definite, possible, or no contraindication for surgery. The final questions on the survey assessed surgery program specific statistics, such as the number of referrals, psychosocial evaluations, and surgeries performed per year. The overall time to complete the survey was estimated to be 15 minutes. No payment for participating in the study was offered.
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RESULTS |
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Table 2 shows the average number of referrals for surgery, completed evaluations, and surgeries performed by these programs. The average number of referrals handled was 399 per year, with 73% of those patients undergoing psychological evaluation and 62% eventually having surgery. On average, respondents estimated that their program disqualified 4% of referred patients because of medical reasons, 7% for financial reasons, and 3% for psychosocial reasons. The mean age for the youngest person undergoing surgery was 17.7 years (range 12–25), and the mean age for the oldest person operated on was 64.1 year (range 55–72).
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Process of the Psychosocial Evaluation
Table 3 summarizes responses to questions regarding the criteria and procedures used by surgery programs for psychosocial evaluations. An overwhelming majority of these programs (86.4%) reported requiring all patients to undergo a psychological evaluation and receive approval from a mental health professional before surgery, regardless of whether or not this is required for insurance approval. In 13.6% of programs, patients are either not evaluated at all or psychological screenings are reportedly conducted by the surgeon, nurse coordinator, or other nonmental health professional. Almost half of the programs requiring an evaluation for approval used formal psychological testing, while 38.3% performed evaluations without formal testing. Only 25.9% of the programs have their own mental health professional on staff, whereas 65% refer patients to mental health professionals in their community. However, only a small minority (6%) allow patients to choose their own mental health provider for the evaluation. A majority of time the professional conducting the evaluations is a clinical psychologist (82.7%), followed by psychiatrists (37%) and master level professionals (13.5%). A total of 50.6% of programs found the psychological evaluation "very valuable," 33% indicated it was "valuable," and only 4.9% found the evaluation "rarely valuable."
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From those programs requiring formal psychological testing, 27 of 81 respondents listed the assessment instruments used in their evaluations, which are shown in Table 4. The psychological tests used vary greatly across different programs. Symptom inventories are used by 55.5% of programs, with the Beck Depression Inventory (BDI) used far more often than other measures, such as the Brief Symptom Inventory or Symptom Checklist. Almost one third of the programs reported using personality inventories, most commonly the Minnesota Multiphasic Personality Inventory (MMPI; 22.2%). Some programs also used other measures to assess quality of life, eating disorder symptoms, and substance abuse.
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In addition to psychological interviews and testing, the vast majority of programs (92.6%) reported routinely incorporating behavioral recommendations as part of the evaluation process (Table 5). Almost all seem to make recommendations to attend support group meetings and increase knowledge about surgery. Other frequently made recommendations include psychotherapy, dietary changes, psychotropic medication evaluation, and keeping food records preoperatively. Weight loss before surgery is very rarely recommended.
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Contraindications for Surgery
Table 6 lists the 37 potential psychosocial contraindications for surgery, which were rated by respondents as definite, possible, or no contraindication for surgery. The most common items endorsed as definite contraindications for surgery approval were current illicit drug abuse (88.9%); active, uncontrolled symptoms of schizophrenia (86.4%); severe mental retardation with an IQ below 50 (81.5%); heavy drinking (77.8%); and lack of knowledge about surgery (77.8%). We divided all contraindication items into three categories that reflected mental health issues, problematic behaviors, and cognitive factors. The three mental health issues that bariatric programs were most concerned about were uncontrolled active schizophrenia, active uncontrolled symptoms of bipolar disorder, and a history of suicide attempts. Problematic behaviors that were most likely to be considered contraindications for surgery were current drug abuse, heavy drinking, and a documented history of medical noncompliance. Cognitive factors that most frequently were considered contraindications included severe mental retardation with an IQ below 50, inadequate knowledge about surgery, and unrealistic expectations for weight loss.
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The items most often labeled "no contraindication" to surgery was above 55-years-old or below 21 years of age. Lack of social support also seemed to be "no contraindication" for surgery in a substantial number of programs. Several behaviors that may interfere with postsurgical success were rated as "possible contraindication" for surgery, such as past criminal behavior and imprisonment, presence of another eating disorder, and inability to maintain a diet for longer than 3 months. Other findings of interest were that active binge eating disorder and current symptoms of depression were considered definite or possible contraindications by 88.8 and 95.1% of programs, respectively. Active symptoms of obsessive compulsive disorder (OCD) were a definite or possible contraindication for 93.9% of programs. Issues other than mental health diagnoses that were of interest are current tobacco use, which is a definite or possible contraindication for 72.8% of programs. The only item that was not considered a definite contraindication by any of the respondents was a history of severe sexual abuse; however, 67.9% considered this a possible contraindication to surgery. These findings underscore the need for continued research to determine whether these variables indeed have a negative impact on postsurgical outcome.
