e-mail: ns@mblcommunications.com


Dr. Sussman is editor of Primary Psychiatry and professor of psychiatry at the New York University School of Medicine in New York City.

Dr. Sussman reports no affiliation with or financial interest in any organization that may pose a conflict of interest.



The clinical use of psychostimulants to treat attention-deficit/hyperactivity disorder (ADHD) is widespread, but the neural mechanisms responsible for their cognition-enhancing/behavioral-calming have never been adequately explained. This lack of clarity makes it more difficult to address criticisms that these drugs are not effective or are harmful. The fact is that stimulants are high on the list of controversial psychotropic medications. Apart from unanswered questions about how these drugs work, a major reason for concern about the use of drugs like amphetamines and methylphenidate is that they have a potential for diversion for recreational use, or some argue, may result in abuse among those who use them therapeutically. Another source of controversy is the fact that these agents are primarily used to treat children and adolescents with ADHD, a diagnosis that itself is actively questioned in the press. Most recently, there have been reports that influential researchers at Harvard Medical School may not have adequately disclosed the extent of their relationships with manufacturers of ADHD medications; these reports have raised additional questions about the validity of some studies that show very favorable risk-benefit profiles when these drugs are used to treat ADHD.1 Not being a specialist in child in adolescent psychiatry, nor having ever done research or consulted for a marketer of psychostimulants, I can only make observations based on my reading of the literature, reports from my patients, and accounts from patients’ family members.

The following are the basic benefits of stimulants. First, among hyperactive patients, the stimulants improve their ability to absorb and integrate information. They also become more focused and attentive. Second, when effective, drugs work rapidly, even within one day. A typical response is “I never thought this could be so easy.” The benefits are usually unmistakable. Last, there is an improvement in self esteem as a response to improved academic performance and a reduction in household tension that may have previously arisen from failure to do homework, reports of behavioral problems in school, and sloppiness at home.

Understanding how a drug works—demystifying its mechanism of action—can go a long way in overcoming excessive skepticism or antipathy to a psychotropic agent. It can also help in the development of more effective or better-tolerated medications. It may be helpful that researchers have made recent progress in explaining how these drugs work. Findings from research on rats that appeared in Biological Psychiatry,2 for example, suggest work by “fine-tuning” neuron activity in the prefrontal cortex, the part of the brain responsible for filtering out distractions and helping people to focus on tasks. University of Wisconsin-Madison researchers Devilbiss and Berridge2 report that methyphenidate “fine-tunes” neuronal activity in the prefrontal cortex. This is the brain region involved in attention, decision-making, and impulse control. Of particular interest  is that the medication had little or no effects on other areas of the brain.

To investigate, Devilbiss and Berridge2 attached tiny electrodes to individual neurons in the brains of normal rats and watched how different doses of the drug affected neuron activity. This is an important study because it seeks a more scientific explanation for the cognition-enhancing/behavioral-calming actions of these drugs.

The usual response to the question of “How do these drugs work?” has been to say that they raise brain activity of the catecholamine neurotransmitters, dopamine and norepinephrine. This study2 provides a more complex but more specific explanation. According to the authors, the study showed that cognition-enhancing doses of methylphenidate…


“…increase the magnitude of both excitatory and inhibitory responses of pre-frontal cortex [PFC] neurons while simultaneously reducing the duration of the inhibitory response. Low-dose methylphenidate also produced ‘gating,’ resulting in a larger number of PFC neurons responsive to CA1-subiculum input. Combined, these observations suggest that low-dose methylphenidate increases both the sensitivity of PFC neurons and the pool of responsive PFC neurons in a more complex manner than simply regulating the level of PFC excitability (ie, gain of neuronal activity), consistent with known actions of catecholamines on cortical neurons.”

A major concern about the use of stimulants is their potential for abuse. In May 2008, the American Journal of Psychiatry published an article3 that suggested there was little or no evidence that the use of stimulants to treat children increased subsequent risk of substance abuse. The study involved >100 young men 10 years after they had been diagnosed with ADHD. The investigators reported that their findings support the hypothesis that stimulant treatment does not increase the risk for subsequent substance use disorders.

In fact, ADHD drugs may be safer in terms of abuse potential and general medical health than the general public believes. Because of unwarranted reluctance to seek help for themselves or their children, many patients suffer needless frustration, poor self-esteem, and both academic and career difficulties. I hope that, as we learn more about the underlying neurobiology of ADHD and the mechanism-of-action of drugs that treat it manifestations, the idea of seeking treatment will become more prevalent and the types of treatment options will expand. PP



1.    Harris G, Carey B. Researchers fail to reveal full drug pay. New York Times. June 8, 2008. Available at: www.nytimes.com/2008/06/08/us/08conflict.html. Accessed July 21, 2008.
2.    Devilbiss DM, Berridge CW. Enhancing doses of methylphenidate preferentially increase prefrontal cortex neuronal responsiveness. Biol Psychiatry. 2008 Jun 26. [Epub ahead of print].
3.    Biederman J, Monuteaux MC, Spencer T, Wilens TE, Macpherson HA, Faraone SV. SStimulant therapy and risk for subsequent substance use disorders in male adults with ADHD: a naturalistic controlled 10-year follow-up study. Am J Psychiatry. 2008;165(5):597-603.

Letter to the Editor

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Adam Keller Ashton, MD
Primary Psychiatry. 2008;15(8)


To the Editor:              

I read Dr. Ginsberg’s comments in the August 2007 Primary Psychiatry1 on aripiprazole’s off-label use for augmentation of established therapy for the treatment of obsessive-compulsive disorder.2 I wanted to alert you that I had written what I believe was the first such report, at least according to the manufacturer Bristol-Myers Squibb (personal communication, September 7, 2007). In January 2005 I reported a woman who had failed trials of six adequately dosed selective serotonin reuptake inhibitors (SSRIs) and clomipramine, as well as having had a course of cognitive-behavioral psychotherapy.3 This patient subsequently improved to what she felt was “55% better” with a combination of sertraline 200 mg/day along with escitalopram 30 mg/day. However, she experienced the most improvement with aripiprazole augmentation using 30 mg/day in addition to her two SSRIs, stating she was now “70%” improved; she has maintained this improvement thus far for >2 years. This report was not referenced in the column1 as I have since discovered that the journal in which it was published does not subscribe to the larger medical reference services.

Case reports such as these are plagued by limitations including small sample size and the possibility of placebo response, although the latter would be unlikely after failing many prior agents as well as experiencing an enduring clinical improvement over the course of years. Nevertheless, I was encouraged to read of this latest example of aripiprazole augmentation as it reinforces what I, too, have seen on occasion, namely, the non-psychotic patient with refractory anxiety who seems to inexplicably respond to the addition of an atypical antipsychotic. Further research in this area will hopefully shed light on which patients may be good candidates for this kind of clinical approach. At the least, reports such as these stimulate academic dialogue and hopefully encourage clinicians to report their findings in peer-reviewed journals.

Adam Keller Ashton, MD

Dr. Ashton is clinical professor of psychiatry at the State University of New York at Buffalo School of Medicine.

Disclosure: Dr. Ashton has been on the speaker’s bureaus of AstraZeneca, Bristol-Myers Squibb, Cephalon, Eli Lilly, Forest, GlaxoSmithKline, Pfizer, sanofi-aventis, Sepracor, Takeda, and Wyeth.



1. Ginsberg DL. Psychopharmacology reviews. Primary Psychiatry. 2007;14(8):19-20.
2. Friedman S, Abdallah TA, Oumaya M, Rouillon F, Guelfi JD. Aripiprazole augmentation of clomipramine-refractory obsessive-compulsive disorder. J Clin Psychiatry. 2007;68(6):972-973.
3. Ashton AK. Aripiprazole augmentation of combination escitalopram and sertraline in the treatment of refractory obsessive-compulsive disorder. Psychiatry. 2005;2(1):18-19.



I extend my sincere thanks to Dr. Ashton for sharing with us his case report. I agree with his comment that gaining better insight into candidate selection for off-label approaches such as the one here is very important to pursue. Our patients’ needs demand it.

David L. Ginsberg, MD

Dr. Ginsberg is Vice-chair of Clinical Affairs in the Department of Psychiatry at New York University Langone Medical Center in New York City, and author of the Primary Psychiatry column “Psychopharmacology Reviews.”

Disclosures: Dr. Ginsberg receives hororaria for lectures, papers, and/or teaching from AstraZeneca and GlaxoSmithKline; and receives research support from Cyberonics.

Please send letters to the editor to Primary Psychiatry, c/o Norman Sussman, MD, 333 Hudson St., 7th Floor, New York, NY 10013; E-mail: ns@mblcommunications.com.


Dr. Franks is associate professor in the Department of Psychiatry and Ms. Kaiser is doctoral candidate in health psychology at the University of North Texas Health Science Center in Fort Worth, Texas.

Disclosures: The authors report no affiliation with or financial interest in any organization that may pose a conflict of interest.
Please direct all correspondence to: Susan F. Franks, PhD, 3500 Camp Bowie Blvd, University of North Texas Health Science Center, Department of Psychiatry, Fort Worth, TX 76107; Tel: 817-735-5122; Fax: 817-735-0615; E-mail: franks@hsc.unt.edu.



Focus Points

• Bariatric surgery candidates are psychologically heterogeneous.
• The preoperative psychological evaluation provides recommendations for optimizing outcomes.
• Psychological risk factors reducing post-operative success must be uniquely considered for the individual patient.



What are the psychological characteristics of bariatric surgery candidates? What components of the preoperative psychological evaluation are the most relevant to postsurgical outcomes? Bariatric surgery is a weight-loss tool that can resolve obesity-related comorbidities and improvements in quality of life. The degree of success experienced by patients depends largely on their ability to maintain postsurgical lifestyle changes affecting weight loss and maintenance. Understanding the psychological and behavioral issues unique to bariatric patients is important for primary care and mental health providers so that pre- and postsurgical treatment recommendations are developed to optimize outcomes.



Bariatric surgery is more common in the United States due to the increasing rate of morbid obesity, advances in surgical techniques, and accessibility of the procedure.1,2 Based on the 1991 National Institutes of Health Consensus Development Panel recommendations3-5 and psychological and behavioral factors impacting obesity and weight loss in conventional programs, it has been widely believed that a presurgical psychological evaluation is valuable to bariatric surgery candidates. While initial hopes were to determine a clear set of prognostic indicators serving to screen those who would not be successful,6,7 it is increasingly clear that this oversimplifies a more complex phenomenon.8,9

Recently, there has been a conceptual shift in the role of the preoperative psychological evaluation.10 In addition to identifying patients who may clearly be unsuitable for the procedure, the preoperative evaluation can be designed to identify risk factors and formulate treatment plans to improve postsurgical outcomes.8 This article provides a clinical-educational review of published data regarding the crucial elements of the preoperative psychological evaluation, highlighting key risk factors of prognostic value that may be used to improve patient outcomes.



The relevant literature was identified through a search on PubMed, MedLine, and PsychInfo. Several reviews, published between 2003 and 2006,9,11-13 were identified that covered a scope similar to this article. To build on these reports, the authors performed a comprehensive review of empirical studies published from January 2003 to March 2008. Articles were excluded if they were in certain categories, including non-English language, adolescent samples, case or questionnaire validation studies, surgical technique, nursing concerns, general commentaries, or <1-year postsurgical follow up. In order to increase the likelihood of adequate statistical power, reports with total sample sizes of <50 were also excluded. Otherwise, articles published between January 2003 and March 2008 that meet the aforementioned criteria were included in this article.

The organization of this article is based on clinical utility. This method of presentation will allow the clinician to process multiple sources of information in a manner consistent with standard training and clinical practice. Elements of the preoperative evaluation are presented as they are customarily organized in a standard diagnostic intake. Table 1 provides commonly used acronyms and their definitions.






The most frequently examined demographic variables were age, gender, and race/ethnicity. Although studies were restricted to investigation of presurgical differences, the present article focuses on how select demographic differences may be related to postsurgical outcomes alone or in combination.



A recent study examining age and gender differences found that older males had the least percent excess weight loss (%EWL).14 Other studies comparing gender directly to postsurgical outcomes have not found a significant relationship.15,16 However, the low proportion of male subjects (16.9% to 24%) in these studies may have obscured the possible influence of gender.

Age has been demonstrated to be a factor in weight-loss outcomes in three of the four studies reviewed.14,15,17,18 Based on a 50% EWL success criterion in a sample of 1,081 subjects followed for 2 years, significant odds ratios for failure were found for patients with higher age, higher initial body mass index (BMI), and lack of either recovery or increased levels of physical activity.17 Others found that while the older patients did not lose as much weight as their younger counterparts, their rates of comorbidity resolution were similar.18

In a recent study19 of 213 African American and Caucasian bariatric surgery candidates matched for age, gender, and presurgical BMI, a lower %EWL was found for African Americans at 3 years postsurgical follow up. Both groups had similar rates of comorbidity resolution. Others have found no difference in %EWL between African Americans and Caucasians. However, the low percentages of African Americans (5.5%) in this study may have interfered with the validity of the findings.20


Medical History

Existing medical factors in bariatric surgery candidates have been an important consideration in approval for surgery, surgical procedure selection, and medical management. Two studies21,22 indicated that diabetics were at greater risk for lower %EWL from 1–2 years post-surgery In one sample21 of 494 subjects, when controlling for age, gender, depression, and baseline weight, diabetes remained a significant predictor of lower %EWL. A review of insurance claims cases (N=1,760) indicated that preoperative sleep apnea or GERD were most predictive of postoperative complication risks.23


Psychiatric History

Recent studies utilizing the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID) to examine a history of diagnosable psychiatric conditions have consistently estimated an approximately 37% lifetime prevalence rate for any Axis I disorder. However, there was less agreement regarding lifetime prevalence rates for specific disorders, even when utilizing the same methodology. Table 2 provides a summary of lifetime prevalence rates for Axis I disorders.24-29



Previous reviews of the literature resulted in slightly differing conclusions regarding the importance of psychiatric history on outcomes of bariatric surgery. While some concluded that a history of psychiatric inpatient admissions were related to postsurgical medical/psychological complications and poor patient satisfaction, the admission number was not related to weight loss.7,9 Prior outpatient treatment was not significantly related to any outcome variable studied. Others found that a history of psychiatric treatment or counseling for substance abuse was a positive predictor for postsurgical weight loss attributable to the development of adaptive lifestyle skills that may generalize to postoperative behavioral and psychological challenges.13


Psychosocial History

Aspects of the psychosocial history of bariatric surgery candidates have been examined for their prognostic role in postsurgical success. These have included childhood abuse and maltreatment, marital status, social support, and psychosocial stress.

Childhood Sexual Abuse and Maltreatment
Utilizing the Childhood Trauma Questionnaire (CTQ), approximately 65% to 69% of patients undergoing Roux-en-Y gastric bypass (RYGB) reported some form of childhood maltreatment estimated to be 2–3 times higher than that found in normative community samples.30,31 Estimated rates of childhood sexual abuse varied widely among studies. When responding to questioning, between 17% and 50% of RYGB candidates reported a history of sexual abuse.32,33 However, in response to the CTQ, approximately 30% of RYGB patients were found to have a childhood history of sexual abuse.30,31,34 Use of the CTQ also determined rates of approximately 47% for childhood emotional abuse, and 29% to 40% for physical abuse.30,31 Physical and emotional neglect were estimated at 32% and 49%, respectively.30 Although BMI in RYGB candidates has not been related to childhood maltreatment, the results of studies examining the relationship between childhood maltreatment and psychopathology have been conflicting.30,31

Specific forms of childhood maltreatment other than sexual abuse have not been studied with regard to bariatric surgery outcomes. Two articles9,13 differed in conclusion regarding the prognostic significance of childhood sexual abuse. Recent studies33,34 comparing patients with and without a history of childhood sexual abuse did not find it to be of prognostic significance at 12 and 24 months post-surgery. Table 3 provides a summary of recent articles related to childhood sexual abuse and postsurgical outcomes.21,33-38



Marital Satisfaction
Two recent reviews of the literature found conflicting results regarding the role of marital satisfaction on weight-loss outcomes in bariatric surgery patients. Herpertz and colleagues39 found that marital dissatisfaction was a positive predictor of weight loss. However, van Hout and colleagues9 suggested that marital satisfaction positively affected weight loss and that problematic marital relationships could potentially create challenges as the patient lost weight.

