(1)
Obesity Institute, Geisinger Medical Center, Southold, NY, USA
Abstract
Behavioral evaluation of candidates for bariatric surgery has been practiced since 1991 and it is generally understood that the long-term success of bariatric surgery depends on the patient’s ability to make enduring changes in lifestyle. Despite the widespread use of behavioral and mental health evaluation prior to bariatric surgery, little has been learned about significant predictors of success or struggles with weight loss. Candidates for bariatric surgery have a higher prevalence of mental health disorders, most of which are mild. However, a significant fraction need immediate attention before surgery and continued concurrent treatment following surgery. Little is known about the long-term fate of candidates for bariatric surgery whose surgery is delayed for mental health treatment. Important mental health conditions which merit further study among candidates for bariatric surgery include deficits in cognitive function, binge eating disorder, and those with a prior history of sexual abuse. There is a need to standardize the behavioral evaluation of bariatric surgery candidates with an accepted comprehensive psychological and behavioral structured clinical interview. It is apparent that mental health expertise is needed for the evaluation of candidates as well as postoperative management.
Patients with the best weight loss and health outcomes after bariatric surgery are those who are successful in making long-term changes in eating behavior and lifestyle. These changes include following a regular nutrition and exercise plan and the acquisition of new cognitive skills, which address the relation between emotional stress and food consumption. Inability to make these behavioral and lifestyle changes is likely to lead to weight loss failure, nutritional complications and major depression after surgery. An increasing awareness and understanding of the critical importance of these lifestyle changes has enhanced the role of the psychological and behavioral evaluation in patient selection and preparation for weight loss surgery.
The National Institute of Health Consensus Development Panel in 1991 recommended that a mental health assessment should be a part of the routine evaluation of candidates for Bariatric Surgery. Despite the fact that this evaluation has been performed in the vast majority of bariatric surgery patients during the past 22 years, we still lack evidence-based guidelines regarding the necessary components of this evaluation, and for the recognition of those individuals whose mental health profile and motivation level predict a good health outcome after surgery. The published literature in this area prior to 2004 is difficult to interpret because of methodological limitations related to inconsistent diagnostic criteria for the diagnosis of mental health conditions, lack of suitable controls, and failure to assess the severity of mental health conditions [1, 2]. The more recent literature is made up of an increasing number of studies where mental health disorders are diagnosed and their severity assessed on the basis of structured clinical interviews.
In addition, mental health personnel are now aware that candidates for weight loss surgery want to appear mentally healthy so that their surgery will not be denied. As a result, those patients who agree to participate in clinical research studies of mental health in bariatric surgery patients are informed that unless the research team identifies issues, which contribute to safety risk, the mental health information would be kept from the surgical team [3]. The tendency of bariatric surgery candidates to withhold mental health information, which may threaten their chances of having surgery, may contribute to error in reporting prevalence rates of mental disorders in surgical candidates.
Candidates for weight loss surgery have a higher prevalence of mental health disorders when compared with other surgical populations, and the extent of mental impairment is related to the degree of obesity [4]. Earlier studies using non-standardized criteria for diagnosis reveal widely divergent prevalence rates, but more recent data are more consistent. Overall, approximately half of bariatric surgery candidates have a lifetime history of a mental health condition [3–7] and about half are taking psychotropic medications [3–7]. The prevalence of current mental health conditions at the time of bariatric surgery evaluation is significantly less and approximates 30 % [3–7].
The most common conditions encountered are Axis I disorders involving mood (major depression or dysthymia), anxiety (generalized anxiety and social phobia), substance abuse, and eating disorders [3–7]. Additional mental health conditions with significant prevalence in bariatric surgery candidates include alcohol abuse [3–5, 7] and personality disorders [7].
Despite the relatively high prevalence of current and lifetime mental health conditions among candidates for bariatric surgery, for most patients, these conditions are either mild, or well controlled because they do not contraindicate bariatric surgery. The findings and results of the psychological evaluations at the University of South Carolina are typical of the findings at most bariatric treatment centers (Fig. 5.1) [8]. In this study, the vast majority of patients had no psychological contraindications for surgery and was considered appropriate for immediate surgery. A small number (15.8 %) were found to be temporarily inappropriate for immediate surgery and surgery was deferred for treatment of a mental health condition, most commonly major depression followed by binge eating disorder. Only 2.9 % were found to be inappropriate for surgery with reasons being active psychosis/thought disorders and inability to provide informed consent [8].
