© Springer International Publishing AG 2017
Sanjeev Sockalingam and Raed Hawa (eds.)Psychiatric Care in Severe Obesity10.1007/978-3-319-42536-8_1313. Psychiatric Suitability Assessment for Bariatric Surgery
(1)
Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 101, Baltimore, MD 21287-7101, USA
13.1 Introduction
The aim of this chapter is to review the current evidence base for a psychosocial assessment of bariatric surgery candidates and provide recommendations for providers who evaluate weight-loss surgery patients preoperatively. The purpose is to equip practitioners working with bariatric surgery candidates with the tools to help perform evaluation and make appropriate recommendations to patients and surgical teams. Two case vignettes of common clinical presentations will be used to illustrate the assessment process and highlight possible challenges. Recent recommendations and guidelines for the aims of the evaluation, the key elements of the assessment, psychosocial contraindications, and the most common outcomes of the evaluation will be summarized. Finally, the need for a standardized assessment tool as well as multidisciplinary and collaborative approach to bariatric candidates will be highlighted.
Case Vignettes
Case Vignette 1: Andrea
Andrea is a 41-year-old divorced female who self-referred to the bariatric program. Her body mass index (BMI) was 42 kg/m2. Her past medical history was significant for gastroesophageal reflux and hypertension as well as obstructive sleep apnea. Her primary care physician recently told her that she was prediabetic. Her past psychiatric history was significant for a long history of Bipolar II disorder and posttraumatic stress disorder related to childhood sexual trauma, as well as a history of cocaine abuse. She was hospitalized psychiatrically 5 years ago for severe depression with suicidal thoughts. Her medication regimen included Lamotrigine 200 mg daily, Bupropion XL 300 mg daily, and Trazodone 100 mg at bedtime as needed for sleep. The surgical team contacted the psychiatrist directly before Andrea’s visit for her evaluation. Both the surgeon and the program coordinator were extremely concerned about Andrea’s psychiatric history and reluctant to consider her a surgical candidate despite patient’s unparalleled enthusiasm and perfect adherence with nutritionist’s recommendations.
Case Vignette 2: Peggy
Peggy is a 50-year-old widowed female who was referred to the bariatric program by her primary care physician. Her BMI was 47 kg/m2. Her past medical history was significant for diabetes, osteoarthritis, and fibromyalgia. She had a past psychiatric history of anxiety and mild depression but was never treated with any psychotropic medications or hospitalized psychiatrically. She had no substance use history. The bariatric team had no concerns about her candidacy, but noticed that she missed 3 out of 5 required weight-loss support groups as well as the scheduled appointment with the program’s nutritionist.
13.2 Background
As described earlier in this book, obesity has reached epidemic proportions in the United States and worldwide [1]. Most conventional treatments for those with severe obesity have a modest and often short-lived effect in terms of weight loss and improvements in obesity-related disorders. Bariatric surgery is the only procedure that has been consistently shown to result in sustainable long-term weight loss and significant improvement in medical comorbidity [2]. Bariatric surgery is recommended for well-informed and motivated patients with a Body Mass Index (BMI) ≥40 kg/m2 or for individuals with a BMI ≥35 kg/m2 and one or more severe obesity-related comorbidities, such as type II diabetes, hypertension, hyperlipidemia, obstructive sleep apnea, nonalcoholic fatty liver disease, and gastroesophageal reflux disease [3]. Patients with a BMI of 30–34.9 kg/m2 with diabetes or metabolic syndrome may also be offered a bariatric procedure, although currently there is a lack of long-term data demonstrating net benefit [4].