Support System
A previous review reported that social support in bariatric patients was an important determinant of adherence to postsurgical lifestyle modifications and may affect weight loss.13 However, others concluded that although low levels of social support were associated with postoperative medical and psychological complications, it had no bearing on weight loss.39

Psychosocial Stress
In comparison to treatment-seeking women with mild and moderate obesity, women with severe obesity seeking bariatric surgery reported experiencing higher levels of stress related to health, legal, or financial matters.40 High levels of preoperative life stress may be positively associated with weight loss, and patients have been found to experience the same positive physical and psychological well-being after surgery regardless of stress level.9,39


Other Issues

Body Dissatisfaction
According to a recent review,41 approximately 70% of patients reported body dissatisfaction prior to surgery. Limited research suggested patients with childhood-onset obesity showed less satisfaction with postsurgical weight and shape than patients whose obesity developed in adulthood.41 Although less presurgical body dissatisfaction has been correlated with greater weight loss, a causal relationship with postsurgical weight loss has not been established.

Studies utilizing self-esteem measures have reported lower self-esteem in bariatric surgery candidates than in normal weight reference groups.41 A comparison study of patients in different weight classification groups found that severely obese bariatric candidates were lower in self-esteem than patients in the lower-level obesity classifications.40 A previous review by van Hout and colleagues9 found conflicting results with regard to the impact of self-esteem on postsurgical weight loss.

Personality Traits
Herpertz and colleagues39 concluded that there was insufficient evidence to support the prognostic value of personality traits with regard to postsurgical weight loss or mental health outcomes. Van Hout and colleagues42 recently utilized a cluster analytic approach to investigate psychological profiles in 153 candidates for vertical banded gastroplasty (VBG). Results confirmed the heterogeneity of the group, indicating three distinct clusters ranging from high to low functioning on a variety of domains, including personality, coping, eating behavior, locus of control, body attitude, social functioning, and health-related quality of life (HRQOL). They suggested that the heterogeneity of bariatric surgery candidates and the reliance on psychological measures not specifically obesity-related may account for the inconsistent findings across studies.


Current Psychiatric Status

Current prevalence rates of specific Axis I pathologies varied widely across studies due to methodologic differences in determining diagnosis.27,40,43-45 For example, clinician-formulated impression determined major depressive disorder (MDD) as the most common Axis I diagnosis,27 whereas the use of the SCID ranked MDD as third most prevalent behind anxiety disorders and eating disorders.45 Recent data indicated that prevalence rates of psychiatric disorders based on the use of formal diagnostic criteria appear to match findings in the general population.45 However, studies of psychopathology have consistently found greater preoperative rates in severely obese patients seeking bariatric surgery as compared to the general population, non-treatment seeking obese individuals, and mild-to-moderately obese treatment-seeking patients.40,43,44 Furthermore, several studies reported sizable numbers of surgical candidates undergoing psychiatric treatment at the time of their evaluation, ranging from 38.9% to 47.7%.10,27 Table 2 provides a summary of prevalence rates for current Axis I disorders.

An absence of psychiatric problems and personality disorders has been associated with greater weight loss and positive postoperative psychosocial outcome.39 Although there has been little systematic study on clinical practice decisions based on preoperative psychological evaluations, Pawlow and colleagues10 reported that recommendations were made to defer surgery for 15.8% of their 449 patients based on a diagnosis of MDD, either as sole or primary psychiatric diagnosis. Sarwer and colleagues27 reported a psychiatric referral rate of 26.7% in their sample of 90 patients evaluated for RYGB and VGB. Slightly >50% of 58 patients diagnosed with a form of psychopathology were undergoing psychiatric treatment at the time of their presurgical evaluation.

The use of SCID-based DSM-IV criteria has yielded substantially lower estimates of MDD (3.4% to 10.4%)24,25,45 than the use of depression questionnaires21 or clinician-driven diagnostic determinations (31.1% to 44.9%; Table 2). Prevalence rates for dysthymia ranged between 1.1% and 5.7%.24,25,45 Based on available empirical evidence, it appears that depression does not prevent postsurgical success. An article by van Hout and colleagues9 found that in many studies, depression predicted less weight loss than in non-depressed patients but was not prognostic of overall failure or success. Rather, bariatric surgery in depressed patients generally appeared to result in significant treatment gains with respect to weight loss, psychosocial function, and quality of life.41,46 Recent follow up with preoperatively depressed patients found that depression was not a negative predictor for postoperative success based on %EWL or HRQOL,21 and in some patients it may promote greater weight loss over the short term.21,35 Table 3 provides a summary of articles related to depression and postsurgical outcomes.

It should be noted that approximately 33% to 50% of bariatric surgery candidates may already be taking antidepressants or be in some other form of psychological treatment prior to surgery, which was not accounted for in these studies.10,27 Pawlow and colleagues10 found antidepressants were the most commonly prescribed psychotropic medication in the 47.7% of 153 patients who were taking at least one psychotropic at the time of their evaluation.10 It was unclear whether these were prescribed for depression or other psychiatric reasons. However, these were most often prescribed by primary care physicians.27

Despite recent findings of considerable prevalence rates, anxiety appears to have been under-recognized in bariatric surgery candidates. There is disagreement between studies regarding rates for specific disorders (Table 2). The role of anxiety in postsurgical outcomes has not been well studied, perhaps due to the assumption that it is largely related to the societal stigma and bias experienced by obese people.24,28 Limited evidence suggested that the presence of anxiety as a correlate of psychosocial stress may be positively associated with weight loss.9,39 At 2-year follow up in the Swedish Obese Subjects study, declining levels of distress were found with increased weight loss.47

Binge Eating Disorder
Prevalence rates of binge eating disorder (BED) and binge eating of any kind in bariatric surgery candidates have been highly variable.25,27,29,36-38,45,48 Previous research has found that most studies reported significant postsurgical weight loss in bariatric patients with BED or binge eating behaviors, although some studies found a smaller percent weight loss for this group than patients without similarly disordered eating.9,13,39,49,50 Patients who develop or redevelop binge eating behaviors postsurgically were found to experience more weight regain at long-term follow up.9,39,50

Recent studies of RYGB and laparoscopic adjustable gastic banding (LAGB) patients have consistently found no significant differences in %EWL between BED and non-binge eating (NBE) for follow-up periods of 1–5 years.33,36,37 However, one prospective study found that patients with a presurgical diagnosis of BED or sub-clinical BED showed less %EWL than NBE at 2-year follow up.38 In a recent study of LAGB patients,37 those with a presurgical diagnosis of BED had a higher frequency of manageable postsurgical complications and underwent more band adjustments than their non eating-disordered counterparts. No differences in postsurgical medical complications between patients with and without BED have been reported for patients undergoing RYGB, suggesting that restrictive procedures hold particular challenges for patients who do not normalize their eating behavior postsurgically. Table 3 provides a summary of articles related to BED and postsurgical outcomes.

Somatization and Hypochondriasis
Only one study28 examining Axis I prevalence rates deteremined the presence of somatization disorder (29.3%) and hypochondriasis (15.0%) in a sample of 294 patients (RYGB candidates) who were evaluated with a screening questionnaire. These findings were attributed to characteristic obesity-related physical concerns and problems. Using the Minnesota Multiphasic Personality Inventory-2 (MMPI-2), higher presurgical elevations of the hypochondriasis and hysteria scales were found for RYGB patients with <50 %EWL as compared to those with >50 %EWL at 1-year follow up.51 However, neither of these two MMPI-2 scales were above the clinical cut off.51 Relationships have been found between the presence of at least one lifetime and current Axis I disorder with BMI, pain, and health-related role limitations.24 The propensity toward somatic focus is unclear as it relates to postoperative outcome.

Personality Disorder
Prevalence rates of Axis II pathologies were generally consistent across studies, ranging from 19.5% to 29%.24,25 The highest prevalence rates were found for Cluster C disorders at approximately 18%, with avoidant personality disorder at 6.8% to 17% and obsessive-compulsive personality disorder between 7.6% and 13.9%.25 Previous articles concluded poor postsurgical weight loss was likely for bariatric candidates with personality disorder due to poor adaptive skills and lack of insight.12,13 Concerns have also been raised regarding the ability of patients with borderline personality disorder to remain stable under the stress inherently associated with any major surgical procedure.13


Eating Patterns

Eating behaviors that have been the subject of recent empirical studies include grazing, night eating syndrome, and emotional eating. Grazing has been a factor in some patients both pre- and postoperatively,52 but the effect on weight loss has not been empirically studied. Table 4 provides a summary of recent studies on eating behavior and outcomes.53-57



Eating Behavior
Aside from the maladaptive eating patterns previously discussed, general eating behavior has been the subject of numerous measurement tools to determine increased risk for disordered eating or obesity (eg, Three-Factor Eating Questionnaire [Eating Inventory], Dutch Eating Behavior Questionnaire, Questionnaire on Eating and Weight Patterns-Revised, Eating Disorders Inventory, Weight and Lifestyle Inventory). Many of these tools have applied slightly different names for the same general constructs of cognitive restraint, disinhibition and hunger described by Stunkard and Messick.58 Bariatric surgery patients have been shown to fall anywhere in the spectrum of these factors. Data59,60 indicated that Eating Inventory scores for hunger and disinhibition drop to the “low-average” range up to 1-year post-LAGB, but whether these changes are stable is unknown.

Recent studies evaluating postsurgical weight loss as related to changes in eating behavior all highlight the importance of this component of postsurgical management.53,54,56,57,61,62 Patients have generally reported that they do not experience hunger in the early months following surgery. If patients are not prepared to cope with a return of hunger cues or a tendency to eat despite a lack of hunger cues, the efficacy of the surgery as a weight-loss tool may be diminished.



Results of the present review highlight the heterogeneity of bariatric surgery candidates, resulting in inconsistent and often conflicting results between studies examining presurgical characteristics and postsurgical outcomes. However, patterns emerge of which the clinican should be alert. This will promote evidence-based decision making and treatment recommendations on behalf of bariatric surgery candidates.

Having reasonable expectations for weight loss is clearly important for diabetics and older patients, who are known to lose less weight than their healthier or younger counterparts. Similarly, patients with a childhood onset of obesity appear to be at risk for dissatisfaction with postsurgical weight and shape. These patients may need additional education and postsurgical support regarding expectations for outcomes. Patients with sleep apnea and GERD need to have an understanding of their postoperative complication risks to increase compliance.

A history of Axis I psychiatric disturbance appears to be important, but the associated positive or negative postsurgical outcomes appear to depend on the degree to which the person was able to benefit from psychological treatment. In addition, patients with psychologically unresolved histories of childhood sexual abuse may be at risk for negative psychological consequences after substantial weight loss and may require additional postsurgical support. Suggestions have been made to inquire about the patient’s attribution of their weight as a psychological “protective factor” to assist the patient in anticipating negative psychological consequences to significant weight loss.13

Based on reports of present practices, there is general agreement that current alcohol and/or illicit substance abuse, active psychosis, and inability to provide informed consent contraindicate surgery.6,10,63 Uncontrolled bipolar disorder and a history of suicide attempts receive similar concerns.6,63 It is also thought that patients with a personality disorder lack the adaptive skills, insight, and mental stability necessary to consistently comply with postoperative recommendations and long-term lifestyle changes. Because such patients are generally screened out in the preoperative evaluation phase, these various conditions have not been empirically studied.

A current diagnosis of depression or anxiety does not generally appear to negatively affect weight loss. However, the extent to which these are tied to the patient’s distress about being obese may be important with regard to psychosocial outcomes and postoperative compliance. Pre- and postsurgical intervention may be necessary for some patients to help increase postoperative compliance and improve quality of life.48 Collazo-Clavell and colleagues64 emphasized the serious effect that psychotropic medications may have on weight and recommended selection or modification of the medication regimen to promote weight loss. Thus, psychotropic medication regimens, regardless of the condition for which they are prescribed, should be evaluated for their efficacy and potential to adversely affect weight and should be monitored over the course of weight loss.

There has been disagreement among authors regarding recommendations for bariatric candidates with BED. Some suggested that significant binge eating should be treated prior to surgery,13 while others concluded that there is insufficient evidence to exclude such patients from bariatric surgery or provide preoperative care.9,37 Others have suggested that postsurgical success in BED patients requires continued postsurgical support and long-term follow up.49 The types of patients who may be at risk for less than optimum weight loss as a result of maintenance or development of binge eating behaviors is unclear and should be further studied. Because LAGB patients with postsurgical binge eating behaviors are at higher risk for medical complications, they should undergo psychological intervention and close postsurgical monitoring.

The quality of the marital relationship and extended social support appear to be important determinants of postsurgical medical and psychological complications. It has been suggested that patients should have an awareness of the impact that dramatic weight loss can have on relationships in order to prepare them for potential psychological challenges.13 Thus, a detailed inquiry regarding the quality of relationships and the patient’s psychological dependence on them is important to determine potential targets of clinical focus.

Findings regarding other demographic, psychiatric, behavioral, and psychosocial issues were either inconsistent or have not been studied well enough to draw conclusions. In addition, the use of a variety of different assessment approaches, often non-standardized, as well as differences in frequency and length of follow up make it difficult to compare studies. Numerous studies were excluded from this article because of small sample sizes that render results without adequate statistical power and subject to the errors of utilizing a non-representative sample from a highly heterogeneous population.

Despite the recognition that there are multiple outcomes by which to measure success, the search for factors predictive of postsurgical outcomes for bariatric patients has been predominantly focused on the 50% EWL criterion. This particular criterion is a statistically derived marker with no demonstrated clinical relevance and is subject to inconsistencies in ideal weight calculations. This asks the therapist to predict degrees of success in comparison to an arbitrary standard, instead of other more clinically relevant outcomes. Weight loss that is less than “ideal” may still represent a positive outcome with regard to reduced comorbidities, improved quality of life, and psychosocial functioning. Furthermore, a standard for postsurgical failure has yet to be defined, certainly a disconcerting fact since the initial purpose of the psychological evaluation was to identify high-risk patients. Since improved medical outcomes provides current justification for the surgery, perhaps postsurgical failure should be considered the point at which obesity-related comorbidities return or do not resolve.



Given the state of current knowledge regarding predictive factors for postsurgical outcomes, there is no empirical basis for widely accepted contraindications to bariatric surgery. Except for the psychopathologic states of patients who are clearly unable to be responsible for their health care, some psychological factors may predispose patients to more or less favorable outcomes. However, this is not to imply that they predict negative outcomes. Such conclusions need to be based on studies identifying patients whose obesity-related comorbidities return or do not resolve.

Furthermore, few preoperative characteristics have been consistently predictive of postoperative outcomes in the type of studies that have been performed. Rather than concluding that preoperative factors are of little utility for prognosis, the field should critically examine the methodologic approach taken to elucidate these relationships. Group-based statistical designs focusing on single, global psychological constructs can obscure results that may be meaningful in aggregate at the individual level. Studies that are designed to examine multiple psychological constructs may prove valuable for developing more sophisticated evidence-based guidelines for presurgical psychological evaluations, prognostic determinations, and treatment recommendations.