Fig. 5.1
The outcomes of psychological and behavioral evaluations in 449 patients from the Bariatric Surgical Program at the University of South Carolina. Modified from Pawlow L, O’Neil P, White M, Byrne T. Findings and Outcomes of Psychological Evaluations of Gastric Bypass Applicants. Surg Obes Rel Dis 2005;1:523–529 [8]
Somewhat similar findings were reported in a small study from the University of Pennsylvania Bariatric Surgery Program where 64 % of patients were immediately cleared for surgery and in only 3 % surgery was found to be contraindicated for mental health reasons [9]. In a survey of Academic and Community bariatric surgery programs, the more common psychosocial reasons for contraindicating surgery were found to be illicit drug abuse, active uncontrolled symptoms of schizophrenia, severe mental retardation (IQ below 50), heavy drinking, and lack of knowledge about surgery [10]. A separate survey of 103 psychologists experienced in evaluations for bariatric surgery revealed that an average of 14.3 ± 12.9 % of candidates are recommended for delay or frank denial of surgery (range: 0–60 %) [11].
Additional generally accepted mental health contraindications to bariatric surgery include recent suicide attempts, recent hospitalizations for mental illness, and borderline personality. At the Mayo Clinic, surgery is delayed until the following criteria are met: no psychiatric hospitalization for 12 months; for substance abuse, ongoing treatment and abstinence for 1 year; for patients with ongoing psychiatric issues, they must be in treatment by a licensed mental health professional who must support the patient’s wish for surgery and agree to provide postoperative follow-up care [12].
These studies indicate that a significant number of surgical candidates who have mental health issues are immediately cleared for surgery. Those who are immediately cleared are likely to be patients whose disease manifestations are mild or controlled and those who are involved in ongoing psychiatric care. A recent small study documents improvement in psychosocial status in the first 2 years after gastric bypass surgery with statistically significant improvement in scores for depression and anxiety [13]. A brief review summarizes the overall positive impact of surgical weight loss on mental health, psychosocial functioning, and health-related quality of life [14]. It is also evident that there are significant numbers of patients who do not benefit psychologically from weight loss surgery [15]. There is a clear need for additional high quality research in this area in order to better identify psychological, behavioral, social, and cognitive traits which will better predict surgical outcomes [10].
Another important area where systematic studies are needed concerns the minority of patients whose surgery is delayed for additional treatment of mental health disorders. Typical reasons for delaying surgery include a poorly controlled or untreated Axis I disorder, active binge eating, and substance abuse. There is very limited information available regarding the fate of this group of patients as follow-up rates in the limited number of studies are poor, and systematic longitudinal studies of those patients who complete treatment and then undergo bariatric surgery are lacking. A recent study indicates that mental health issues are common in bariatric surgery candidates who drop out of programs because of failure to complete program requirements [16].
The relatively high prevalence of binge eating disorder in bariatric surgery candidates, and the conflicting results in the limited available literature argue strongly for additional studies in order to better understand the influence of this disorder on surgical outcomes. Short- and medium-term studies indicate that meaningful surgical weight loss can occur in these patients and that the revised foregut anatomy may limit binge eating as well as make it more difficult to assess this disorder after bariatric surgery [2, 17]. Others feel that overeating and loss of control can develop after surgery and adversely affect long-term weight loss [7]. Most recommend that patients with active binge eating disorder symptoms should have surgery deferred for counseling and behavioral treatment. If they respond and are cleared for surgery, ongoing adjuvant psychological treatment will be essential during follow-up. Clearly, additional information is needed regarding Binge Eating, and the newly diagnosed Night Eating Syndrome (both conditions common in bariatric surgery candidates), in regard to optimum management in conjunction with bariatric surgery [1].
Another component of the psychological and behavioral evaluation of candidates for bariatric surgery, which is emerging as a possible outcome predictor, is cognitive function ability. Several studies have identified deficits in cognitive function both in obese subjects [18, 19], and in bariatric surgery candidates [20, 21
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