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DISCUSSION |
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Almost 90% of the programs responding to this survey reported requiring all patients to undergo psychological evaluation, and over 80% of respondents rated these evaluations as "very valuable" or "valuable." However, we do not have any information on how results of the psychological evaluation are used by programs and how they ultimately affect decision making about candidates suitability for the operation. This is an area in which further research is necessary. Although the majority of programs require evaluation by a mental health professional, most often a clinical psychologist, only about half used formal psychological testing, and the specific tests employed vary substantially. In addition to the diagnostic interview and standardized testing, most programs also reported incorporating behavioral recommendations.
The most commonly used psychological assessment instruments were the BDI and MMPI. The BDI is a frequently used screening tool for depression, although its utility with the bariatric surgery population has been largely unexamined. The use of the MMPI with obese individuals has been studied, especially in the 1980s when research focused on identifying a personality profile of the obese individual (29). Gradually the research focus shifted to identifying predictors of the MMPI for postoperative outcome. An early study found that the number of MMPI scores elevated above a T-Score of 70 related to postoperative weight loss (19). A more recent examination of the predictive value of the MMPI-2 scales revealed that people with postoperative weight loss of <50% excess body weight had elevations on the F, Hysteria, Paranoia, and Health Concerns subscales (30). Unfortunately our data does not allow us to determine which aspects of the MMPI-2 are used to screen patients, and certainly this is an area of much needed further research.
A few items were considered to be definite psychiatric contraindications for surgery by almost all of the respondents; these include uncontrolled symptoms of severe mental illness, significant mental retardation, and drug/alcohol abuse. Thus, a psychiatric history per se does not seem to interfere necessarily with patients’ approval for surgery, although referrals for psychotherapy or psychotropic medication evaluation are common presurgical recommendations. Some cognitive and behavioral factors that may be expected to be poor prognostic indicators by interfering with proper adherence were considered definite contraindications by fewer programs. These included poor social support and inability to diet for over 3 months.
Contrary to other variables, binge eating has been examined by several research groups (22,23). Although rates of binge eating are elevated within the obese, literature varies on whether binge eating behavior persists or subsides after surgery. Kalarchian et al. (23) observed that 2 to 7 years postoperatively nearly 50% of patients reported continued difficulties with overeating resulting in less overall weight loss. Green et al. (22) also found that people with binge eating behaviors have worse postoperative outcome. However, there is also support that binge eating subsides following bariatric surgery (31,32). A possible explanation for these somewhat incongruent findings may be that, although eating patterns after surgery are very likely to shift because of anatomical alterations inherent in the procedure, patients with a history of binge eating continue to show postoperative eating disturbances that interfere with optimal weight loss (33). In light of these studies, 48.1% of programs would consider active binge eating disorder a definite contraindication, 6.2% would consider a history of binge eating disorder a definite contraindication, and 3.7% would consider the presence of an eating disorder a contraindication for surgery.
Only 11.1% of programs list an age younger than 21 as a definite contraindication for surgery, suggesting that many programs are presently operating, or consider operating, on adolescents. Given the sparse amount of data on this population and the current controversy regarding weight reduction surgery in adolescents, some might view this finding with concern (34). Adolescents do present with special circumstances, most notably a level of cognitive development that makes it difficult to fully grasp the extent and effort required in initiating and maintaining life-long behavior changes. One might question whether or not adolescents are capable of giving informed consent for an elective procedure with life-long medical and behavioral consequences. However, given the increase in childhood obesity, bariatric surgery in younger patients is likely to become more common. This development will greatly increase the need for pre and postoperative psychological protocols designed specifically for this population and calls for additional research in this area.
Current use of tobacco products is a definite contraindication for 37% and a possible contraindication for 36% of programs. This issue may be a topic of contention, those who do not consider tobacco use a contraindication for weight reduction surgery may argue that patients’ health-related quality of life and medical comorbidities deserve to be treated in their own right. Others may argue that weight reduction is largely dependent on habit change and that surgery is a tool to assist with implementing healthier habits. Furthermore, because surgery is costly it seems that requiring patients to cease other health-compromising behaviors such as tobacco use will reinforce the overall goal of surgery, namely improvement of health and quality of life.
Active depression was considered a definite or possible contraindication for surgery by 96% of participants. Unlike many of the other contraindications listed in our survey, the relationship between depression, obesity, and postoperative outcome has been documented in various articles. Obese individuals have a higher likelihood of developing depression, with estimates of a life-time prevalence ranging from 29 to 51% (14,35). Furthermore, although the prevalence of depression decreases after surgery there still remains a subgroup of people who remain depressed following the operation (36). These individuals tend to report poorer postsurgical quality of life and weight loss (13).
Other findings worth discussing are that the majority of respondents found active symptoms of obsessive compulsive disorder and a history of severe sexual abuse to be at least a possible contraindications to surgery. Symptoms of OCD may be linked to compulsive eating behaviors, although no strong literature exists to support this. Evaluation of a patient with active symptoms of OCD should include an assessment of whether these symptoms translate into compulsive eating behaviors. Unfortunately sexual abuse is common within the obese population and seems to have a negative effect on weight loss efforts (37). Careful consideration and treatment of unresolved sexual abuse may therefore be indicated for the bariatric surgery patient.