Bariatric surgery is currently the most effective treatment for obesity in terms of the amount of weight lost and, therefore, offers the best hope for resolution of the associated comorbidities. Future studies should also investigate the trajectory of biologic and psychological change over long-term follow up, in order to determine a true marker by which success and failure can be explored. Until then, a clinician in the preoperative psychological evaluation must converge multiple factors at the individual level in order to determine pre- and post-treatment recommendations that will maximize an individual patient’s chances for optimal postsurgical outcomes. PP



1.    Steinbrook R. Surgery for severe obesity. N Engl J Med. 2004;350(11):1075-1079.
2.     Nguyen NT, Root J, Zainabadi K, et al. Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery. Arch Surg. 2005;140(12):1198-1202.
3.    NIH Consensus Development Conference. Gastrointestinal Surgery for Severe Obesity. National Library of Medicine 1991. Available at: http://consensus.nih.gov/1991/1991GISurgeryObesity084PDF.pdf. Accessed May 5, 2008.
4.    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(3):361-369.
5.    Buchwald H. Consensus conference statement bariatric surgery for morbid obesity: health implications for patients, health professionals, and third-party payers. Surg Obes Relat Dis. 2005;1(3):371-381.
6.    Bauchowitz AU, Gonder-Frederick LA, Olbrisch ME, et al. Psychosocial evaluation of bariatric surgery candidates: a survey of present practices. Psychosom Med. 2005;67(5):825-832.
7.    Ashton D, Favretti F, Segato G. Preoperative psychological testing-another form of prejudice. Obes Surg. 2008. Epub ahead of print.
8.    O’Neil PM. Editorial: lessons from, and on, the psychological assessment of bariatric surgery patients. Surg Obes Relat Dis. 2006;2(2):133-135.
9.    van Hout GC, Verschure SK, van Heck GL. Psychosocial predictors of success following bariatric surgery. Obes Surg. 2005;15(4):552-560.
10.    Pawlow LA, O’Neil PM, White MA, Byrne TK. Findings and outcomes of psychological evaluations of gastric bypass applicants. Surg Obes Relat Dis. 2005;1(6):523-527.
11.    Greenberg I. Psychological aspects of bariatric surgery. Nutr Clin Pract. 2003;18(2):124-130.
12.    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(11):1300-1314.
13. Grothe KB, Dubbert PM, O’Jile JR. Psychological assessment and management of the weight loss surgery patient. Am J Med Sci. 2006;331(4):201-206.
14. Branson R, Potoczna N, Brunotte R, et al. Impact of age, sex and body mass index on outcomes at four years after gastric banding. Obes Surg. 2005;15(6):834-842.
15.    Dallal RM, Bailey L. Outcomes with the adjustable gastric band. Surgery. 2008;143(3):329-333.
16.    Tymitz K, Kerlakian G, Engel A, Bollmer C. Gender differences in early outcomes following hand-assisted laparoscopic Roux-en-Y gastric bypass surgery: gender differences in bariatric surgery. Obes Surg. 2007;17(12):1588-1591.
17.    Chevallier JM, Paita M, Rodde-Dunet MH, et al. Predictive factors of outcome after gastric banding: a nationwide survey on the role of center activity and patients’ behavior. Ann Surg. 2007;246(6):1034-1039.
18.    Frutos MD, Lujan J, Hernandez Q, Valero G, Parrilla P. Results of laparoscopic gastric bypass in patients > or =55 years old. Obes Surg. 2006;16(4):461-464.
19.    Parikh M, Lo H, Chang C, Collings D, Fielding G, Ren C. Comparison of outcomes after laparoscopic adjustable gastric banding in African-Americans and whites. Surg Obes Relat Dis. 2006;2(6):607-610.
20.    Lutfi R, Torquati A, Sekhar N, Richards WO. Predictors of success after laparoscopic gastric bypass: a multivariate analysis of socioeconomic factors. Surg Endosc. 2006;20(6):864-867.
21.    Ma Y, Pagoto SL, Olendzki BC, et al. Predictors of weight status following laparoscopic gastric bypass. Obes Surg. 2006;16(9):1227-1231.
22.    Melton GB, Steele KE, Schweitzer MA, Lidor AO, Magnuson TH. Suboptimal weight loss after gastric bypass surgery: correlation of demographics, comorbidities, and insurance status with outcomes. J Gastrointest Surg. 2008;12(2):250-255.
23.    Cawley J, Sweeney MJ, Kurian M, Beane S. Predicting complications after bariatric surgery using obesity-related co-morbidities. Obes Surg. 2007;17(11):1451-1456.
24.    Kalarchian MA, Marcus MD, Levine MD, et al. Psychiatric disorders among bariatric surgery candidates: relationship to obesity and functional health status. Am J Psychiatry. 2007;164(2):328-334.
25.    Mauri M, Rucci P, Calderone A, et al. Axis I and II disorders and quality of life in bariatric surgery candidates. J Clin Psychiatry. 2008;69(2):295-301.
26.    Rosenberger PH, Henderson KE, Grilo CM. Correlates of body image dissatisfaction in extremely obese female bariatric surgery candidates. Obes Surg. 2006;16(10):1331-1336.
27.    Sarwer DB, Cohn NI, Gibbons LM, et al. Psychiatric diagnoses and psychiatric treatment among bariatric surgery candidates. Obes Surg. 2004;14(9):1148-1156.
28.    Rosik CH. Psychiatric symptoms among prospective bariatric surgery patients: rates of prevalence and their relation to social desirability, pursuit of surgery, and follow-up attendance. Obes Surg. 2005;15(5):677-683.
29.    de Zwaan M, Mitchell JE, Howell LM, et al. Characteristics of morbidly obese patients before gastric bypass surgery. Compr Psychiatry. 2003;44(5):428-434.
30.    Grilo CM, Masheb RM, Brody M, Toth C, Burke-Martindale CH, Rothschild BS. Childhood maltreatment in extremely obese male and female bariatric surgery candidates. Obes Res. 2005;13(1):123-130.
31.    Wildes JE, Kalarchian MA, Marcus MD, Levine MD, Courcoulas AP. Childhood maltreatment and psychiatric morbidity in bariatric surgery candidates. Obes Surg. 2008;18(3):306-313.
32.    Buser A, Dymek-Valentine M, Hilburger J, Alverdy J. Outcome following gastric bypass surgery: impact of past sexual abuse. Obes Surg. 2004;14(2):170-174.
33.    Fujioka K, Yan E, Wang HJ, Li Z. Evaluating preoperative weight loss, binge eating disorder, and sexual abuse history on Roux-en-Y gastric bypass outcome. Surg Obes Relat Dis. 2008;4(2):137-143.
34.    Grilo CM, White MA, Masheb RM, Rothschild BS, Burke-Martindale CH. Relation of childhood sexual abuse and other forms of maltreatment to 12-month postoperative outcomes in extremely obese gastric bypass patients. Obes Surg. 2006;16(4):454-460.
35.    Averbukh Y, Heshka S, El-Shoreya H, et al. Depression score predicts weight loss following Roux-en-Y gastric bypass. Obes Surg. 2003;13(6):833-836.
36.    Bocchieri-Ricciardi LE, Chen EY, Munoz D, et al. Pre-surgery binge eating status: effect on eating behavior and weight outcome after gastric bypass. Obes Surg. 2006;16(9):1198-1204.
37.    Busetto L, Segato G, De LM, et al. Weight loss and postoperative complications in morbidly obese patients with binge eating disorder treated by laparoscopic adjustable gastric banding. Obes Surg. 2005;15(2):195-201.
38.    Sallet PC, Sallet JA, Dixon JB, et al. Eating behavior as a prognostic factor for weight loss after gastric bypass. Obes Surg. 2007;17(4):445-451.
39.    Herpertz S, Kielmann R, Wolf AM, Hebebrand J, Senf W. Do psychosocial variables predict weight loss or mental health after obesity surgery? A systematic review. Obes Res. 2004;12(10):1554-1569.
40.    Wadden TA, Butryn ML, Sarwer DB, et al. Comparison of psychosocial status in treatment-seeking women with class III vs. class I-II obesity. Surg Obes Relat Dis. 2006;2(2):138-145.
41.    Swan-Kremeier LA. Psychosocial Outcome of Bariatric Surgery. In: Mitchell JE, deZwaan M, eds. Bariatric Surgery: A Guide for Mental Health Professionals. New York, NY: Taylor & Francis Group; 2005:101-118.
42.    Van Hout GC, Van Oudheusden I, Krasuska AT, van Heck GL. Psychological profile of candidates for vertical banded gastroplasty. Obes Surg. 2006;16(1):67-74.
43.    Maddi SR, Fox SR, Khoshaba DM, Harvey RH, Lu JL, Persico M. Reduction in psychopathology following bariatric surgery for morbid obesity. Obes Surg. 2001;11(6):680-685.
44.    Mathus-Vliegen EM, de Weerd S, de Wit LT. Health-related quality-of-life in patients with morbid obesity after gastric banding for surgically induced weight loss. Surgery. 2004;135(5):489-497.
45.    Rosenberger PH, Henderson KE, Grilo CM. Psychiatric disorder comorbidity and association with eating disorders in bariatric surgery patients: a cross-sectional study using structured interview-based diagnosis. J Clin Psychiatry. 2006;67(7):1080-1085.
46.    Kalarchian MA, Marcus MD. Bariatric Surgery and Psychopathology. In: Mitchell JE, deZwaan M, eds. Bariatric Surgery: A Guide for Mental Health Professionals. New York: Taylor & Francis Group; 2005:59-76.
47.    Ryden A, Karlsson J, Sullivan M, Torgerson JS, Taft C. Coping and distress: what happens after intervention? A 2-year follow-up from the Swedish Obese Subjects (SOS) study. Psychosom Med. 2003;65(3):435-442.
48.    Dymek-Valentine M, Rienecke-Hoste R, Alverdy J. Assessment of binge eating disorder in morbidly obese patients evaluated for gastric bypass: SCID versus QEWP-R. Eat Weight Disord. 2004;9(3):211-216.
49.    Greenberg I, Perna F, Kaplan M, Sullivan MA. Behavioral and psychological factors in the assessment and treatment of obesity surgery patients. Obes Res. 2005;13(2):244-249.
50.    Niego SH, Kofman MD, Weiss JJ, Geliebter A. Binge eating in the bariatric surgery population: a review of the literature. Int J Eat Disord. 2007;40(4):349-359.
51.    Tsushima WT, Bridenstine MP, Balfour JF. MMPI-2 scores in the outcome prediction of gastric bypass surgery. Obes Surg. 2004;14(4):528-532.
52.    Saunders R. “Grazing”: a high-risk behavior. Obes Surg. 2004;14(1):98-102.
53.    Hotter A, Mangweth B, Kemmler G, Fiala M, Kinzl J, Biebl W. Therapeutic outcome of adjustable gastric banding in morbid obese patients. Eat Weight Disord. 2003;8(3):218-224.
54.    Colles SL, Dixon JB, O’Brien PE. Grazing and loss of control related to eating: two high-risk factors following bariatric surgery. Obesity (Silver Spring). 2008;16(3):615-622.
55.    Zijlstra H, Larsen JK, van Ramshorst B, Geenen R. The association between weight loss and self-regulation cognitions before and after laparoscopic adjustable gastric banding for obesity: a longitudinal study. Surgery. 2006;139(3):334-339.
56.    Colles SL, Dixon JB, O’Brien PE. Hunger control and regular physical activity facilitate weight loss after laparoscopic adjustable gastric banding. Obes Surg. 2008. Epub ahead of print.
57.    van Hout GC, Jakimowicz JJ, Fortuin FA, Pelle AJ, van Heck GL. Weight loss and eating behavior following vertical banded gastroplasty. Obes Surg. 2007;17(9):1226-1234.
58.    Stunkard AJ, Messick S. The three-factor eating questionnaire to measure dietary restraint, disinhibition and hunger. J Psychosom Res. 1985;29(1):71-83.
59.    Kaiser KA, Franks SF, Hall JR, McGill JC, Berbel G, Smith AB. Changes in psychological dimensions of eating behavior after laparoscopic banding: a preliminary analysis. Ob Res. 2004;12:353-P, A91.
60.    Smith, AB, Franks, SF, Kaiser, KA, Carroll, JF. Eating behavior patterns and weight loss one year after laparoscopic banding surgery. Paper presented at: 25th Annual Meeting of the American Society for Metabolic and Bariatric Surgery; June 15-20, 2008; Washington, DC.
61.    Guerdjikova AI, West-Smith L, McElroy SL, Sonnanstine T, Stanford K, Keck PE Jr. Emotional eating and emotional eating alternatives in subjects undergoing bariatric surgery. Obes Surg. 2007;17(8):1091-1096.
62.    Fischer S, Chen E, Katterman S, et al. Emotional eating in a morbidly obese bariatric surgery-seeking population. Obes Surg. 2007;17(6):778-784.
63.    Walfish S, Vance D, Fabricatore AN. Psychological evaluation of bariatric surgery applicants: procedures and reasons for delay or denial of surgery. Obes Surg. 2007;17(12):1578-1583.
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Needs Assessment: Methods of pre-surgical psychological evaluation, post-operative psychological support, and common psychological issues are presented to mental health professionals following patients’ surgery. As the field of bariatric surgery grows rapidly, it is necessary to be familiar with these issues to provide adequate care.

Learning Objectives:
• Understand the various roles mental health professionals play in a multidisciplinary team of a surgical weight-loss program.
• List the objectives of a pre-surgical weight-loss evaluation.
• Recognize common psychological issues patients face at various stages after bariatric surgery.

Target Audience: Primary care physicians and psychiatrists.

CME Accreditation Statement: This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the Mount Sinai School of Medicine and MBL Communications, Inc. The Mount Sinai School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.

Credit Designation: The Mount Sinai School of Medicine designates this educational activity for a maximum of 3 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Faculty Disclosure Policy Statement: It is the policy of the Mount Sinai School of Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices. This information will be available as part of the course material.

This activity has been peer-reviewed and approved by Eric Hollander, MD, chair and professor of psychiatry at the Mount Sinai School of Medicine, and Norman Sussman, MD, editor of Primary Psychiatry and professor of psychiatry at New York University School of Medicine. Review Date: June 23, 2008.

Drs. Hollander and Sussman report no affiliation with or financial interest in any organization that may pose a conflict of interest.

To receive credit for this activity: Read this article and the two CME-designated accompanying articles, reflect on the information presented, and then complete the CME posttest and evaluation. To obtain credits, you should score 70% or better. Early submission of this posttest is encouraged: please submit this posttest by August 1, 2010 to be eligible for credit. Release date: August 1, 2008. Termination date: August 31, 2010. The estimated time to complete all three articles and the posttest is 3 hours.

Primary Psychiatry. 2008;15(8):42-47


Dr. Huberman is clinical instructor in the Department of Psychiatry at New York University School of Medicine and in private practice in New York City.

Disclosure: Dr. Huberman reports no affiliation with or financial interest in any organization that may pose a conflict of interest.

Please direct all correspondence to: Warren L. Huberman, PhD, 104 East 40th St, Suite 206, New York, NY 10016; Tel: 212-983-6225; Fax: 212-692-9305; E-mail: whuberman@verizon.net.




The role of a mental health professional working with surgical weight-loss patients is diverse. Primary responsibilities include the provision of patients’ evaluations prior to surgery and either individual or group counseling after surgery. Consultation with the surgeon at various points of patient care is also common. While there is no consensus regarding the content of pre-surgical evaluations or the criteria used to exclude patients from surgery, it is generally accepted that the evaluation is necessary and beneficial. Research supports the benefits of post-surgical mental health services as well. This article suggests pre-surgical evaluations should not primarily focus on psychopathology but on patient expectations and preparedness for the behavioral and emotional changes following surgery. Common reasons patients present for post-operative psychotherapy are reviewed and a stage model of psychological change following surgery is presented.



It is a pleasure to contribute to this issue on psychological considerations of bariatric surgery. I began working as the consulting psychologist to the New York University (NYU) Program for Surgical Weight Loss in 2000 and have had the good fortune of working with Christine Ren Fielding, MD, George Fielding, MD, and Marina Kurian, MD. The field has changed in numerous ways since 2000, and the knowledge base regarding the psychological impact of weight-loss surgery has grown considerably.

When I was first introduced to bariatric surgery, I was quite skeptical. Having worked extensively as a cognitive-behavioral psychologist focusing on health-behavior change, I was leery that bariatric surgery was another hoax or quick fix for obesity. After having the privilege to work with >5,000 patients, I think that bariatric surgery may represent the only empirically valid treatment for morbid obesity.

In recent years, the use of bariatric surgery as a treatment for obesity has increased significantly, a trend that will grow as obesity rates continue to climb.1 The number of patients presenting for surgery may also increase, as research continues to demonstrate the benefits to both physical health2 and various aspects of psychological well-being and quality of life (QOL).3 The objective of this article is to overview the role of the mental health professional working with surgical weight-loss patients both before and after surgery and to share observations based on my experience with this population.


