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Behavioral and Psychological Factors in the Assessment and Treatment of Obesity Surgery Patients Isaac Greenberg,* Frank Perna,† Marjory Kaplan,‡ and Mary Anna Sullivan§

Abstract GREENBERG, ISAAC, FRANK PERNA, MARJORY KAPLAN, AND MARY ANNA SULLIVAN. Behavioral and psychological factors in the assessment and treatment of obesity surgery patients. Obes Res. 2005;13:244 –249. Objective: To provide evidence-based guidelines on the psychological and behavioral screening of weight loss surgery (WLS) candidates and the impact of psychosocial factors on behavior change after gastric bypass surgery. Research Methods and Procedures: The members of the Behavioral and Psychological subgroup of the Multidisciplinary Care Task Group conducted searches of MEDLINE and PubMed for articles related to WLS, behavior changes, and mental health, including quality of life (QOL) and behavior modification. Pertinent abstracts and literature were reviewed for references. A total of 198 abstracts were identified; 17 papers were reviewed in detail. Search periods were from 1980 to 2004. Results: We found a high incidence of depression, negative body image, eating disorders, and low QOL in severely obese patients. Our task subgroup recommended that all WLS candidates be evaluated by a licensed mental health care provider (i.e., psychiatrist, psychologist, or social worker), experienced in the treatment of severely obese patients and working within the context of a multidisciplinary care team. We also recommended development of pre- and postsurgical treatment plans that address psycho-

The costs of publication of this article were defrayed, in part, by the payment of page charges. This article must, therefore, be hereby marked “advertisement” in accordance with 18 U.S.C. Section 1734 solely to indicate this fact. *Obesity Consult Center, Tufts-New England Medical Center, Boston, Massachusetts; †Boston University School of Medicine, Psychiatry & Graduate Medical Sciences, Boston, Massachusetts; ‡Division of Preventive and Behavioral Medicine, University of Massachusetts, Worcester, Massachusetts; §Department of Psychiatry, Lahey Clinic Medical Center, Burlington, Massachusetts. Address correspondence to: Isaac Greenberg, Obesity Consult Center, Tufts-New England Medical Center, 750 Washington Street, Tufts-NEMC 900, Boston, MA 02111. E-mail: [email protected] Copyright © 2005 NAASO

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social contraindications for WLS and potential barriers to postoperative success. Discussion: The psychological consequences of obesity can range from lowered self-esteem to clinical depression. Rates of anxiety and depression are three to four times higher among obese individuals than among their leaner peers. A comprehensive multidisciplinary program that incorporates psychological and behavior change services can be of critical benefit in enhancing compliance, outcome, and QOL in WLS patients. Key words: weight loss surgery, psychological evaluation, binge eating disorders, bariatric surgery

Introduction Approximately two-thirds of individuals living in the United States are overweight; of those, almost one-half are obese (1). The BMI subgroups experiencing the most rapid growth are 35 or higher (23 million) and 40 or higher (8 million) (2,3). The disease remains largely refractory to diet and drug therapy but generally responds well to weight loss surgery (WLS)1 (4). Multiple studies have documented the numerous physiological benefits of WLS for the severely obese (5,6). However, WLS is not without risk, and not all patients benefit from the procedure (7). Determining a patient’s psychological suitability for surgical intervention can be challenging but is critically important (8). Psychological and/or psychiatric difficulties before WLS are quite common (7) and are likely to influence outcome (9). Previous research has documented a high prevalence of psychiatric comorbidities in severely obese patients, including eating disorders, especially binge eating (10 –16), and depression (17,18), anxiety, and personality disorders (19 – 21). Data also show that WLS patients experience great psychosocial stress at work and in social and intimate relationships.

1

Nonstandard abbreviations: WLS, weight loss surgery; QOL, quality of life.