13.3 Psychopathology in Bariatric Candidates
The current and lifetime rates of psychopathology in bariatric surgery candidates are very high. About one-third of patients presenting for a preoperative evaluation have at least one current Axis I diagnosis and over two-thirds have a lifetime history of any psychiatric diagnosis [5]. Recent meta-analysis of 59 published papers estimated that 23 % of bariatric candidates suffer from current mood disorder and about 17 % present with current eating disorder. The most common psychiatric disorders are depression (19 %), binge eating disorder (17 %), and anxiety (12 %) [6]. In addition, prevalence estimates are 9 % for history of suicidal ideations, 3 % for substance use disorders, and 1 % for Post-traumatic Stress Disorder [6]. While presurgical psychological evaluations may be helpful in identifying psychopathology, in prospective studies, preoperative psychiatric diagnoses have not been consistently linked to suboptimal weight loss, weight regain, or redevelopment of maladaptive behaviors [7]. A substantial proportion of bariatric candidates present themselves in an overly favorable light during the psychological evaluation, and there is low congruence between clinically derived and research-based diagnoses, which may impact accurate assessment.
Depression. As outlined earlier, depression is a significant comorbidity in obese individuals. Preoperative depression may impede postoperative weight loss, and higher depression scores after the surgery have been associated with less weight loss. However, some studies have reported that depression improves significantly after the surgery, but the improvement may begin to decline over time [2]. Dawes et al. [6] found that there is no clear evidence that preoperative depression affects weight loss. In addition, moderate-quality evidence supports findings that weight-loss surgery is associated with reduction in prevalence, frequency, and severity of depressive symptoms. This can be potentially related to improvement in body image and interpersonal relationships after massive weight loss, as well as possible alteration in brain biochemical signaling.
Self-harm and suicide. Existing evidence has identified an increased rate of suicide after bariatric surgery, as well as an increased rate of self-harm emergencies [8]. A systematic review of 30 studies suggested that suicide risk for patients undergoing bariatric surgery was four times higher than in the general population [9]. While the exact reasons for an increased risk of suicide in this population are unknown, several factors have been postulated, including possible depression and difficulty adjusting to changes in lifestyle and eating behavior [10], increased prevalence of a past history of suicide attempts (73 times higher than in the normal population) [11], disappointment with inadequate weight loss or subsequent weight regain [12], increased alcohol abuse after the surgery [6], or the lack of an antidepressant effect of ghrelin leading to depression and suicidal tendencies [13]. In addition, Bhatti et al. [8] recently reported that self-harm emergencies in bariatric patients (primarily medication overdose) increased by approximately 50 % in the 3 years after the surgery .
Eating disorders. The most common eating disorder in the presurgical candidates is binge eating disorder (BED) , and it is the second most common psychiatric disorder in this population, following major depressive disorder. Its rates vary from 4 to 49 % and are difficult to estimate primarily due to classification problems because the actual diagnostic criteria were not developed until the publication of DSM-5. Some studies suggest a relationship between preoperative BED and poorer outcomes, yet the majority of studies have not found this association. The impact of the development of BED postoperatively or the continuation of preexisting BED on bariatric surgery outcomes is another important issue and it is affected by surgical alterations causing inability to ingest large amounts of food. Therefore, some authors have proposed that the experience of loss of control over eating even small amounts of food should define binge eating in postsurgical population [14]. Very little is known about the prevalence of bulimia nervosa prior to bariatric surgery, perhaps due to denial or minimization of purging symptoms out of concern for surgical eligibility, as bulimia nervosa is considered a contraindication for bariatric surgery [4]. There have been reports of development of bulimia nervosa postoperatively; however, the actual rates are unknown. There is also a dearth of information about a lifetime history of anorexia nervosa in patients seeking bariatric procedures. Anorexia nervosa-like presentation appears to be quite frequent among patients receiving specialized care for eating disorders after the surgery and includes patients with significant weight loss, fear of weight gain, dietary restriction, and disturbances in self-perception of shape and weight [15]. In addition, it is important to remember certain behaviors after gastric bypass surgery that can be easily confused with disordered eating, such as vomiting, which frequently occurs in the short term after bypass surgery as patients adjust to their diminished intake capacity. It can also present in response to “plugging” when they experience the sensation of food being stuck in the stomach pouch, and it typically decreases as patients adjust and learn how to eat appropriately. However, these behaviors should be monitored as some patients will self-induce them as a means of weight loss or to prevent weight gain after the surgery [14].