The Role of the Mental Health Professional

Most surgical weight-loss practices adopt a multidisciplinary approach and have accepted that this is needed to help patients achieve success from bariatric surgery.4 The definition of “success” from weight-loss surgery should extend beyond weight loss per se and include improvements in patients’ QOL as well. A mental health professional is typically a member of the team along with nurses, a nutritionist, surgeons, and other clinical staff.

Common responsibilities of a mental health professional in a bariatric surgery program include conducting pre-surgical psychological evaluations, running support groups, and providing individual psychological services to patients before and after surgery. However, there is much variability from program to program. Some programs require pre-surgical psychological evaluations of all patients while others do not.5-10 Numerous programs offer support groups while others do not. This author is unaware of any program that requires patients to participate in ongoing psychological counseling following surgery although some may recommend this practice and make such services available. At least one study has demonstrated that participation in psychotherapy can result in increased weight loss following surgery.11


Pre-surgical Evaluations

Both the Surgical Review Corporation and the American College of Surgeons require the involvement of mental health experts in screening bariatric patients for their respective accreditation processes. Numerous experts agree that psychopathology and a number of pre-morbid psychological difficulties can have an effect on post-operative success.12-13 However, findings of studies investigating underlying psychopathology or other emotional obstacles in the bariatric population have yielded inconsistent results. Early studies seemed to suggest there was no greater incidence of psychopathology among the morbidly obese.

Recent studies suggest that morbidly obese patients may have significant symptoms of depression, eating disorders, poor body image, low QOL, and other coexisting mental disorders.5,14-20 In addition to attempting to avoid post-operative psychiatric crises, there is also a strong desire for surgical weight-loss practices to avoid legal proceedings in the event of an adverse surgical outcome. For example, a surgeon would have difficulty defending him- or herself against a legal proceeding from a patient with poorly controlled bipolar disorder who experienced an adverse surgical outcome if the surgeon made little effort to identify and evaluate that such a pre-morbid psychiatric history was present. Such occurrences are commonly reviewed at bariatric conferences and in the general literature.21-26

Interestingly, there is still little consensus as to what the contents of a psychological evaluation should be. Some professionals use structured inventories and psychological instruments such as the Minnesota Multiphasic Personality Inventory-2, Medical Outcomes Study 36-item short form health survey, and a variety of instruments that assess the presence and severity of eating disorders while other professionals rely primarily on a structured clinical interview.27 There is little evidence that any method or instrument of assessment is superior in either identifying inappropriate candidates for surgery or predicting long-term success from surgery.

There is also little consensus as to what specific psychological factors predict outcome, despite the increased focus on inventories or structured tests to identify such variables (GM Boulton-Lewis, unpublished material, 2008).6,10 Numerous variables, including age, gender, socioeconomic status, comorbidities, pre-operative body mass index, prior weight-loss attempts, eating disorders, disordered eating, personality disorders, motivational factors, history of sexual abuse, and social support, among others, have all received some investigation into their effect on surgical outcome, yet none have demonstrated any consistent effects (GM Boulton-Lewis, unpublished material, 2008).


Post-Operative Care and Support

Mental health services can be provided as either a prophylaxis against the occurrence of difficulties or a way to address them as they occur. When patients struggle to achieve satisfactory weight loss and medical explanations are inadequate, it is reasonable to consider that psychological variables may be involved. At these times, the surgeon can consult with the mental health professional regarding a difficult case or could refer the patient for psychotherapy.

In addition, several weight-loss surgery programs offer post-operative support groups. These groups may be run by a professional or by patients themselves. There is some debate as to whether support groups or therapy groups are more appropriate28; however, there is little debate that such groups are helpful and desirable. Studies have demonstrated that patients who attended support groups following surgery lost more weight than those who did not attend.29,30 Another study noted that the most highly valued aspect of overall treatment was the provision of continuing care followed by group supports.31


Personal Experience

Pre-surgical Evaluations

My initial role as the consulting psychologist to the NYU Program for Surgical Weight Loss was to conduct pre-surgical psychological evaluations. I was familiarized with the types of surgeries, current literature, and nature of the information she wanted me to acquire through the evaluation. My objective in conducting the evaluations was to follow generally accepted practices and to address particular questions and concerns. My objectives for the pre-surgical evaluations have evolved to include the following, as shown in Table 1.



I created a questionnaire that assesses eating habits, social support, weight-loss history, and mental health history among other areas and have revised it over the years. The questionnaire serves as a template that would enable me to take the patient through a structured yet simple process that is more like a conversation than a clinical interview.

Patients are often anxious about the evaluation because they either have never met with a mental health professional or fear that they will disclose information that will disqualify them from surgery. Patients who have never met with a mental health professional will often ask where the couch is, which is a prompt to explain the objectives of this meeting.

The majority of patients with anxiety fear they may disclose something that will disqualify them from having surgery. I inform patients that this is rare and would most likely be their decision. I have recommended that a surgeon deny surgery to a patient in only a few cases. I can generally explain to the patient why I believe he or she is not presently suitable for surgery and have him or her take steps to address my concerns before moving forward.

It is important to understand the context in which the patient is seeking surgery. One may ask how they learned about it, why they have chosen the present time to pursue surgery, and what the “tipping point” was. The latter question often indicates the patient’s primary objective in having surgery and what his or her expectations are from surgery. It is the opinion of this author that patients do not have surgery simply to lose weight but to accomplish what they believe “thinnerness” will provide. Some patients have dieted for so long that they forgot that weight loss in and of itself is not the final objective. Such patients may not be psychologically prepared for surgery. For most patients, goals include improvements in physical functioning, improved esteem, improved health, and improved interpersonal relationships.

Interestingly, a primary objective in having surgery cited by an overwhelming number of patients is to end the psychological exhaustion from dieting and chronic feelings of failure for their inability to lose weight. Most patients that present for surgery have successfully lost weight before and many have lost >50 pounds on more than one occasion. Unfortunately, most patients believe that maintaining such weight loss with diet and exercise is commonplace and indicate that their family and friends believe this as well, although virtually all clinical research suggests this is hardly the case. For this reason, many patients report feeling guilt and shame over their resorting to surgery as opposed to losing weight the “normal” way. I commonly dispute this notion and refer patients to the clinical literature on this subject.32-34

When patients recognize that the objective is not to try to disqualify them, the assessment becomes a conversation more than an evaluation. For many, this meeting will be their only interaction with a mental health professional, and it is my responsibility that they leave the meeting with a favorable impression of our profession. In doing so, I believe that patients may be more willing to seek out help should the need arise in the future.

The evaluation is as much educational as it is an assessment. In past years, I spent a great deal of time evaluating psychopathology. Colleagues indicated their practice of disqualifying candidates if they expressed a history of major depressive disorder (MDD), suicidality, substance abuse, eating disorders, and other issues. I have since worked with individuals who have had histories of numerous diagnoses and many have done well in terms of both weight loss and improvements in QOL. I continue to assess the presence of Axis I and II pathology but move on to other areas if these issues are absent or are well controlled. This focus on areas beyond psychopathology during the pre-surgical evaluation is receiving further support.35

In the experience of myself and colleagues at NYU, patients with histories of psychopathology, if appropriately managed in follow-up care, can react well. In fact, one study found that patients who met criteria for MDD before surgery did better than non-depressed patients in terms of total weight loss.36 It does not appear that the presence of any particular personality type, trait, or characteristic assures an unsatisfactory outcome from surgery.

Another objective is to encourage the patient to think about life beyond surgery. I ask patients to consider the issues they believe cause behavioral and emotional difficulties after surgery and how they would address them should they occur. Most patients understand the rationale for seeking help if they struggle to lose weight. Fewer patients understand why I ask about potential emotional difficulties that could arise should they be successful in losing weight. Most cannot see weight loss as anything other than desirable, but for patients who see beyond that particular end, they understand completely.

Patients who have been sexually abused or who are socially anxious are often aware of, and have reservations about, making their body more appealing to others. Such patients often report feeling “invisible” in their obesity and are concerned about becoming more “visible” to others following surgery. Numerous morbidly obese patients report that others have ignored them, failed to make eye contact, or rolled their eyes and sighed when they came near. They anticipate that social interactions will change considerably when they begin to lose weight and some have anxiety about these changes.

Patients also express concern that the expectations they have of themselves and that others have of them will change. Such patients acknowledge their weight as a “grand excuse” for shortcomings in various areas of their lives and recognize that improvements in these areas will be expected as they lose weight. For example, many patients fear that they will feel pressure to begin dating now that they are thinner or to begin interviewing for a new job now that concern about weight discrimination has diminished.

It has been my experience that most morbidly obese patients either are, or can become, suitable candidates for surgery. If a patient appears unsuitable, it is likely that he or she is simply not ready at that time. Many patients have presented for surgery in the midst of other issues (ie, divorce, recent loss of a loved one), and when I suggest that they wait until such issues are resolved, it is generally well received. For the vast majority of patients, the medical and psychological benefits of bariatric surgery significantly outweigh its potential consequences so much that there must be an extraordinary reason to deny a patient this opportunity. For this reason, it is imperative that the pre-surgical evaluation is conducted by a clinician who has expertise in the field, so that patients are not inappropriately screened out of surgery, and that those who are allowed to proceed are fully educated and emotionally prepared to do so.


Surgical Weight-Loss Patients in Follow Up

Almost all patients who have followed up with me after surgery have been successful from the perspective of weight loss. Most are seeking assistance in making the emotional and behavioral adjustments in their personal and social lives that their weight loss has necessitated. I have yet to speak to a patient who has expressed regret with his or her decision to have surgery. Most patients express satisfaction with the outcome of their surgery, including many who have experienced complications related to surgery. Weight-loss surgery is a powerful tool that enables dramatic weight loss and helps patients to make significant life changes. Therefore, weight-loss surgery should be made available to the majority of patients unless extraordinary circumstances suggest otherwise.

Interestingly, some of the issues that have received significant media coverage have not been common concerns among my patients. I have yet to work with a patient complaining of “food mourning,” wherein one experiences the loss of eating as a primary mechanism to cope with negative emotions because they cannot eat in the manner they did before surgery. Similarly, I have seen only one or two patients who reported increased consumption of alcohol or other substances following surgery (ie, “addiction transfer”). Much has been discussed on this topic and more research is required37 before any conclusions are drawn. In circumstances where my patients have reported increased alcohol consumption following surgery, it has generally been a natural consequence of becoming more socially active after losing weight and not a cause for alarm. However, there are physiologic changes in the way alcohol is absorbed and metabolized, particularly following gastric bypass and other malabsorptive surgeries, and patients need to be aware of the potential problems associated with this phenomenon.

I have seen numerous people who continued to have issues with emotional eating and binge eating following surgery, but many of these patients achieved expected weight loss and did not report dissatisfaction from surgery. These eating issues can continue to be addressed during follow-up but do not necessarily need to be “cured” before surgery is indicated.


A Stage Model of Psychological Change Following Bariatric Surgery

In my experience, patients who present for bariatric surgery can be viewed as being in one of two groups: those who are generally satisfied with their lives and those who are not. Those in the former group generally want to lose weight to address health concerns or to stop their weight from interfering with their ability to enjoy their lives as they are. Such patients usually adjust well after surgery, as their primary objective is to lose weight to better enjoy what is already present in their lives.

Those in the latter group are typically the patients who present for post-operative psychotherapy; their lives remain unsatisfying despite the weight loss. Such patients often have impaired esteem, poor body image, unsatisfying or non-existent intimate relationships, minimal or unsatisfying social contacts, and other issues that need to be addressed. For these patients, losing weight may be the easy part. I often tell patients that “fat body goes away faster than fat brain,” explaining that losing the weight takes less time than making the psychological adjustments to the weight loss. Many continue to emotionally feel like their formerly obese selves long after the weight has been lost. Making the life changes that enable them to achieve a greater QOL, the true “success” that I referred to earlier is a more difficult and time-consuming task.

By my observation, many patients go through a series of four stages in making the psychological adjustments to dramatic weight loss following bariatric surgery (Table 2). During the first stage, the focus is on maintaining compliance with dietary rules and on losing weight. Choosing the right foods and learning how to eat properly are of primary concern. Emotionally, there can be excitement from losing weight or apprehension if complications are experienced and weight loss is slow.



During the second stage, patients may begin to incorporate other tools such as dietary change and exercise and are trying to achieve weight-loss goals whether measured by pounds or by sizes. Rudimentary psychological changes occur such as learning to accept compliments and adjusting to changes in social interactions. Patients are in pursuit of their weight-loss goal and the changes they anticipate will occur when that goal is reached.

During the third stage, patients have achieved or approximated major milestones such as losing 75 or 100 pounds or achieving a desired size. Many will punctuate their accomplishment through a physical achievement or by taking a major step in their personal lives. I have had numerous patients run a marathon or take a physically demanding vacation while others will post their profile on an Internet dating site or begin attending social events. This stage involves experimentation and risk taking as if to demonstrate to themselves and others that they are truly a new person.

The fourth stage can be the most enduring and difficult. It is the stage during which depression and other emotional difficulties are most likely to occur. In this stage, patients begin to adjust to life after weight loss. The life-long objective to defeat obesity in terms of numerical weight may have been accomplished. Friends and family are no longer cheering and the weight loss has become old news. The focus of their life needs to transition from losing weight to adjusting to life in a thinner body and moving beyond weight-related objectives. This is the stage during which changes in one’s personal, social, and professional lives are to occur and is thus ongoing. Success in working through this stage will define overall success from bariatric surgery for many patients.



There is a significant contribution that mental health professionals can and do make to bariatric surgery patients and surgeons alike. They play a vital role in patient selection, preparation, and education before surgery and inpatient care following surgery. In many regards, the treatment of morbid obesity through bariatric surgery is as much psychological as it is physical. The work is rich and extremely gratifying; it can have a great impact on patient outcomes. In addition, as the field is growing with the rising number of patients undergoing bariatric surgery, familiarity with the issues faced by these patients is necessary.