GBP

GBP

VBG

GBP

LAGB

GBP

GBP

GBP

GBP

Waters (37)

Vallis (28)

Mitchell (41)

Dixon (42)

Kalarchian (36)

Powers (15)

Saunders (35)

Ray (24)

Population

Tsushima (9)

Study

Table 1. Psychological studies

Baseline, N ⫽ 149; follow-up, N ⫽ 63

125

116

99

218

Case series or report Cohort study

Cohort study

Cohort study

Case series

Cohort study

Cohort study

Baseline, N ⫽ 110; follow-up, N ⫽ 48 100

Cohort study

Cohort study

Design

462

52

N

Sexual abuse history, psychological coping resiliency, seeking surgery for health-related reasons, greater presurgical life stress, and greater social support were associated with greater weight loss at follow-up.

The MMPI-2 appears to be associated with weight loss outcome 1-year after RYGB. Psychological traits such as anxiety and excessive health concerns are likely to influence surgery outcome. Scores on anxiety, depression, well-being, and selfcontrol improved significantly at 6- and 12-month follow-up, but returned to baseline at 24- to 36month follow-up. VBG results in improved QOL and emotional distress and normalized eating attitudes regardless of presurgical functional and emotional status. Majority of individuals who have had GBP surgery feel that the procedure benefited them, although some reported long-term difficulties adjusting to different style of eating. Physical disability and comorbidity predicted poor QOL at baseline and greatest improvement after surgery. 46% of patients experienced recurrent loss of control over eating at follow-up. Patients with binge eating tendencies experienced less favorable outcome, including greater weight gain. Preoperative binge eating occurred in 52% of patients, but there was no association between presurgical eating pathology and weight outcomes or presence of vomiting at follow-up. Binge eating present in 33% of patients.

Major findings

B

B

B

B

B

C

B

B

B

Evidence grade

Psychological Evaluation, Greenberg et al.


245

246


GBP

GBP

VBG

RYGB

GBP, gastrogastrostomy, gastroplasty

Powers (15)

Herpertz (31)

Black (27)

Clark (7)

Hawke (43)

18

80

44

NA

116

27

Cohort study

Cohort study

Nonrandomized clinical trial

Meta-analysis

Cohort study

Case series or report

Patients with preoperative eating disorders may have short-term improvement in disorder. Most were able to sustain long-term weight loss, although there was some weight gain at 2-year follow-up. Eating pathology at follow-up related to vomiting, not binging. No relationship found between preoperative eating pathology and amount of weight lost. Postsurgery, mental health and psychosocial status increased, and psychiatric comorbidity, affective disorders, and psychopathic symptoms decreased. Effect on binge eating disorder depends largely on type of operation. The data suggest that Axis I and Axis II diagnosis were not predictive of weight loss after VBG during a 6-month follow-up. Patients who received treatment for substance abuse or psychiatric comorbidity lost more weight than those without treatment. Broad improvement in physical and psychosocial factors at 3-year follow-up. Improvements include mobility, self-image, and social life. B

B

C

A

B

C

MMPI-2, Minnesota Multiphasic Personality Inventory-2; RYGB, Roux-en-Y gastric bypass; VBG, vertical banded gastroplasty; LAGB, laparoscopic adjustable gastric band; GBP, gastric bypass; NA, not applicable.

GBP

Hsu (33)



Surgery is a high-risk, invasive procedure that requires careful evaluation of medical, psychological, and behavioral factors to ensure that the most appropriate treatment option is selected ((8). Kral (22) has described WLS as behavioral surgery for which a psychological assessment is critical in patient selection. Sogg and Mori (8) note that psychologists, as part of a multidisciplinary team, are in a unique position to evaluate behavioral, psychiatric, and emotional variables and provide treatment recommendations that can enhance the likelihood of success. In this paper, we provide an evidence-based assessment of how psychological factors impact WLS outcomes and the role of mental health professionals within a multidisciplinary treatment team (Table 1).