Anxiety disorders. Prevalence estimates for anxiety disorders (including generalized anxiety disorder and social phobia) in bariatric population vary from 12 to 24 % at the time or presurgical evaluation, and are even up to 37.5 % for a lifetime diagnosis of anxiety disorder [7]. In addition, the rates seem to remain the same after the surgery [16]. Studies of association of anxiety and postoperative outcomes have yielded inconsistent findings, and most recent meta-analysis of available research evidence reported no association between anxiety and postsurgical weight loss [6].
Substance use disorders. A lifetime history of substance use disorder is more likely in bariatric surgery candidates compared with general population [17]. About one-third of patients have a lifetime history of alcohol use disorder [7]. In contrast, current rates of alcohol and substance use are only around 3 % and are much lower than in general population [4]. Following RYGB there are certain changes in pharmacokinetics of alcohol, including accelerated alcohol absorption, higher maximum alcohol concentration, and a longer time to eliminate alcohol. Similar changes have been demonstrated in patients following sleeve gastrectomy. These alterations have been postulated to cause increase in alcohol consumption and increased rates of alcohol use disorders after the weight-loss surgery [6]. Overall, the literature regarding the impact of alcohol and substance use disorders on weight-loss outcomes is mixed. It has been suggested that the patients who fail to make lifestyle changes in regards to their substance use may fail to make other changes (including dietary) and it could impact their outcomes long term. There is a general consensus that patients with current substance use disorders should delay surgery until their problem is addressed [18]. It may be useful for patients to agree to toxicology screening as a part of their treatment plan. Bariatric candidates should be warned about increased risk for alcohol use disorders after the surgery and may be advised to avoid all alcohol after the procedure [19]. According to national statistics, cannabis (marijuana) is the most commonly used illicit drug in the USA, and its use among young people has been increasing since 2007. However, no empirical research has examined the effects of cannabis use after the weight-loss surgery. A review of the obesity surgery literature revealed that many practitioners generalize from data regarding alcohol abuse to all substances, and for the majority of the programs cannabis use remains a contraindication to bariatric surgery [20].
Thought disorders. There is a very limited research that has examined whether bariatric surgery can be safe and effective in patients diagnosed with thought disorders, including schizophrenia. As discussed in contraindications section of this chapter, these patients are typically denied the surgery despite overall lack of research to support this recommendation. Patients with thought disorders exhibit deficits in memory, attention, and executive functioning and similar cognitive deficits are associated with obesity across the lifespan and can be further exacerbated by medical comorbidities such as sleep apnea and type II diabetes [7]. It has been reported that patients with thought disorders have similar weight-loss outcomes as matched controls; however, their underlying psychopathology may worsen following the surgery [21].
Psychotropic medications use in bariatric population. Almost half of individuals seeking bariatric surgery report current use of psychotropic medications, which is more than six times higher than in general population. Overwhelming majority reports taking antidepressants (87.7 %), followed by anxiolytics (9.6 %) and mood stabilizers (2.7 %) [22]. In addition, most patients continue using antidepressant medications after the surgery [23]. Current research supports the need for careful monitoring of psychiatric medication use and ongoing monitoring of patients’ psychiatric symptoms after the surgery, especially in malabsorptive procedures. Reduced antidepressant levels can occur immediately postsurgery, leading to discontinuation syndrome and adverse effects, and they can remain decreased up to 1 year after the procedure [24]. Alterations in pharmacokinetics of psychotropic medications are not very well understood and can be affected by the type of surgical procedure, the changes in the gastrointestinal tract milieu, and medication solubility and availability (see Chap. 20 for further details). It is important to remember that the vast majority of patients prescribed medications receive them from their primary care physician and they may benefit from referral to a mental health professional that is familiar with taking care of bariatric surgery patients [25].