There is a unique quality in working with bariatric surgery patients as well. When Dr. Ren Fielding and I met 7 years ago, I asked her what motivated her to work with the morbidly obese. I was touched by her reply and have since adopted it as my own. Her reply was that “surgery is generally about saving lives…weight-loss surgery is often about giving life.” PP



1.    Steinbrook R. Surgery for severe obesity. N Engl J Med. 2004;350(11):1075-1079.
2.    Maggard MA, Shugarman LR, Suttorp M, et al. Meta-analysis: surgical treatment of obesity. Ann Intern Med. 2005;142(7):547-559.
3.    Wadden TA, Sarwer DB, Fabricatore AN, Jones L, Stack R, Williams NS. Psychosocial and behavioral status of patients undergoing bariatric surgery: what to expect before and after surgery. Med Clin North Am. 2007;91(3):451-469.
4.    Buchwald H. Bariatric surgery for morbid obesity: health implications for patients, health professionals, and third-party payers. J Am Coll Surg. 2005;200(4):593-604.    
5.    Greenburg I, Perna F, Kaplan M, Sullivan MA. Behavioral and psychological factors in the assessment and treatment of obesity surgery patients. Obes Res. 2005;13(2):244-249.
6.    Lemont D, Moorehead MK, Parish MS, Reto CS, Ritz SJ. Suggestions for the pre-surgical psychological assessment of bariatric surgery candidates. Gainesville, FL: American Society for Metabolic and Bariatric Surgery; 2004.
7.    Sogg S, Mori DL. The Boston interview for gastric bypass: determining the psychological suitability of surgical candidates. Obes Surg. 2004;14(3):370-380.
8.    Fabricatore AN, Crerand CE, Wadden TA, Sarwer DB, Krasucki JL. How do mental health professionals evaluate candidates for bariatric surgery? Survey results. Obes Surg. 2006;16(5):567-573.
9.    Buchwald H. Bariatric surgery for morbid obesity: health implications for patients, health professionals, and third-party payers. J Am Coll Surg. 2005;200(4):593-604.
10.    Wadden TA, Sarwer DB. Behavioral assessment of candidates for bariatric surgery: a patient-oriented approach. Surg Obes Rel Dis. 2006;2(2):171-179.
11.    Nicolai A, Ippoliti C, Petrelli MD. Laparoscopic adjustable gastric banding: essential role of psychological support. Obes Surg. 2002;12(6):857-863.
12.    Simon GE, Von Korff M, Saunder K, et al. Association between obesity and psychiatric disorders in the US adult population. Arch Gen Psychiatry. 2006;63(7):824-830.
13.    Herpertz S, Kielmann R, Wolf AM, Hebebrand J, Senf W. Do psychosocial variables predict weight loss or mental health after obesity surgery? A systematic review. Obes Res. 2004;12(10):1554-1569.
14.    Larsen JK, van Ramshorst B, Geenen R, Brand N, Stroebe W, van Doornen LJ. Binge eating and its relationship to outcome after laparoscopic adjustable gastric banding. Obes Surg. 2004;14(8):1111-1117.
15.    Kinzl JF, Schrattenecker M, Traweger C, Mattesich M, Fiala M, Biebl W. Psychosocial predictors of weight loss after bariatric surgery. Obes Surg. 2006;16(12):1609-1614.
16.    Carpenter KM, Hasin DS, Allison DB. 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(2):251-257.
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(12):1139-1147.
18.    Allison KC, Stunkard AJ. Obesity and eating disorders. Psychiatr Clin North Am. 2005;28(1):55-67.
19.    Berkowitz RI, Fabricatore AN. Obesity, psychiatric status, and psychiatric medications. Psychiatr Clin North Am. 2005;28(1):39-54.
20.    Wadden TA, Butryn ML, Sarwer BD, et al. Comparison of psychosocial status in treatment-seeking women with class III vs. class I-II obesity. Surg Obes Rel Dis. 2006;2(2):138-145.
21.    Lindstrom W. Professional liability and risk management. Presented at: 19th Annual Meeting of the American Society for Metabolic and Bariatric Surgery; June 24-28, 2002; Las Vegas, NV.
22.    Saxton J, Corboy PH, Sheldon A. Bariatric surgery: what the plaintiff’s lawyers think, the defense lawyers, and most importantly the jurors! Presented at: 23rd Annual Meeting of the American Society for Metabolic and Bariatric Surgery; June 26-July 1, 2006; San Francisco, CA.
23.    Saxton JW. Reducing your bariatric risk while enhancing your program. Presented at: Adding, Updating, and Expanding Bariatric Surgery Centers of Excellence Hospitals and Health Systems Conference; March 8, 2007; San Francisco, CA.
24.    Wittgrove AC. An interview with Alan C. Wittgrove, MD. Bariatric Times. 2007;4(3):13-16.
25.    Wong-Swartz E. Minimizing risk exposure in bariatric surgery. Bariatric Times. 2006;3(5):42-44.
26.    Eagan MC. Bariatric surgery: malpractice risks and risk management guidelines. Am Surg. 2005;71(5):369-375.
27.    Wadden TA, Sarwer DB, Womble LG, Foster GD, McGuckin BG, Schimmel A. Psychosocial aspects of obesity and obesity surgery. Surg Clin North Am. 2001;81(5):1001-1024.
28.    Janeway JM, Sparks K. Support versus therapy: have you got it right? Bariatric Times. 2007;4(9):1,14-17.
29.    Elakkary E, Elhorr A, Aziz F, Gazayerli MM, Silva YJ. Do support groups play a role in weight loss after laparoscopic adjustable gastric banding? Obes Surg. 2006;6(3):331-334.
30.    Latner JD, Stunkard AJ, Wilson GT, Jackson ML. The perceived effectiveness of continuing care and group support in the long-term self-help treatment of obesity. Obesity (Silver Spring). 2006;14(3):464-471.
31.    Song Z, Reinhardt K, Buzdon M, Liao P. Association between support group attendance and weight loss after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2008;4(2):100-103.
32.    Brownell KD. Obesity: understanding and treating a serious, prevalent, and refractory disorder. J Consult Clin Psychol. 1982;50(6):820-840.
33.    Tsai AG, Wadden TA. Systematic review: an evaluation of commercial weight loss programs in the United States. Ann Intern Med. 2005;142(1):56-66.
34.    Mann T, Tomiyama AJ, Westling E, Lew AM, Samuels B, Chatman J. Medicare’s search for effective obesity treatments: diets are not the answer. Am Psychol. 2007;62(3):220-233.
35.    Bauchowitz A, Azarbad L, Day K, Gonder-Frederick L. Evaluation of expectations and knowledge in bariatric surgery patients. Surg Obes Rel Dis. 2007;3(5):554-558.
36.    Averbukh Y, Heshka S, El-Shoreya H, et al. Depression score predicts weight loss following Roux-en-Y Gastric Bypass. Obes Surg. 2003;13(6):833-836.
37.    Sogg S. Alcohol misuse after bariatric surgery: epiphenomenon or “Oprah” phenomenon? Surg Obes Rel Dis. 2007;3(3):366-368.


Needs Assessment: Weight-loss surgery patients present with issues specific to the weight-loss surgery experience and substantial weight loss. Awareness of the challenges these patients typically face will enable physicians to provide appropriate health and mental health care.

Learning Objectives:

• Identify at least four positive interpersonal changes likely to occur after weight-loss surgery.
• Identify at least four potential interpersonal challenges arising after weight-loss surgery.
• Provide medical or mental health care sensitive to interpersonal changes after weight-loss surgery.

Target Audience:
Primary care physicians and psychiatrists.

CME Accreditation Statement: This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the Mount Sinai School of Medicine and MBL Communications, Inc. The Mount Sinai School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.

Credit Designation: The Mount Sinai School of Medicine designates this educational activity for a maximum of 3 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Faculty Disclosure Policy Statement: It is the policy of the Mount Sinai School of Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices. This information will be available as part of the course material.

This activity has been peer-reviewed and approved by Eric Hollander, MD, chair and professor of psychiatry at the Mount Sinai School of Medicine, and Norman Sussman, MD, editor of Primary Psychiatry and professor of psychiatry at New York University School of Medicine. Review Date: June 23, 2008.

Drs. Hollander and Sussman report no affiliation with or financial interest in any organization that may pose a conflict of interest.

To receive credit for this activity: Read this article and the two CME-designated accompanying articles, reflect on the information presented, and then complete the CME posttest and evaluation. To obtain credits, you should score 70% or better. Early submission of this posttest is encouraged: please submit this posttest by August 1, 2010 to be eligible for credit. Release date: August 1, 2008. Termination date: August 31, 2010. The estimated time to complete all three articles and the posttest is 3 hours.

Primary Psychiatry. 2008;15(8):61-66


Drs. Sogg and Gorman are staff psychologists at the Massachusetts General Hospital Weight Center and instructors in psychology at the Harvard University School of Medicine in Boston, MA.

Disclosure: Drs. Sogg and Gorman report no affiliation with or financial interest in any organization that may pose a conflict of interest.

Please direct all correspondence to: Stephanie Sogg, PhD, MGH Weight Center, 50 Staniford St, 4th Fl, Boston, MA 02114; Tel: 617-726-6761; Fax: 617-724-6565; E-mail: ssogg@partners.org.





Weight-loss surgery literature suggests that the majority of patients experience the changes that occur as a result of dramatic weight loss after weight-loss surgery as being overwhelmingly positive. However, even positive change may pose a variety of psychosocial challenges. In the case of weight-loss surgery, these changes and challenges often manifest themselves in a variety of interpersonal realms, including everyday social interactions and relationships with close friends and loved ones. In addition, patients must learn to function in certain interpersonal situations they may not have had to navigate in years or have never encountered before. This article examines some of the interpersonal changes and challenges arising after weight-loss surgery, with a brief review of empirical literature on this topic. It concludes with a discussion of the ways healthcare providers can facilitate smooth adjustment to interpersonal changes after weight-loss surgery.



Due to the rapidly increasing prevalence of weight-loss surgery in recent years,1-4 healthcare professionals of all disciplines are more likely to encounter weight-loss surgery patients in their clinical practices. Therefore, it is important for clinicians who do not specialize with this population to become knowledgeable about weight-loss surgery and the common post-operative experiences patients face to ensure the provision of appropriate care and referrals.

A growing body of empirical literature suggests that after weight-loss surgery, the majority of patients experience overwhelmingly positive changes,5-10 including dramatic improvements in medical comorbidities2,11-16; enhanced energy, mobility, mood, and self-esteem; and increased desire and ability to engage in a variety of activities.5,6,8,11,17 However, even positive change may pose a variety of psychosocial challenges.5

For weight-loss surgery patients, these changes and challenges often manifest themselves in a variety of interpersonal realms. Weight-loss surgery may affect spheres ranging from everyday social interactions to relationships with close friends and loved ones. In addition, patients must learn to function in certain interpersonal situations they may not have had to navigate in years or have never encountered before. This article examines some of the interpersonal changes and challenges arising after weight-loss surgery, including a brief review of empirical literature on this topic. Ways to facilitate smooth adjustment to interpersonal changes after weight-loss surgery are discussed as well.

It should be noted that there is a relative dearth of empirical literature examining this topic6; many of these studies were published decades ago, involve small samples, and pertain to bariatric procedures that are now rarely performed. Examination of interpersonal outcomes tends to be done in broad strokes,6 with patients rating general satisfaction or improvement, rather than focusing on specific types or mechanisms of change. Thus, patient report and clinical experience must often be used to inform the effect of weight-loss surgery on interpersonal functioning.


Everyday Social Interactions

Positive Changes

Almost immediately after surgery, patients report receiving increased attention from supportive family and friends around taking an important step in addressing their health risks. As patients lose weight, positive attention often takes the form of compliments, which many patients report finding pleasurable and gratifying. In addition, patients frequently report that both strangers and acquaintances tend to be more likely to approach and generally act more positively toward them. Patients typically attribute these changes directly to improved appearance. Though this may be the case, it is likely that this change is partly attributable to changes in the way the patients interact with others. As their mood, self-confidence, and self-esteem improve, patients may approach others more often and more positively, effecting a change in how others respond to them.



While receiving compliments is pleasurable for most people, it is not uncommon for weight-loss surgery patients to feel uncomfortable when this occurs, especially if they were not accustomed to receiving compliments in the past. Numerous patients express concern that they will appear conceited if they do not downplay or reject compliments. Frequently, it takes some time before a patient’s self-concept becomes consistent with his or her changed outward appearance.18 Therefore, compliments may be perceived as uncomfortably discordant with the patient’s self-image; one patient described the experience of receiving a compliment as causing “a short-circuit in my brain.” In other cases, patients simply have not developed the basic skill of responding to a compliment by merely saying, “Thank you.” Fortunately, this skill can be developed through a very brief intervention of guided role-playing (and some practice), greatly easing this type of social transaction.

For some patients, changes in the way others respond to them can be experienced as insulting. Some patients report feeling resentful about being treated better by other people simply because they lost weight.5,6 Patients may interpret a sudden increase in compliments to mean that before surgery, people found them unappealing; one patient reported responding to enthusiastic compliments with the thought, “Wow, what must they have thought of me before?”

Before weight-loss surgery, patients frequently report experiencing significant stigma and discrimination related to their weight.6,19-23 Numerous patients complain about bias at work, within their families, and from strangers; empirical investigations substantiate the reality of widespread prejudice and discrimination against individuals with obesity.21,22,24-30 It has been found that medical professionals,18,25,31-35 even those who specialize in studying and treating obesity,29,36 hold such prejudices. It has been noted that obesity is “one of the last acceptable forms of prejudice” in our society.37 Further, unlike members of other stigmatized groups, it has been found that people with obesity tend to internalize these biases.20,22,25,28,38,39 Because of the stigma related to obesity, research has demonstrated that people with obesity are more susceptible to depression and lowered self-esteem.40-46 Fortunately, after weight-loss surgery, as patients lose weight, they encounter fewer of these experiences.23 However, they often remain acutely aware of and troubled by the prejudice that exists toward individuals with obesity in Western culture.5 It can be particularly uncomfortable when patients catch themselves engaging in this type of stigmatizing behavior. One patient described feeling horrified and saddened when, having just been cut off by another driver in a parking lot, she found herself making disparaging observations about that driver’s being overweight.

Weight-loss surgery may also lead to unwanted inquiries by others. For many reasons, the topic of weight-loss surgery seems to be quite interesting to the lay public, and weight-loss surgery patients often find themselves reluctantly assuming the role of “weight-loss surgery ambassador” to their family and friends. Patients report being subjected to frequent questions about the surgery and post-operative regimen. Although patients often report being enthusiastic about their experiences and wanting to share them with others, some patients find it tiresome to answer repetitive questions about weight-loss surgery or find that conversations with others too frequently focus on this topic. In addition, patients sometimes report being asked intrusive personal questions, such as “How much weight have you lost?” or “What did you weigh before?” Patients also often report that others appear to be inordinately curious about what, how much, and how fast they can eat.

One of the more distressing challenges that weight-loss surgery patients sometimes face is being subjected to the opinions of people who mistakenly believe that weight-loss surgery is somehow “cheating” or “taking the easy way out,” when the patient “should have been able to lose the weight on his or her own.” This is yet another expression of the bias and misapprehensions about obesity among the general public, and it leaves the patient in an unpleasant position of having to justify his or her decision to have surgery. Unfortunately, in Western society, obesity is often believed to be the result of a psychiatric or behavioral disorder, laziness, or failure of will power.24-26 However, a growing body of research strongly indicates that biologic factors are very powerful in determining body weight.26,47 In fact, it has been estimated that 40% to 85% of the individual variation in obesity may be attributable to genetic factors.48,49 In addition, once it has developed, obesity is notoriously resistant to nonsurgical treatments such as lifestyle change or weight-loss medications regardless of etiology,12,50-56 leaving weight-loss surgery as most patients’ best hope for improvement or reversal of the dangerous comorbidities of obesity.1,12,14,15,57-59 It is often incumbent upon weight-loss surgery patients to explain these facts to others, which can be tedious at best and, at worst, demoralizing.


Intimate Relationships

Positive Changes

Another realm of interpersonal changes after weight-loss surgery is in the sphere of intimate relationships: close friendships, family relationships, and romantic partnerships. Before surgery, patients frequently report that their weight diminishes both the ability and the desire to engage in a variety of activities.42,60,61 After weight-loss surgery, improvements in health, mobility, energy, mood, and self-confidence render patients more able and eager to engage in a wider spectrum of activities.5,6,10,11,18,62 This can translate into more enjoyable time spent with friends and loved ones and participation in or rediscovery of activities and hobbies that had been abandoned in the past. Patients report being able to take long walks with their spouses or chase their grandchildren around the backyard. One patient reported feeling elated by the simple pleasure of being able to cook a meal for her spouse, an activity that was impossible before weight-loss surgery, as she could not stand at the stove for more than a few minutes at a time.

Additionally, improved mood and self-confidence make social situations more enjoyable after weight-loss surgery. Patients report that after weight-loss surgery, they appreciate becoming free of the constant awareness of their size; the fear of being evaluated negatively by others diminishes.6,11,18,62,63 Patients who, before surgery, tended to avoid parties and other social situations because they were self-conscious about their appearance no longer feel they have to refuse invitations.

The vast majority of weight-loss surgery patients report that having surgery has affected their romantic relationships in a positive way.8,62,64-69 As noted above, weight-loss surgery offers patients the opportunity to engage in more shared activities with their partners62,68 or to resume a larger share of household responsibilities. Additionally, weight-loss surgery appears to lead to significant improvements in most patients’ sexual functioning.62,64,67,70,71 Patients often report that improved mood, body image, and self-confidence significantly increase their sexual desire and level of comfort with physical intimacy.8,66,70 Sexual activity becomes mechanically easier due to increased endurance, improved mobility, and smaller body size.5,66,70 Some patients report that their partners show a renewed or increased sexual interest toward them as they lose weight.62 One study70 found that patients’ partners reported being even more satisfied with sexual changes after weight-loss surgery than the patients themselves.