Results Preoperative Evaluation A study on how psychosocial factors affect weight loss showed that patients who successfully participated in either substance abuse or mental health treatment had improved weight loss compared with those who had no history of treatment (7). Other data show associations between weight loss and depression (23), perceived ill health, stress, and measures of coping (24). Tsushima et al. (9) have indicated that results from a standard personality test are associated with 1-year weight loss and that psychological traits (e.g., anxiety and excessive health concerns) are likely to influence WLS outcomes. However, Sogg and Mori (8) have reported that there is no commonly used, standardized protocol for pre-WLS psychological evaluations and few empirical data on those factors that predict successful surgical outcomes. For example, several investigators have reported no predictive relationship between preoperative psychological evaluations and postoperative weight loss (25–27). Vallis et al. (28) found that patients with the lowest level of psychological function received the greatest benefit from WLS (28). Arcila et al. (29) found significantly higher physical and mental well-being and overall quality of life (QOL) in patients who received WLS compared with those who did not. Guisado et al. (30) reported a strong correlation between greater weight loss and improved QOL, including less psychopathology and disturbed eating. Herpertz et al. (31) have suggested that symptoms of psychiatric comorbidity decrease after WLS. In light of these data, Buddeberg-Fischer et al. (32) have concluded that even though high levels of psychosocial stress seem unrelated to outcome, patients should receive pre- and postoperative counseling to reduce anxiety and increase compliance after surgery. Evidence-based statements (Category D) include: ●

Each candidate for WLS should be evaluated by a credentialed expert in psychology and behavior change (i.e., a psychiatrist, psychologist, or social worker);

●

●

Consensus on the criteria for successful treatment and more prospective and long-term observational trials are needed to better understand the effect of specific psychosocial variables on WLS outcomes; and Major behavioral and psychological changes occur postoperatively, and mental health clinicians can provide appropriate levels of support.

Binge Eating and WLS Outcomes Hsu et al. (33) have identified binge eating as a factor leading to poor WLS outcomes and have recommended that the disorder be studied to improve patient selection. Similarly, other data suggest that obese binge eaters report significantly more psychiatric symptoms and less satisfactory weight loss than non-binge eating WLS patients (34). Saunders (35) found a high prevalence of binge eating problems and associated depression in WLS patients and suggested that the identification and treatment of such disorders may be critical to the long-term success. Kalarchian et al. (36) also found that self-reported loss of control over eating was related to weight regain after surgery and might be an important target for clinical intervention. Waters et al. (37) have suggested that long-term follow-up and continued emotional support are essential for success. Finally, in a recent report, Green et al. (38) found that binge eaters had significantly higher levels of hunger and lower levels of social functioning both preoperatively and 6 months postoperatively as well. Furthermore, the binge eater group had a significantly lower percentage of excess weight loss than the non-binge eater group at 6 months postsurgery. Evidence-based statements (Category B) include: ●

Binge eating is not necessarily a contraindication for WLS, but efforts should be made to identify candidates with binge eating or other eating disorders and treat them before surgery.

Discussion Although major mental illness is not a rule-out for WLS, it raises significant concerns about a patient’s ability to appropriately care for him- or herself postsurgically. A preoperative mental status exam allows determinations to be made about a patient’s ability to make informed decisions and participate actively in his or her treatment and helps to ensure that appropriate psychiatric supports are in place for patients meeting psychiatric diagnostic criteria or for those exhibiting high stress levels (8). Mental health professionals are frequently called on to conduct presurgical evaluations. However, effective assessment is difficult if the clinician is not familiar with the procedure, its expected results, and the postoperative regimen. OBESITY RESEARCH Vol. 13 No. 2 February 2005

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WLS can produce significant weight loss and improved QOL, even in those with major mental illness (39). The best results are achieved by well-informed patients whose care is provided by a dedicated multidisciplinary team (40). As part of that team, the mental health clinician can formulate specific psychosocial and behavioral recommendations and provide critical feedback that may greatly enhance the chances for postsurgical success (8).