Given the lack of studies identifying psychosocial and behavioral predictors, the variability in contraindications considered by programs is not surprising. The results of this study clearly point out the need for research to identify psychological, behavioral, cognitive, and social characteristics that are predictive of surgery outcomes. Presently, professionals are asked to make decisions about bariatric candidates without empirical support. The impact of potentially important variables, such as knowledge and expectations about bariatric surgery, is simply unknown.
Because little consensus exists on how to evaluate patients seeking bariatric surgery, we strongly encourage the development of guidelines. A consensus among mental health professionals dedicated to both research and practice in bariatric surgery is desirable. Because of the scarcity of empirical data, such a consensus could make inferences from literature on psychological evaluation of other medically compromised patient populations as well as from the clinical experience of experts in the field. There are some indications of an emerging standard of care from this survey data. The vast majority of programs require evaluation by a mental health professional, almost always by a clinical psychologist or psychiatrist, and rarely by the surgeon or a nurse coordinator. Only a small number of programs (6%) allow patients to select a mental health professional to perform the evaluation. This is encouraging because this practice can result in patients selecting professionals who may not have adequate understanding of or experience with this medical procedure. It can also lead to patients "shopping" for a professional who will approve surgery in spite of negative indicators. Because of the special requirements of the bariatric population, and the need to prepare patients for a variety of lifestyle changes, to detect and treat a disordered relationship with food, and to address distorted cognitions regarding potential weight loss and psychosocial outcomes, mental health providers with an expertise in medical psychology would be strongly recommended.
Surgery programs requiring comprehensive evaluations may also help in developing a consensus and standard of care by publishing detailed descriptions of their procedures. Glinski, Wetzler, and Goodman published an excellent review of important aspects of the interview and provided program specific statistics about prevalence of particular phenomena frequently encountered during the evaluation. These include denial of problems, difficulties with modulating thoughts, feelings and behaviors, cognitive distortion, low self-esteem, and family dynamics, to highlight a few that are separate from psychopathology per se (38). Another recent publication introduced the Boston Interview for Gastric Bypass, a detailed semi-structured interview for the evaluation of bariatric surgery candidates (39). This comprehensive interview is designed to assist with the overall evaluation and formulation of interventions to increase patients’ success following surgery. In addition to a standard psychiatric diagnostic interview, this evaluation includes a detailed weight, diet, and nutrition history and a review of current eating behaviors as well as assessments of knowledge and expectations related to surgery. A similar procedure is used at the University of Virginia, where a standardized interview and protocol, specifically tailored for this population, is used. Publications like those described above can help guide the profession to think beyond a standard psychiatric interview for bariatric surgery patients and provide specific suggestions about conducting a bariatric evaluation.
The question remains as to how psychologists can deal with the increasing demand for presurgical evaluations without empirical data to back up their conclusions. We first suggest that increase of research in this area should be a foremost priority. Second, a closer network of psychologists working with bariatric patients could facilitate sharing of clinical practices to begin developing a uniform process for the evaluation of surgery candidates. And third, psychologists may want to re-evaluate their role within bariatric surgery teams. Specifically, psychologists may wish to broaden their role beyond conducting traditional psychiatric evaluations for patient screening, to include interventions geared toward preparing patients for surgery and monitoring their success postoperatively. Thus, the evaluation would not solely be aimed at identifying predictors of success but would also include the development of an individually tailored intervention to increase the patients’ postoperative success.
This paper is not designed to make assertions about best practices for preoperative psychological evaluations. Given the descriptive nature of this study, these results are not meant to be understood as identifying actual predictors of postoperative success. The report simply serves to highlight the variety of current approaches to psychological evaluation of bariatric surgery candidates. Results of this survey indicate that there is little consensus about screening procedures or criteria for patient selection. Therefore, more effort is needed to develop guidelines for psychosocial screening and selection of bariatric surgery candidates. Descriptive studies, like this survey, can contribute toward this goal, as well as the sharing by experienced programs of evaluation procedures that have been developed over time to improve patient outcome. However, the most critical need is for systematic, prospective, longitudinal scientific studies to identify those factors that have the largest impact on patient outcome and satisfaction after bariatric surgery.
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NOTES |
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Received for publication October 7, 2004; revision received May 24, 2005.
DOI:10.1097/01.psy.0000174173.32271.01
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This article has been cited by other articles:
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  M. A. Kalarchian, M. D. Marcus, M. D. Levine, A. P. Courcoulas, P. A. Pilkonis, R. M. Ringham, J. N. Soulakova, L. A. Weissfeld, and D. L. Rofey Psychiatric Disorders Among Bariatric Surgery Candidates: Relationship to Obesity and Functional Health Status Am J Psychiatry, February 1, 2007; 164(2): 328 - 334. [Abstract] [Full Text] [PDF]
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