Despite the positive changes described, challenges may arise in close relationships after weight-loss surgery. As the patient loses weight, friends or family members may become envious or competitive.5,6,72 It is not uncommon for patients to report that a close friend or relative has commented, “Wow, you are getting close to my size, now–I should go on a diet!” In some cases, the weight-loss surgery patient was part of a friendship, family, or social group in which he or she played the role of “the fat one,” someone who was less assertive or posed less of a threat or competition for the opposite sex. As the patient loses weight after surgery, this dynamic may be changed, disrupting the equilibrium of the friendship, family, or social group.

Relationships that in the past had centered around eating, cooking, or visiting restaurants may have to undergo some adjustments after the patient undergoes weight-loss surgery, and friends and family members may also be concerned about losing an “eating buddy.” In Western culture, it can be difficult to find opportunities for socialization that do not focus on food or drink.6 In addition, as patients create healthier eating patterns for themselves, eating in the entire household is likely to be affected. In some cases, patients may feel guilty about the possibility that family meals will be disrupted or worry that loved ones will feel deprived of certain favorite foods. Conversely, some weight-loss surgery patients find that friends or family begin to act as the “food police,” monitoring and commenting on each bite the patient eats. Although this behavior may reflect genuine caring and concern on the part of the friend or family member, it can be quite aversive to the patient.

Another potential challenge is possible sabotage by a friend or family member in the form of exhortations to eat more or expressions of concern about the patient losing too much weight. This type of behavior may be either intentional or unintentional, driven by envy, insecurity, or a lack of knowledge of the post-operative regimen. Examples of this type of challenge can range from a concerned relative repeatedly asking, “Is that all you’re going to eat?” or serving the patient too much at family dinners, to a partner complaining because there is no longer any ice cream in the house or refusing to buy healthier foods for the home.

Although the effect of weight-loss surgery on romantic relationships tends to be overwhelmingly positive, some patients report significant disruption in their romantic relationships. Family systems theory holds that a homeostatic balance is established and maintained within relationships by each member fulfilling his or her specific role in relation to the other. When one person in a relationship changes, this disrupts homeostasis, and if the relationship does not change accordingly, balance will not be re-established and destabilization will occur.73 Empirical investigation of marital changes after weight-loss surgery suggests that relationships that were strong before surgery tend to stay that way, while relationships that were less healthy originally are more likely to be destabilized.17,62,64,66 For example, an improved self-image and feelings of self-worth may make a patient less willing to tolerate a relationship in which he or she is not treated with kindness and respect.5 In one study, wives rated themselves as more sociable and interesting after surgery, while rating their husbands as less sociable and interesting than they did before surgery.63 As the patient develops a stronger sense of self-worth, the balance of power may shift in a friendship or romantic relationship.5 In a healthy relationship, a new, positive equilibrium is reached, while in an unhealthy one, this shift in power may lead to the dissolution of the relationship. Similarly, because of the disability and ill-health that may accompany severe obesity, some patients may have become reliant on their partners in a variety of ways. As health improves and autonomy grows, the relationship may be disrupted if, as the patient asserts newfound independence, his or her partner feels that he or she has lost an important role or is no longer needed.5,62,63,72 In addition, some patients report that their partners become jealous, or express anxiety about patients leaving the relationship as they lose weight and become more attractive to others.5,66,72

It is worth noting that although patients commonly report improvements in their sexual functioning and sexual relationships after weight-loss surgery, a significant minority of patients report a negative impact on their sex lives.66 For some, wound complications or other early surgical sequelae interfere with sexual functioning.62,70 Some patients may experience a short-term decrease in sex drive after weight-loss surgery5,62,66 Though most patients experience improvement in their body image and improvements in their sexual functioning, for some patients, excess skin, which can develop after a significant weight loss, may actually worsen body image10 and increase inhibitions toward sexual intimacy.66


New Experiences

As weight-loss surgery patients lose weight and regain energy, mobility, and self-confidence, they may begin to find themselves in a variety of situations that they have not encountered in the past, or which they had avoided for some time because of the functional or psychological impact of their obesity.5,74 For example, before surgery many patients find that because of their obesity people do not really see or pay attention to them. After losing weight, however, weight-loss surgery patients sometimes note that they are no longer “invisible.”5 Although in general this is likely to be a positive change, it can be uncomfortable and it may take patients time to become accustomed to being “visible” again.

This newfound visibility may lead to increased romantic or sexual attention, which is welcome and exciting for most patients and contributes to improved confidence, mood, self-esteem, and body image. However, for others, this type of attention may be disruptive. Some patients with a history of sexual abuse may find increased sexual or romantic attention to be threatening.5,17 It has been hypothesized that these patients may experience their extra weight as a defense or protective factor that minimizes the risk of receiving sexual attention or finding themselves in sexual situations,41,75,76 and losing this buffer may lead to feelings of vulnerability.5,17 One study found that patients with a history of sexual abuse lost less weight at 12 months post-surgery.71 Another77 found that while there was no difference in weight loss 2 years after surgery between patients with and without a history of sexual abuse, those with an abuse history were significantly more likely to report having had a psychiatric hospitalization in the first 2 post-operative years. However, it is important to note that a history of sexual abuse is not considered to be a contraindication for weight-loss surgery, and research studies have typically found that such a history has no impact on post-surgical weight loss or psychosocial adjustment in the long term.78-81

Even for those patients for whom an increase in romantic opportunities is a welcome change, this new situation may still pose challenges. Some patients, particularly those who are younger at the time of surgery, report that they had never been involved in romantic relationships before and may never have grown accustomed to dating or developed necessary dating “skills.”5 Learning how to navigate the world of romantic relationships can be a complicated experience, even if it is an enjoyable one. For other patients, it may have been years since they were involved in dating, and they may find that their skills are “rusty,” or that the norms in the dating world have changed. For example, expectations about which party asks or pays for the date, or how quickly sexual activity is introduced, may be quite different now than they were when the patient last dated. For some patients, vigilance about sexually transmitted diseases is a new development that requires some consideration. Those whose fertility may have been impaired by their obesity may not appreciate the increased need for protection against unplanned pregnancy. This is particularly problematic, since there is risk for birth defects in pregnancies occurring within the first 12–18 months after weight-loss surgery.82,83



Although patients presenting for weight-loss surgery are highly motivated to achieve and maintain significant weight loss, they may not anticipate the impact the surgery could have on their interpersonal functioning. Weight-loss surgery typically results in changes experienced as extremely positive and enriching, especially in the interpersonal realm. However, these changes may also present significant challenges. Clinicians caring for weight-loss surgery patients must be aware of the significant changes and challenges that may arise. As noted above, these may include changes in everyday social interactions and close interpersonal relationships, and facing situations with which the patient had little experience before losing weight. There are numerous opportunities for healthcare providers to facilitate successful adjustment to weight-loss surgery.

This may begin even before surgery, with the pre-operative psychosocial evaluation. This evaluation serves the function of identifying potential post-surgical challenges and affords the opportunity to help the patient to proactively formulate appropriate coping strategies. Educating the patient about potential challenges is an important and powerful tool for enhancing adjustment after surgery.84 Further, the evaluating clinician need not be relegated to the role of “gatekeeper”; a mental health practitioner can also serve as the facilitator of whatever intervention is needed to clear the patient’s path to surgery and increase the safety and efficacy of this important medical procedure.45,84-87

During the perioperative and early adjustment period, clinicians who are mindful of the potential changes and challenges discussed above can provide appropriate psychosocial intervention; this may be done within the surgical program itself or, if no appropriate clinician is on staff, referrals can be made to clinicians in the community who have experience working with weight-loss surgery patients.

It is also important that ongoing psychosocial support is available in the long term after weight-loss surgery.17,84,86,88 It is recommended that routine follow-up visits extend beyond the first 6–12 months after surgery, as many of the challenges described above may emerge at a longer latency after surgery.88 Regular, long-term follow up fosters working relationships in which the patient feels comfortable discussing any challenges that may arise, as well as increasing opportunities for doing so. Programs that incorporate or have a close association with mental health providers can provide appropriate referrals for patients to receive assistance in coping with adjustment to life after weight-loss surgery. In addition, other healthcare providers can be helpful to patients navigating the interpersonal challenges that may arise after weight-loss surgery by being aware of the common issues. Sensitivity to these issues will allow medical and mental health providers to provide better care, make sensitive inquiries during routine visits, and make the appropriate referrals when necessary. PP



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2.    Maggard MA, Shugarman LR, Suttorp M, et al. Meta-analysis: surgical treatment of obesity. Ann Intern Med. 2005;142(7):547-559.
3.    Saber AA, Elgamal MH, McLeod MK. Bariatric surgery: the past, present, and future. Obes Surg. 2008;18(1):121-128.
4.    Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. JAMA. 2005;294(15):1909-1917.
5.    Bocchieri LE, Meana M, Fisher BL. Perceived psychosocial outcomes of gastric bypass surgery: a qualitative study. Obes Surg. 2002;12(6):781-788.
6.    Bocchieri LE, Meana M, Fisher BL. A review of psychosocial outcomes of surgery for morbid obesity. J Psychosom Res. 2002;52(3):155-165.
7.    Burgmer R, Petersen I, Burgmer M, de Zwaan M, Wolf A, Herpertz S. Psychological outcome two years after restrictive bariatric surgery. Obes Surg. 2007;17(6):789-795.
8.    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(11):1300-1314.
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10.    van Hout GC, Boekestein P, Fortuin FA, Pelle AJ, van Heck GL. Psychosocial functioning following bariatric surgery. Obes Surg. 2006;16(6):787-794.
11.    Karlsson J, Sjostrom L, Sullivan M. Swedish obese subjects–an intervention study of obesity. Two-year follow-up of health-related quality of life and eating behavior after gastric surgery for severe obesity. Int J Obes Relat Metab Disord. 1998;22(2):113-126.
12.    Karlsson J, Taft C, Ryden A, Sjostrom L, Sullivan M. Ten-year trends in health-related quality of life after surgical and conventional treatment for severe obesity: the SOS intervention study. Int J Obes (Lond). 2007;31(8):1248-1261.
13.    Korenkov M, Shah S, Sauerland S, Duenschede F, Junginger T. Impact of laparoscopic adjustable gastric banding on obesity co-morbidities in the medium- and long-term. Obes Surg. 2007;17(5):683-687.
14.    Kushner RF, Noble CA. Long-term outcome of bariatric surgery: an interim analysis. Mayo Clin Proc. 2006;81(10 suppl):46-51.
15.    O’Brien PE, Dixon JB, Laurie C, et al. Treatment of mild to moderate obesity with laparoscopic adjustable gastric banding or an intensive medical program: a randomized trial. Ann Intern Med. 2006;144(9):625-633.
16.    Sjostrom L, Narbro K, Sjostrom CD, et al. Effects of bariatric surgery on mortality in swedish obese subjects. N Engl J Med. 2007;357(8):741-752.
17.    Wadden TA, Sarwer DB, Womble LG, Foster GD, McGuckin BG, Schimmel A. Psychosocial aspects of obesity and obesity surgery. Surg Clin North Am. 2001;81(5):1001-1024.
18.    Ogden J, Clementi C, Aylwin S. The impact of obesity surgery and the paradox of control: a qualitative study. Psychol Health. 2006;21(2):273-293.
19.    Ashmore JA, Friedman KE, Reichmann SK, Musante GJ. Weight-based stigmatization, psychological distress, & binge eating behavior among obese treatment-seeking adults. Eat Behav. 2008;9(2):203-209.
20.    Friedman KE, Reichmann SK, Costanzo PR, Zelli A, Ashmore JA, Musante GJ. Weight stigmatization and ideological beliefs: relation to psychological functioning in obese adults. Obes Res. 2005;13(5):907-916.
21.    Puhl RM, Andreyeva T, Brownell KD. Perceptions of weight discrimination: prevalence and comparison to race and gender discrimination in America. Int J Obes. 2008;32:992-1000.
22.    Puhl RM, Moss-Racusin CA, Schwartz MB, Brownell KD. Weight stigmatization and bias reduction: perspectives of overweight and obese adults. Health Educ Res. 2008;23(2):347-358.
23.    Rand CS, Macgregor AM. Successful weight loss following obesity surgery and the perceived liability of morbid obesity. Int J Obes. 1991;15(9):577-579.
24.    Andreyeva T, Puhl RM, Brownell KD. Changes in perceived weight discrimination among Americans, 1995-1996 through 2004-2006. Obesity. 2008;16(5):1129-1134.
25.    Crandall CS. Prejudice against fat people: ideology and self-interest. J Pers Soc Psychol. 1994;66(5):882-894.
26.    Friedman JM. Modern science versus the stigma of obesity. Nat Med. 2004;10(6):563-569.
27.    Puhl R, Brownell KD. Bias, discrimination, and obesity. Obes Res. 2001;9(12):788-805.
28.    Schwartz MB, Vartanian LR, Nosek BA, Brownell KD. The influence of one’s own body weight on implicit and explicit anti-fat bias. Obesity (Silver Spring). 2006;14(3):440-447.
29.    Teachman BA, Brownell KD. Implicit anti-fat bias among health professionals: is anyone immune? Int J Obes Relat Metab Disord. 2001;25(10):1525-1531.
30.    Teachman BA, Gapinski KD, Brownell KD, Rawlins M, Jeyaram S. Demonstrations of implicit anti-fat bias: the impact of providing causal information and evoking empathy. Health Psychol. 2003;22(1):68-78.
31.    Chambliss HO, Finley CE, Blair SN. Attitudes toward obese individuals among exercise science students. Med Sci Sports Exerc. 2004;36(3):468-474.
32.    Falkner NH, French SA, Jeffery RW, Neumark-Sztainer D, Sherwood NE, Morton N. Mistreatment due to weight: prevalence and sources of perceived mistreatment in women and men. Obes Res. 1999;7(6):572-576.
33.    Foster GD, Wadden TA, Makris AP, et al. Primary care physicians’ attitudes about obesity and its treatment. Obes Res. 2003;11(10):1168-1177.
34.    Hebl MR, Mannix LM. The weight of obesity in evaluating others: a mere proximity effect. Pers Soc Psychol Bull. 2003;29(1):28-38.
35.    Puhl RM, Schwartz MB, Brownell KD. Impact of perceived consensus on stereotypes about obese people: a new approach for reducing bias. Health Psychol. 2005;24(5):517-525.
36.    Schwartz MB, Chambliss HO, Brownell KD, Blair SN, Billington C. Weight bias among health professionals specializing in obesity. Obes Res. 2003;11(9):1033-1039.
37.    Stunkard AJ, Sorensen TI. Obesity and socioeconomic status–a complex relation. N Engl J Med. 1993;329(14):1036-1037.
38.    Puhl RM, Moss-Racusin CA, Schwartz MB. Internalization of weight bias: Implications for binge eating and emotional well-being. Obesity (Silver Spring). 2007;15(1):19-23.
39.    Wang SS, Brownell KD, Wadden TA. The influence of the stigma of obesity on overweight individuals. Int J Obes Relat Metab Disord. 2004;28(10):1333-1337.
40.    Chen E, Bocchieri-Ricciardi L, Munoz D, et al. Depressed mood in class III obesity predicted by weight-related stigma. Obes Surg. 2007;17(5):673-675.
41.    Kalarchian MA, Marcus MD, Levine MD, et al. Psychiatric disorders among bariatric surgery candidates: Relationship to obesity and functional health status. Am J Psychiatry. 2007;164(2):328-334.
42.    Kasen S, Cohen P, Chen H, Must A. Obesity and psychopathology in women: a three decade prospective study. Int J Obes (Lond). 2007;32(3):558-566.
43.    Stout AL, Applegate KL, Friedman KE, Grant JP, Musante GJ. Psychological correlates of obese patients seeking surgical or residential behavioral weight loss treatment. Surg Obes Relat Dis. 2007;3(3):369-375.
44.    van der Merwe MT. Psychological correlates of obesity in women. Int J Obes (Lond). 2007;31(suppl 2):14-18.
45.    Wadden TA, Butryn ML, Sarwer DB, et al. Comparison of psychosocial status in treatment-seeking women with class III vs. class I-II obesity. Obesity (Silver Spring). 2006;14(suppl 2):90-98.
46.    Wadden TA, Sarwer DB, Fabricatore AN, Jones L, Stack R, Williams NS. Psychosocial and behavioral status of patients undergoing bariatric surgery: what to expect before and after surgery. Med Clin N Am. 2007;91(3):451-469.
47.    Bouchard C. The biological predisposition to obesity: beyond the thrifty genotype scenario. Int J Obes (Lond). 2007;31(9):1337-1339.
48.    Farooqi IS, O’Rahilly S. Genetic factors in human obesity. Obes Rev. 2007;8(suppl 1):37-40.
49.    Wardle J, Carnell S, Haworth CM, Plomin R. Evidence for a strong genetic influence on childhood adiposity despite the force of the obesogenic environment. Am J Clin Nutr. 2008;87(2):398-404.
50.    Bray GA, Ryan DH. Drug treatment of the overweight patient. Gastroenterology. 2007;132(6):2239-2252.
51.    Dansinger ML, Tatsioni A, Wong JB, Chung M, Balk EM. Meta-analysis: the effect of dietary counseling for weight loss. Ann Intern Med. 2007;147(1):41-50.
52.    Elfhag K, Rossner S. Who succeeds in maintaining weight loss? A conceptual review of factors associated with weight loss maintenance and weight regain. Obes Rev. 2005;6(1):67-85.
53.    Foster GD, Makris AP, Bailer BA. Behavioral treatment of obesity. Am J Clin Nutr. 2005;82(1 suppl):230-235.
54.    Mun EC, Blackburn GL, Matthews JB. Current status of medical and surgical therapy for obesity. Gastroenterology. 2001;120(3):669-681.
55.    Wadden TA, Butryn ML, Byrne KJ. Efficacy of lifestyle modification for long-term weight control. Obes Res. 2004;12(suppl):151-162.
56.    Wadden TA, Butryn ML, Wilson C. Lifestyle modification for the management of obesity. Gastroenterology. 2007;132(6):2226-2238.
57.    Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gastric bypass surgery. N Engl J Med. 2007;357(8):753-761.
58.    Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292(14):1724-1737.
59.    Buchwald H. Bariatric surgery for morbid obesity: health implications for patients, health professionals, and third-party payers. J Am Coll Surg. 2005;200(4):593-604.
60.    Fabricatore AN, Wadden TA, Sarwer DB, Faith MS. Health-related quality of life and symptoms of depression in extremely obese persons seeking bariatric surgery. Obes Surg. 2005;15(3):304-309.
61.    Wadden TA, Sarwer DB. Behavioral assessment of candidates for bariatric surgery: a patient-oriented approach. Obesity (Silver Spring). 2006;14(suppl 2):53-62.
62.    Rand CS, Kowalske K, Kuldau JM. Characteristics of marital improvement following obesity surgery. Psychosomatics. 1984;25(3):221-223,226.
63.    Hafner RJ. Morbid obesity: effects on the marital system of weight loss after gastric restriction. Psychother Psychosom. 1991;56(3):162-166.
64.    Applegate KL, Friedman KE, Grant JP. Assessments of relationship satisfaction and stability one year after weight loss surgery: a prospective study [abstract]. Surg Obes Relat Dis. 2006;2(3):310.
65.    Cooper KM, Wells M. Effects of bariatric surgery on marital satisfaction [abstract]. Surg Obes Relat Dis. 2006;2(3):334.
66.    Kinzl JF, Trefalt E, Fiala M, Hotter A, Biebl W, Aigner F. Partnership, sexuality, and sexual disorders in morbidly obese women: Consequences of weight loss after gastric banding. Obes Surg. 2001;11(4):455-458.
67.    Kinzl JF, Traweger C, Trefalt E, Biebl W. Psychosocial consequences of weight loss following gastric banding for morbid obesity. Obes Surg. 2003;13(1):105-110.
68.    Rand CS, Kuldau JM, Robbins L. Surgery for obesity and marriage quality. JAMA. 1982;247(10):1419-1422.
69.    Sarwer DB, Wadden TA, Fabricatore AN. Psychosocial and behavioral aspects of bariatric surgery. Obes Res. 2005;13(4):639-648.
70.    Camps MA, Zervos E, Goode S, Rosemurgy AS. Impact of bariatric surgery on body image perception and sexuality in morbidly obese patients and their partners. Obes Surg. 1996;6(4):356-360.
71.    Ray EC, Nickels MW, Sayeed S, Sax HC. Predicting success after gastric bypass: the role of psychosocial and behavioral factors. Surgery. 2003;134(4):555-563.
72.    Andrews G. Intimate saboteurs. Obes Surg. 1997;7(5):445-448.
73.    Klein D, White J. Family Theories: An Introduction (Understanding Families). 2nd ed. Thousand Oaks, CA: Sage Publicatons; 2002.
74.    Hsu LK, Benotti PN, Dwyer J, et al. Nonsurgical factors that influence the outcome of bariatric surgery: a review. Psychosom Med. 1998;60(3):338-346.
75.    Felitti VJ. Childhood sexual abuse, depression, and family dysfunction in adult obese patients: a case control study. South Med J. 1993;86(7):732-736.
76.    Wiederman MW, Sansone RA, Sansone LA. Obesity among sexually abused women: an adaptive function for some? Women Health. 1999;29(1):89-100.
77.    Clark M, Hanna B, Mai J, et al. Sexual abuse survivors and psychiatric hospitalization after bariatric surgery. Obes Surg. 2007;17(4):465-469.
78.    Buser A, Dymek-Valentine M, Hilburger J, Alverdy J. Outcome following gastric bypass surgery: impact of past sexual abuse. Obes Surg. 2004;14(2):170-174.
79.    Fujioka K, Yan E, Wang HJ, Li Z. Evaluating preoperative weight loss, binge eating disorder, and sexual abuse history on Roux-en-Y gastric bypass outcome. Surg Obes Relat Dis. 2008;4(2):137-143.
80.    Larsen JK, Geenen R. Childhood sexual abuse is not associated with a poor outcome after gastric banding for severe obesity. Obes Surg. 2005;15(4):534-537.
81.    Oppong BA, Nickels MW, Sax HC. The impact of a history of sexual abuse on weight loss in gastric bypass patients. Psychosomatics. 2006;47(2):108-111.
82.    Wax JR, Pinette MG, Cartin A, Blackstone J. Female reproductive issues following bariatric surgery. Obstet Gynecol Surv. 2007;62(9):595-604.
83.    Woodard CB. Pregnancy following bariatric surgery. J Perinat Neonatal Nurs. 2004;18(4):329-340.
84.    Sogg S, Mori DL. Revising the Boston Interview: incorporating new knowledge and experience. Surg Obes Relat Dis. 2008;4(3):455-463.
85.    Bauchowitz A, Azarbad L, Day K, Gonder-Frederick L. Evaluation of expectations and knowledge in bariatric surgery patients. Surg Obes Relat Dis. 2007;3(5):554-558.
86.    Lanyon R, Maxwell B. Predictors of outcome after gastric bypass surgery. Obes Surg. 2007;17(3):321-328.
87.    Sogg S, Mori DL. The boston interview for gastric bypass: determining the psychological suitability of surgical candidates. Obes Surg. 2004;14(3):370-380.
88.    Greenberg I, Sogg S, Perna F. Behavioral and psychological care in weight loss surgery–best practice update. Obesity. In press.