Acknowledgments The authors thank George Blackburn, Frank Hu, and Rita Buckley for manuscript preparation and Barbara Ainsley for administrative support. This manuscript was supported in part by the Center for Healthy Living at Harvard Medical School and by the Boston Obesity Nutrition Research Center P30DK46200. This report on WLS was prepared for the Betsy Lehman Center for Patient Safety and Medical Error Reduction (Department of Public Health, Boston, MA). References 1. Centers for Disease Control and Prevention. National Center for Health Statistics NHANES IV Report. http://www.cdc. gov/nchs/product/pubs/ (accessed October 20, 2004). 2. Flegal KM, Carroll MD, Ogden CL, Johnson CL. Prevalence and trends in obesity among US adults, 1999-2000. JAMA. 2002;288:1723–7. 3. Sturm R. Increases in clinically severe obesity in the United States, 1986 –2000. Arch Intern Med. 2003;163:2146 – 8. 4. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004; 292:1724 –37. 5. Mun EC, Blackburn GL, Matthews JB. Current status of medical and surgical therapy for obesity. Gastroenterology. 2001;120:669 – 81. 6. Pories WJ, Swanson MS, MacDonald KG, et al. Who would have thought it? An operation proves to be the most effective therapy for adult onset diabetes mellitus. Ann Surg. 1995;222:339 –52. 7. Clark MM, Balsiger BM, Sletten CD, et al. Psychosocial factors and 2-year outcome following bariatric surgery for weight loss. Obes Surg. 2003;13:739 – 45. 8. Sogg S, Mori DL. The Boston interview for gastric bypass: determining the psychological suitability of surgical candidates. Obes Surg. 2004;14:370 – 80. 9. Tsushima WT, Bridenstine MP, Balfour JF. MMPI-2 scores in the outcome prediction of gastric bypass surgery. Obes Surg. 2004;14:528 –32. 10. Adami GF, Gandolfo P, Bauer B, Scopinaro N. Binge eating in massively obese patients undergoing bariatric surgery. Int J Eat Disord. 1995;17:45–50. 11. Busetto L, Valente P, Pisent C, et al. Eating pattern in the first year following adjustable silicone gastric banding (ASGB) for morbid obesity. Int J Obes Relat Metab Disord. 1996;20:539 – 46. 12. de Zwaan M, Mitchell JE, Howell LM, et al. Characteristics of morbidly obese patients before gastric bypass surgery. Compr Psychiatry. 2003;44:428 –34. 248


13. Hsu LK, Mulliken B, McDonagh B, et al. Binge eating disorder in extreme obesity. Int J Obes Relat Metab Disord. 2002;26:1398 – 403. 14. Kalarchian MA, Wilson GT, Brolin RE, Bradley L. Binge eating in bariatric surgery patients. Int J Eat Disord. 1998;23: 89 –92. 15. Powers PS, Perez A, Boyd F, Rosemurgy A. Eating pathology before and after bariatric surgery: a prospective study. Int J Eat Disord. 1999;25:293–300. 16. Williamson DK, Martin CK. Binge eating disorder: a review of the literature after publication of DSM-IV. Eating Weight Disord. 1999;4:103–14. 17. Onyike CU, Crum RM, Lee HB, Lyketsos CG, Eaton WW. Is obesity associated with major depression? Results from the Third National Health and Nutrition Examination Survey. Am J Epidemiol. 2003;158:1139 – 47. 18. Carpenter KM, Hasin DS, Allison DB, Faith MS. Relationships between obesity and DSM-IV major depressive disorder, suicide ideation, and suicide attempts: results from a general population study. Am J Public Health. 2000;90:251–7. 19. Becker ES, Margraf J, Turke V, Soeder U, Neumer S. Obesity and mental illness in a representative sample of young women. Int J Obes Relat Metab Disord. 2001;25(Suppl 1): S5–9. 20. Berman WH, Berman ER, Heymsfield S, Fauci M, Ackerman S. The effect of psychiatric disorders on weight loss in obesity clinic patients. Behav Med. 1993;18:167–72. 21. Black DW, Goldstein RB, Mason EE. Prevalence of mental disorder in 88 morbidly obese bariatric clinic patients. Am J Psychiatry. 1992;149:227–34. 22. Kral JG. Surgical treatment of obesity. Med Clin North Am. 1989;73:251– 64. 23. Averbukh Y, Heshka S, El-Shoreya H, et al. Depression score predicts weight loss following Roux-en-Y gastric bypass. Obes Surg. 2003;13:833– 6. 24. Ray EC, Nickels MW, Sayeed S, Sax HC. Predicting success after gastric bypass: the role of psychosocial and behavioral factors. Surgery. 2003;134:555– 63. 25. Schrader G, Stefanovic S, Gibbs A, Elmslie R, Higgins B, Slavotinek A. Do psychosocial factors predict weight loss following gastric surgery for obesity? Aust N Z J Psychiatry. 1990;24:496 –9. 26. Webb WW, Morey LC, Castelnuovo-Tedesco P, Scott HW Jr. Heterogeneity of personality traits in massive obesity and outcome prediction of bariatric surgery. Int J Obes. 1990;14: 13–20. 27. Black DW, Goldstein RB, Mason EE. Psychiatric diagnosis and weight loss following gastric surgery for obesity. Obes Surg. 2003;13:746 –51. 28. Vallis TM, Butler GS, Perey B, Veldhuyzen van Zanten SJ, MacDonald AS, Konok G. The role of psychological functioning in morbid obesity and its treatment with gastroplasty. Obes Surg. 2001;11:716 –25. 29. Arcila D, Velazquez D, Gamino R, et al. Quality of life in bariatric surgery. Obes Surg. 2002;12:661–5. 30. Guisado JA, Vaz FJ, Alarcon J, Lopez-Ibor JJ Jr, Rubio MA, Gaite L. Psychopathological status and interpersonal