13.4 Mental Health Evaluation
Unlike many other surgical and medical procedures, both short-term and long-term outcomes associated with weight-loss surgery are dependent on psychological and behavioral factors present before and after the surgery. Successful bariatric outcomes are not only dependent on the surgical procedures but also require significant and lifelong changes in eating patterns and physical activity. At the same time, weight-loss surgery has wide-ranging and profound psychosocial effects. Thorough and specialized preoperative psychosocial assessment is an important part of a comprehensive bariatric treatment protocol [26]. This is endorsed in the 2013 update for the clinical practice guidelines for the preoperative nutritional, metabolic, and nonsurgical support of bariatric candidates [4]. Based on the survey of present practices, preoperative psychosocial assessment has become the standard of care in about 90 % of centers offering weight-loss surgery [27], and it is required for bariatric surgery centers to be nationally accredited by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery . There is a growing emphasis that the preoperative psychosocial assessment at the very minimum should be used to identify possible contraindications for surgery, such as uncontrolled substance use or poorly controlled mental illness [4]. More comprehensive evaluation can provide information that can guide treatment planning and provide recommendations to both the patient and surgical team that are aimed at facilitating the best possible outcomes [28]. While there may be psychological reasons for denying clearance for surgery, it has been stressed that the evaluation is not only diagnostic and that it should not be seen as a gatekeeper, but as an opportunity to provide support and education. It can be an intervention preparing the candidates for required postsurgical behavioral changes and it can help challenge unrealistic weight-loss expectations that patients may have [29]. The psychosocial evaluation of weight-loss surgery candidates should be a multifaceted process that can serve many functions. On one hand, it can help enhance the patient’s readiness for weight-loss procedure through increasing knowledge of surgery and postoperative behavioral regimen. On the other hand, it can help minimize the barriers to optimal weight-loss outcomes through identifying and addressing potential postoperative challenges and establishing ongoing connection with behavioral health providers [30]. In addition, it can be an invaluable contribution to the interdisciplinary bariatric team, through reducing clinic burden, helping managing risk and liability, and providing comprehensive guidance [26].
13.4.1 Process of the Evaluation
Psychosocial evaluation, as well as pre- and postoperative support are essential in the process of weight-loss surgery, but are not recognized as a formal area of specialization.
Specific testing methods, evaluator credentials , and the degree to which results of the assessment influence surgical decision making vary among bariatric programs and might be influenced by local or national quality criteria to which particular center adheres [31]. According to the best practice update of evidence-based guidelines for psychosocial evaluation and treatment of weight-loss surgery patients, assessment should be performed by a social worker, psychologist, or psychiatrist with a background and at least some experience in pre- and postoperative assessment of bariatric candidates [17]. Most mental health professionals involved with bariatric programs report approximately a 4-year experience performing presurgical evaluations [32]. Based on the survey of 103 psychologists who indicated that they provided presurgical evaluations, about one-third of them (34 %) reported having done 101–500 evaluations, and 19 % of responders reported having completed over 500 evaluations. The amount of experience required to establish competence in this task remains unknown [33]. It has been stressed however, that because of special requirements of the bariatric population, and the need to prepare patients for variety of lifestyle changes, as well as the need to detect and treat disordered relationship with food, mental health providers should be familiar with medical psychology [27]. About 26 % of the weight-loss surgery programs in the US have their own mental health professional on staff, and 65 % refer patients to mental health providers in their community . Only 6 % allow patients choose their own provider for the evaluation. Most frequently the professional conducting evaluation is a clinical psychologist, followed by psychiatrist and master level professional [27]. While there is a considerable variability in the content of presurgical psychosocial assessment across different bariatric centers, information is typically gathered via a clinical interview and administration of self-report questionnaires [2]. More than half of the programs use formal psychological testing as a part of the assessment. Despite the frequency of use of psychological testing, there are little guidelines available on which tests should be utilized to assess patient suitability for surgery. Commonly used symptom inventories or screening instruments assess symptoms of depression, eating disorders, and anxiety disorders. They include the Beck Depression Inventory (BDI-II) , which has demonstrated satisfactory internal consistency and validity in bariatric surgery population [31], and Minnesota Multiphasic Personality Inventory (MMPI-2) which assesses psychiatric and personality traits and has been found reliable and valid to use in this population [34]. The Symptom Checklist-90-Revised (SCL-90-R) has also been validated in bariatric surgery patients and its hostility scale was predictive to the adherence to treatment plans [35]. Other tests used in the process of evaluation of bariatric candidates include Eating Disorder Inventory-2 , Beck Anxiety Inventory , Eating Disorders Examination (EDE-Q) , Binge Eating Scale , and cognitive measures, such as Mini Mental Status Exam [27, 32, 33].