Dr. Robinson is a consultant with Worldwide Drug Development in Burlington, Vermont.

Disclosure: Dr. Robinson has served as a consultant to Bristol-Myers Squibb, Epix, Johnson and Johnson, PGxHealth, Pfizer, and Schering.



The profound influence of the pharmaceutical and drug devices industry on clinical medicine, medical education, and research is a source of growing concern raised in the medical literature and media.1,2 The potential for bias due to commercial interests prompted editors of leading international medical journals to endorse greater transparency in reporting of clinical trials regarding authorship, financial support, and potential conflict of interest as a prerequisite for reviewing submitted manuscripts.3,4 This editorial posture taken by prestigious medical journals worldwide helped foster legislation that requires advance registration of phase II and III clinical trials prior to study inception.5

Evidence-based medicine has become the accepted standard for the teaching and practice of medicine.6 A basic premise underlying informed decision-making is accurate and complete reporting of clinical trial outcomes. Applying principles of evidence-based medicine to psychiatric practice is essential.7,8 Three recent articles9-11 explore issues of selective reporting of clinical trial data, guest authorship, and ghostwriting in reports of drugs with psychotropic effects.


Selective Publication of Antidepressant Efficacy Trials

Academic investigators lacking ties to the pharmaceutical industry conducted a comprehensive review9 of Food and Drug Administration documents pertaining to pre-approval phase 2 and phase 3 efficacy trials of 12 antidepressants. These antidepressants, approved for marketing between 1987 and 2004, involved enrollment of >12,500 adult patients in efficacy trials. FDA medical and statistical review documents for each of the antidepressants were procured through the Freedom of Information Act12 and the FDA Web site.13 Turner and colleagues9 examined efficacy data from randomized, double-blind, placebo-controlled trials reported to the FDA and compared these data with that contained in published reports of efficacy trials for each of these drugs. Only data for approved dosages were included in the analyses. Each efficacy trial is categorized in the FDA Summary Basis of Approval (SBA) document as positive (ie, indicative of efficacy) or negative (ie, inconclusive or no efficacy).

Turner and colleagues9 conducted an exhaustive literature search to identify all placebo-controlled clinical trials published for each of the antidepressants. Their search strategy involved several steps: searching for articles in PubMed; searching for references cited in review articles; searching the Cochrane Central Registry of Controlled Trials; contacting the medical information department of each pharmaceutical sponsor; and finally, contacting in writing by certified letter addressed to the medical-information department of the drug sponsor to request a written response to the query of whether the results of an efficacy trial listed in the SBA document had been published. If none of these steps yielded evidence of publication, it was concluded that the efficacy results for the trial had never been reported.

Comparison of FDA regulatory data with published data included statistical analyses that compared sample sizes as reported to the FDA and in published trial reports, and computed effect-sizes for each drug from data contained in FDA documents versus published reports. A single weighted effect size for each antidepressant was derived by pooling data from published journal articles. This value was compared with the computed effect size from the FDA medical and statistical review documents, which contain complete data sets for each antidepressant, both published and unpublished.


Efficacy Outcome and Publication Status

Turner and colleagues9 examined the publication status of FDA-registered antidepressant efficacy trials over the period from the mid-1980s onward. Of 74 clinical trials registered with the FDA and included in the new drug applications of the 12 antidepressants, no evidence of publication was found for 23 (31%) of the placebo-controlled efficacy trials (Table). Unavailability of published data in peer-reviewed journals for 23 of these antidepressants amounts to information on a total of 3,500 patients in therapeutic trials unavailable to public scrutiny.



In the FDA medical and statistical reviews, it was deemed that 38 of the 74 efficacy trials (51%) were positive studies, and all but one of these trials have been published. The remaining 36 studies (49%) were either negative (n=24) or were considered inconclusive for efficacy (n=12). Of these, 11 studies were published as being positive efficacy trials even though they conflicted with the FDA assessment. Only three of 24 negative efficacy trials (13%) have been published.

An important finding of this analysis is that negative efficacy trials of antidepressants (and presumably, most psychotropics) are infrequently reported in the medical literature. Furthermore, trials with mixed or inconclusive efficacy outcomes are often reported as positive studies, even though the primary outcome measure may have failed to show efficacy and may not be apparent in the report.


Effect Sizes of Antidepressants versus Published Data

Turner and colleagues9 computed weighted effect-size values from pooling of journal reports for each antidepressant and compared this value with effect sizes computed from the FDA summary documents. In each instance, the computed effect-size based on the published literature was higher than the effect-size value based on FDA documentation. The weighted effect sizes from the published literature ranged from 11% to 69% higher than the effect sizes computed from FDA data (mean=32%, P<.001). It is interesting that effect sizes using the FDA database ranged from 0.2–0.4 for the 12 antidepressants, where 0.2 is regarded as a small effect size and 0.5 a medium effect size. Effect sizes based on pooled published reports were consistently higher for every one of the 12 antidepressants, and effect size exceeded 0.5 for mirtazapine, paroxetine, and venlafaxine.

The findings of this study should be interpreted cautiously. It must be kept in mind that absence of statistical significance in a trial does not necessarily signify lack of efficacy. There can be valid reasons during the second and third phases of development for trials to fail unrelated to intrinsic efficacy of the agent. Failed and negative trials may result from escalating placebo response rates in efficacy studies, a changing population of depressed subjects recruited primarily by advertisement, or a relative dearth of competent investigators who carefully select and rate patients who are likely to be drug responsive.14,15 There are numerous factors influencing whether results of a study may go unpublished, including failure to submit manuscripts or decisions by journal editors not to accept negative trials. The recently established clinical trial registries and the requirement of journals and the FDA that trials be registered may foster wider dissemination of efficacy outcomes of trials.4,5


Guest Authorship and Ghostwriting

Apparent misrepresentation of clinical trial results and manipulation of research articles relating to rofecoxib (Vioxx) has emerged as a result of litigation.1,10,11 Court documents originally obtained during litigation against Merck and Company allowed access to company policies and decision making regarding publication of clinical trial results of rofecoxib.

A recent study10 by authors involved in the litigation and interested in company practices about guest authorship, ghostwriting, and financial disclosures examined several thousand court documents to investigate these issues. Guest authorship is defined as designation of an individual as author who does not meet accepted authorship criteria; that is, an individual who did not make a substantial contribution to the research or writing the manuscript.16 Inspection of the rofecoxib litigation yielded approximately 250 documents relating to publication of clinical trials of rofecoxib and allowed a determination to be made as to use of professional medical writing in manuscript preparation and subsequent recruitment of opinion leaders to be authors. Internal documents revealed that Merck marketing employees commonly hired medical writing companies to ghostwrite scientific review articles and recruited external experts to serve as authors. Recruited authors of ghostwritten papers often served as sole author and received an honorarium. Numerous instances were found where authors did not appear to be involved in the design or conduct of the study or to have made substantive contributions to the manuscript other than minor editing. Among 96 relevant published articles, the authors found that 92% (22 of 24) of published clinical trials disclosed Merck financial support, but only 50% (36 of 72) of therapeutic review articles about rofecoxib disclosed Merck sponsorship or financial compensation of the author.


Data Misrepresentation and Selective Reporting

Two biostatisticians, also involved in the rofecoxib litigation and familiar with the clinical data, examined internal documentation relating to three placebo-controlled clinical trials of rofecoxib in the treatment of Alzheimer patients. The authors also conducted their own independent statistical analysis of the safety data from these long-term multicenter trials.11 In April 2001, the drug sponsor conducted an intention-to-treat analysis that revealed increased risk of mortality associated with rofecoxib treatment of cognitive impairment among patients with Alzheimer’s disease, but this analysis was not submitted to the FDA until 2003. Instead, the data reported to the FDA in 2001 as part of a required annual safety update used a variety of counting methods, such as an on-treatment analyses. This type of statistical analysis, unlike a more conservative intention-to-treat analysis, minimized appearance of excess mortality risk with rofecoxib. The drug sponsor also failed to inform investigational review boards of the findings of the intention-to-treat analysis as required. Investigators in the ongoing multi-year study remained blind to this emerging safety data, unlike the Merck research staff, who failed to discern a safety issue. The company allowed the study to continue for 2 more years because of slower than planned enrollment.