31.

32.

33.

34.

35. 36.

functioning following weight loss in morbidly obese patients undergoing bariatric surgery. Obes Surg. 2002;12: 835– 40. Herpertz S, Kielmann R, Wolf AM, Langkafel M, Senf W, Hebebrand J. Does obesity surgery improve psychosocial functioning? A systematic review. Int J Obes Relat Metab Disord. 2003;27:1300 –14. Buddeberg-Fischer B, Klaghofer R, Sigrist S, Buddeberg C. Impact of psychosocial stress and symptoms on indication for bariatric surgery and outcome in morbidly obese patients. Obes Surg. 2004;14:361–9. Hsu LK, Benotti PN, Dwyer J, et al. Nonsurgical factors that influence the outcome of bariatric surgery: a review. Psychosomatic Med. 1998;60:338 – 46. Guisado Macias JA, Vaz Leal FJ. Psychopathological differences between morbidly obese binge eaters and non-binge eaters after bariatric surgery. Eat Weight Disord. 2003;8:315– 8. Saunders R. Binge eating in gastric bypass patients before surgery. Obes Surg. 1999;9:72– 6. Kalarchian MA, Marcus MD, Wilson GT, Labouvie EW, Brolin RE, LaMarca LB. Binge eating among gastric bypass patients at long-term follow-up. Obes Surg. 2002;12:270 –5.

37. Waters GS, Pories WJ, Swanson MS, et al. Long-term studies of mental health after the Greenville gastric bypass operation for morbid obesity. Am J Surg. 1991;161:154 –7. 38. Green AE, Dymek-Valentine M, Pytluk S, le Grange D, Alverdy J. Psychosocial outcome of gastric bypass surgery for patients with and without binge eating. Obes Surg. 2004; 14:975– 85. 39. Hamoui N, Kingsbury S, Anthone GJ, Crookes PF. Surgical treatment of morbid obesity in schizophrenic patients. Obes Surg. 2004;14:349 –52. 40. Stocker DJ. Management of the bariatric surgery patient. Endocrinol Metab Clin North Am. 2003;32:437–57. 41. Mitchell J, Lancaster K, Burgard M, et al. Long-term follow-up of patients’ status after gastric bypass. Obes Surg. 2001;11:464 – 8. 42. Dixon JB, Dixon ME, O’Brien PE. Quality of life after lap-band placement: influence of time, weight loss, and comorbidities. Obes Res. 2001;9:713–21. 43. Hawke A, O’Brien P, Watts J, et al. Psychosocial and physical activity changes after gastric restrictive procedures for morbid obesity. Aust N Z J Surg. 1990;60: 755– 8.


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