13.4.2 Psychosocial Contraindications for Weight-Loss Surgery
While there is a growing emphasis on preoperative psychosocial assessment, ineligibility criteria are discussed infrequently in the literature. To this date research has not identified consistent contraindications to weight-loss surgery. This may be because mental heath professionals may have different approach and may use different criteria when evaluating bariatric candidates for distinctive weigh-loss surgical procedures, as gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB) carry different risks, produce different mean weight loss, and have different postsurgical requirements [32]. In addition, ethical concerns are raised whether psychosocial characteristics should disqualify patients from the most effective weight loss and potentially a lifesaving treatment [31]. Clinical practice guidelines published in 2013 list only substance abuse, poorly controlled psychiatric illness, and bulimia as clear contraindications to the surgery [4]. There is a general consensus that a psychiatric disorder per se should not be an exclusion criterion for bariatric surgery. Nevertheless, there may be psychiatric reasons to delay or deny surgery [36]. Based on the survey of present practices in 2005, the most commonly endorsed definite psychosocial contraindications for surgery included: current illicit drug use (88.9 %), active and uncontrolled symptoms of schizophrenia (86.4 %), severe developmental disability with IQ below 50 (81.5 %), heavy alcohol drinking (77.8 %). Most frequently reported possible contraindications included presence of an eating disorder, symptoms of bipolar disorder, and history of suicide attempts [27]. The survey of mental health professionals performing bariatric evaluations by Fabricatore in 2007 yielded similar results, with substance abuse or dependence, eating disorders, psychotic disorders, depression, suicidal ideations, and suicide attempts being cited as most common psychiatric contraindications [32]. To summarize, the most common reasons for deferring bariatric surgery are significant psychopathology such as active psychosis (including thought disorder symptoms), current substance dependence, untreated eating disorders (specifically anorexia nervosa or bulimia nervosa), untreated depression, and/or active suicidal ideation [2]. In addition, inadequate knowledge about the surgery resulting in inability to provide informed consent, unrealistic expectations for weight loss, and lack of social support have most frequently been reported as nonpsychiatric contraindications [2, 27, 32, 33, 36].
13.4.3 Key Elements of the Evaluation
The American Society for Metabolic and Bariatric Surgery divided the key elements of the assessment into four main categories, as outlined in the guidelines published in 2004: behavioral, cognitive and emotional, psychiatric, and current life situation. One of the first published clinical psychosocial assessment tools—the Boston Interview for Bariatric Surgery provided a standardized approach to interviewing patients for bariatric surgery. It has been widely used since its publication in 2004; however, procedures for psychosocial evaluations have remained quite varied across different bariatric programs [37]. Wadden and Sarwer [38] published the model of assessment that incorporated a self-report instrument called WALI—the Weight and Lifestyle Inventory . It is focused on the same areas of evaluation, with emphasis on patient-oriented approach. Recently, Thiara et al. [39] developed a comprehensive tool called the Toronto Bariatric Interprofessional Psychosocial Assessment of Suitability Scale (BIPASS) and assessed its reliability and validity using retrospective patient data in a multiprofessional clinical setting (see Appendices). The significance of the BIPASS lies in its ability to standardize the psychosocial assessment process and increase the rigor in identifying psychosocial risks that warrant further intervention before the surgery. The use of clinical assessment tools such as the BIPASS could streamline the decision-making process when determining surgical candidacy by reducing clinician bias and presenting pertinent psychosocial information in a succinct and reliable manner. It could also help standardize the psychosocial assessment process across the bariatric centers, guide future research directions, and improve clinical outcomes. Although to this date a standardized protocol for preoperative psychological evaluation does not exist, there is a general consensus among bariatric surgery centers, that the domains that should be assessed include: weight history, current and past weight-loss attempts, eating and diet behavior, eating pathology, current and past psychiatric functioning, substance use, medical history, understanding and knowledge about the surgery and pre- and postsurgical behavioral change requirements, motivation and expectations about surgery, physical activity, and relationships and support system [4, 17, 18, 29, 31, 38].
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