A review article, funded by Merck and published in November 2001, based on a meta-analysis of cardiovascular thrombotic events in 23 clinical trials of this cyclo-oxygenase agent included two of the rofecoxib Alzheimer’s disease trials, yet the authors, five of whom were Merck employees, did not take the opportunity to report the mortality findings of the intention-to-treat analysis.11 It was not until July 2003, that a final safety report filed with the FDA furnished this evidence of excess mortality in Alzheimer’s disease patients (Hazard Ratio, 2.71, P<.001). Independent analysis by the authors of the present report of the Alzheimer’s safety data available in 2001 confirms that this excess mortality in elderly patients associated with rofecoxib treatment was known.11



Three studies that prompted a recent Journal of the American Medical Association editorial1 examined issues pertaining to the reporting clinical trial data.9-11 Greater than 30% of pre-approval, placebo-controlled, efficacy trials of antidepressants approved in the past 15 years were found never to have been published. Guest authorship and ghostwriting of articles was a frequent practice for a popular drug, later removed from the market for safety reasons. For the same drug, apparent misreporting of mortality data in Alzheimer’s disease patients occurred. Accurate and complete reporting of clinical trial results is essential to the teaching and practice of evidence-based medicine. Precautions taken by medical journals, such as submitting original study protocols and independent statistical analyses, may be necessary to ensure accuracy and transparency of published reports. PP



1.    DeAngelis CD, Fontanarosa PB. Impugning the integrity of medical science: the adverse effects of industry influence. JAMA. 2008;299:1833-1835.
2.    Carlat D. Dr drug rep. New York Times Magazine. November 25, 2007.
3.    Angell M. Time for a drug test registry. Washington Post.com. August 13, 2004:25.
4.    International Committee of Medical Journal Editors. Uniform requirements for manuscripts submitted to biomedical journals. Available at: http://icmje.org. Accessed July 9, 2008.
5.    Food and Drug Administration Amendments Act of 2007. HR3580, enacted by the House and Senate, Pub L No 110-85. Available at: http://frwebgate,access,gpo.gov/cgi-bin/getdoc.cgi?dbname=110_cong_bills&docid=f:h3580enr.txt.pdf. Accessed October 11, 2007.
6.    Sackett DL, Strauss SE, Richardson WS, et al. Evidence-Based Medicine: How to Practice and Teach EBM. New York, NY: Churchill-Livingston; 2000.
7.    Gray GE, Pinson LA. Evidence-based medicine and psychiatric practice. Psychiatr Q. 2003;74(4):387-399.
8.    Gupta M. Does evidence-based medicine apply to psychiatry? Theor Med Bioeth. 2007;28(2):103-120.
9.    Turner EH, Matthews AM, Linardatos E, Tell RA, Rosenthal R. Selective publication of antidepressant trials and its influence on apparent efficacy. N Engl J Med. 2008;358(3):252-260.
10.    Ross JS, Hill KP, Egilman DS, Krumholz HM. Guest authorship and ghostwriting in publications related to rofecoxib: a case study of industry documents from rofecoxib litigation. JAMA. 2008;299(15):1800-1812.
11.    Psaty BM, Kronmal RA. Reporting mortality findings in trials of rofecoxib for Alzheimer disease or cognitive impairment: a case study based on documents from rofecoxib litigation. JAMA. 2008:299(15):1813-1817.
12.    Committee on Governmental Reform, U.S. House of Representatives, 109th Congress, 1st session. A citizen’s guide on using the Freedom of Information Act and the Privacy Act of 1974 to request government records. Report no. 109-226. Washington, DC: Government Printing Office; 2005.
13.    Center for Drug Research. Food and Drug Administration. Rockville, Maryland. Available at: www.fda.gov/cder/foi/nda. Accessed July 9, 2008.
14.    Robinson DS, Rickels K. Concerns about clinical drug trials. J Clin Psychopharmacol. 2000;20(6):593-596.
15.    Kobak KA, Kane JM, Thase ME, Nierenberg AA. the problem of measurement error in clinical trials: time to test new paradigms? J Clin Psychopharmacol. 2007;27(1):1-5.
16.    Rennie D, Yank V, Emmanuel L. When authorship fails: a proposal to make contributors accountable. JAMA. 1997;278(7):579-585.


Ms. Nesbitt is music therapist and Ms. Tabatt-Haussmann is art therapist in the Pediatrics Department at New York University Langone Medical Center in New York City.

Disclosure: The authors report no affiliation with or financial interest in any organization that may pose a conflict of interest.

Please direct all correspondence to: Kim Tabatt-Haussmann, MA, ATR-BC, Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders, 160 E 32nd St, Second Floor, New York, NY 10016; Tel: 212-263-9923; Fax: 212-263-8410; E-mail: kim.tabatt@nyumc.org.



Focus Points

• The use of the creative arts therapies in pain management is a successful non-pharmacologic intervention.
• The presence of music and art therapy provide a context of normalization for a child in a medical environment.


The positive effects of art and music therapies for distraction during medical visits and procedures have been well studied. These interventions can reduce anxiety, promote relaxation, and minimize the perception of pain. This article describes combined art and music therapy interventions in the pediatric oncology/hematology environment and discusses various goals addressed during out-patient visits. Patient experiences are described as they relate to engagement in procedural accompaniments, creative arts therapy groups, individual therapy sessions, and group music therapy sessions. Interventions discussed include art making, active music listening, progressive muscle relaxation, music technology, active participation in music making, songwriting, and lyric analysis. The patients’ social, emotional, cognitive, and physical outcomes are discussed as they relate to treatment. In addition, the significance of the interventions for creative arts therapy practiced and researched is explored.



For over 50 years, creative arts therapists have been used in hospital environments to facilitate relaxation, decrease anxiety, and provide distraction. During this time, extensive research documented in medical journals has proven that non-pharmacologic interventions such as art and music therapy have a positive impact on the patient’s quality of life.1-5

The following description offers insight into the interventions provided by the art and music therapists at an outpatient pediatric hematology/oncology clinic at New York University Langone Medical Center. Both therapists worked individually with patients and families and exercised their specific skills to achieve various goals, including facilitating relaxation, providing social and peer interaction, decreasing anxiety, and providing an environment to normalize the patient within the medical environment. In the past year both disciplines collaborated so that patients and their families could have more opportunities to actively participate in the creative arts. The outcome was extremely positive.


The Creative Arts Defined

Music therapy is the art of using music to address a non-musical goal. In pediatric medical settings, the music therapist particularly focuses on decreasing a patient’s anxiety and normalizing the hospital or clinical environment through music activities.1-5 A variety of interventions can be used to bring about relaxation, promote normalization, and provide distraction, including progressive muscle relaxation with music, music and imagery, hypnosis, procedural accompaniment, songwriting, lyric analysis, and music and movement.1-5

In a medical environment, the music therapist works with patients, families, and medical staff in the treatment room. During various procedures, the therapist engages the patient in live music and introduces relaxation skills, including self-hypnosis, progressive muscle relaxation, and music-assisted imagery, to distract the patient from pain and decrease anxiety. Music therapy establishes a “therapeutic environment that enhances the effects of medication and involves patients in activities that direct attention away from the stresses of illness.”3 Once patients focus less on the stress and anxiety of an illness, their perception of pain often abates. West4 relates that relaxation, a goal in music-therapy interventions, decreases muscle tension and anxiety and results in a “positive influence on pain perception, nausea, and other symptoms.”

Art therapy, with the creative process of art making, improves and enhances the physical, mental, and emotional well being of individuals of all ages. It is based on the belief that clinical intervention with the act of art making can heal patients and enhance their quality of life while helping to reduce stress, increase self awareness, and cope with difficult experiences.6-11

Medical art therapy is a term applied to “the use of art expression and imagery with individuals who are physically ill, experiencing trauma to the body, or who are undergoing aggressive medical treatment such as surgery or chemotherapy.”7 A study of the innovative use of art therapy in relieving symptoms in cancer provides beginning evidence for the efficacy of art therapy in reducing a broad spectrum of symptoms in cancer patients.8

“When art therapy is partnered with medical treatment, children can meet the challenges of serious illness. For instance, when children create art in the medical setting, they have a sense of the familiar that produces pleasurable and positive associations. The child artist gains control by mastering art materials and developing personal imagery in a situation that is often out of his/her control.”9

A study of art therapy as a support for children during painful procedures was shown to be a useful intervention that can prevent permanent trauma and support children and parents during intrusive interventions.10

In medical settings, when children are not well enough or are unable to visit the playroom for an art therapy group, individual art therapy sessions can be provided in the treatment room so as to normalize their clinic environment and provide opportunities for socialization and expression.

“One of the contributions of art therapy to cancer treatment is the possibility of helping young people emerge from their illness as emotionally whole and healthy as possible. Encouraging growth and development through art activities can help the ill child preserve many areas of normal functioning.”12


A Collaborative Approach: Art and Music Group at the Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders

Art therapy and music therapy used collaboratively in a group provides the children and families with an outlet for stress management. In such an environment, they can sustain social and peer interactions as well as normalization. In addition, they have an opportunity to develop effective coping skills. Furthermore, art and music “therapists can address the functional skills of individual patients and encourage improved social skills, while providing the emotional outlet that is necessary for patients and families involved” in treatment for cancer and blood disorders.5 The art and music group takes place 1–2 times a week during clinic hours. Patients are invited to the Wellness Room, which is a large, open, non-threatening space with ceiling tiles designed as night-time stars. A large sheet of blank mural paper lies in the center of the room, and plush pillows and blankets are placed around the art area for the patients’ comfort. Children, parents, and siblings are assisted into the room, and markers, crayons, colored pencils, foam cutouts, and a variety of other art mediums are available. The music therapist sitting on a bench near the art area begins the session by introducing a theme, such as a trip to the zoo, life under the sea, space exploration, future dreams, or the patient’s view of him- or herself. The music therapist chooses appropriate music for the theme, and the art therapist asks the patients to close their eyes or focus on the song lyrics. After the music therapist sings and plays the first verse of the song, the art therapist invites the children to draw, color, or paint what or how the music made them feel. As the group progresses, different songs related to the theme are introduced. This technique facilitates diverse imagery evident by the distinctive pictures that appear on the mural paper. At the conclusion of the group, patients are asked to draw a final image reflecting the creative arts group theme. The result is a beautiful, unique mural designed by the participants that reflects their self-concept and emotions.


Benefits of Combining Art and Music Therapy

Combining art and music therapy at the Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders (SDHCC) of New York University Langone Medical Center not only increases the participants’ creativity but also distracts them from the clinic environment. The interventions offered within the group “focus the attention away from the physical sensation of pain to other aspects of the person.”13 Pediatric-oncology patients are confronted with numerous challenging situations, as most of them have to undergo chemotherapy, radiation, and surgery. Because of their treatment, they are unable to experience a carefree childhood. Since patients often experience the side effects of treatment, including pain and nausea, non-pharmacologic treatments are extremely important in distracting them from the psychological aspects of pain. Music and art therapies actively involve patients in the creative process and, as a result, are able to draw attention “toward the art and music.”9 Therefore, “when an investment in the art or music occurs, an exchange of energy results, and energy is refocused [away] from the pain.”13 When music and art work together to enhance the creative process, the outcome is positive because it reveals decreased anxiety, distraction from pain, and increased relaxation response.

The music and art therapy group also provides children and families with an opportunity to develop a positive social support group. Not only do pediatric patients miss out on classroom activities with their teachers and peers when they are at a clinic, but they miss out on being with their friends and participating in community activities as well. However, with the combination of music and art in a social setting, children are able to socialize with peers in similar circumstances and not feel as isolated. In the creative arts group, patients have the opportunity to feel normal, make friends, work on art together, play and sing, learn, and, most importantly, have fun in a safe creative environment.


The Music and Art Group Defined

Patients visit the outpatient clinic with parents/guardians, siblings, grandparents, other relatives and friends. Because cancer affects the child’s family and network of support, the therapists encourage and invite caregivers to actively participate in the creative arts group. Focusing on family-centered care, the group aims to reduce anxiety and educate participants on effective coping skills and relaxation tools to increase understanding and support. For each caregiver present, the group work reinforces the idea that the child’s creativity, imagination, development, and spirit are maintained and validated throughout their treatment.

The Music and Art Group is a 45-minute session that takes place in a controlled and comfortable space with minimal design and distraction. The Wellness Room is separate from the playroom and waiting room, which helps participants focus on the music and art. Mural paper is placed in the middle of the floor as well as markers, crayons, foam shapes, and colored pencils. Pillows surround the paper, posing as comfortable seats for the participants.

The therapists decide on a theme for the group (eg, animals, beach activities, rainbows, water and outer space) that has vivid imagery related to it. After the music therapist collects appropriate song material, both therapists gather the patients to begin the group. The art therapist provides various materials and co-facilitates guiding participants in imagery before the art creating begins.

The group is encouraged to sit comfortably and participate in active listening, a music therapy intervention. As the music therapist performs the song, participants are asked to listen to the music, close their eyes, and imagine the pictures that come to mind from the song lyrics. Songs performed in the past to elicit vivid imagery include “Going to the Zoo,” “Under the Sea,” “Rocketship Run,” and “Puff the Magic Dragon” (Figures 1–4).


While the music therapist continues to perform a variety of theme-related songs, the patients and families, who often sing along, are encouraged by the art therapist to begin drawing images on the mural paper. While they are listening and singing, the art therapist helps the participants think about the song and images that come to mind. Working on one piece of mural paper, which is a metaphor for the group working together, encourages therapeutic play through image making. One initial image inspires another and gradually transforms the mural into storytelling through music and art.

While the group is creating images and listening to the music, individuals often talk about their drawings, and others sing and dance to the music. As they observe the dynamics of the group, the leaders reinforce the idea that there is no right or wrong method.

As the session ends, the therapists review the journey and discuss the images created on the mural paper, naming the particular songs that guided the patients’ imagination. Participants are encouraged to first discuss the images and music then choose a title for the group mural. All participants sign their names on the artwork, an act which increases their self-esteem, produces self-actualization, and provides positive reinforcement for their creative abilities. The group mural is then displayed in the playroom for the SDHCC’s staff, patients, and families. The participants take pride in their finished product, and as a result, more patients are encouraged to participate in the next creative arts group.



Art and music therapy used together is extremely effective, especially with pediatric oncology/hematology patients, because it helps them address the physical issues of pain as well as the emotional issues in a non-pharmacologic and non-threatening way. The dynamics of sound and its impact on physical symptoms should be understood. For example, when sound travels through the “reticular activating system of the brain stem [and] coordinates sensory input, it alerts the cortex to incoming information.”1 Therefore, when the brain is activated, the sound “competes for cognitive awareness” and causes pain and nausea to be ignored.1

Music therapy and its effect on anxiety and relaxation have been well documented in research and case studies over the years.2,5,13,14 Hanser2 reports decreased scores on the A-State Anxiety Inventory in the presence of induced anxiety when music is playing, whereas Trauger-Querry relates that music has a way to “engage, activate and alter affective, cognitive and sensory processes through distraction, alteration of mood, improved sense of control, the use of prior skills and relaxation.”2,13 Exercising these skills and establishing a normal environment where pediatric patients can play and have fun without thinking about their illness is of paramount importance.
Imagery, facilitated by the art and music therapist, is another layer that can be added to musical stimuli in diverting pain perception. A study in which progressive muscle relaxation and guided imagery was used to delay or prevent “chemotherapy-induced nausea and vomiting” with HIV patients was conducted, and the findings demonstrated that 24 hours after chemotherapy, the experimental group, having used guided imagery techniques, had decreased levels of nausea for up to 60 hours after treatment.15 As patients focus positively and reach new levels of awareness through music and art, their tension and anxiety decrease. PP



1.    Skaggs R. The Bonny Method of Guided Imagery and music in the treatment of terminal illness: a private practice setting. Music Therapy Perspectives. 1997;15(1):39-44.
2.    Hanser SB. Music therapy and stress reduction research. J Music Ther. 1985;22:193-206.
3.    Blom RC, Wylie ME. Guided imagery and music with hospice patients. Music Therapy Perspectives. 1986;3:25-28.
4.    West TM. Psychological issues in hospice music therapy. Music Therapy Perspectives. 1994;12(2):117-124.
5.    Barker VL, Brunk B. The role of a creative arts group in the treatment of clients with traumatic brain injury. Music Therapy Perspectives. 1991;9:26-31.
6.    Malchiodi C. Medical art therapy with children. London, UK: Jessica Kingsley Publishers; 1999.
7.    Malchiodi C. Introduction to special issue: art and medicine. Art Ther J Am Art Ther Assoc. 1993;10(2):66-69.
8.    Nainis N, Paice J, Ratner J, Wirth J, Lai J, Shott S.  Relieving symptoms in cancer: innovative use of art therapy. J Pain Symptoms Manage. 2006;31:162-169.
9.    Council T. Art Therapy with pediatric cancer patients: helping normal children cope with abnormal circumstances. Art Ther J Am Art Ther Assoc. 1993;10(2):78-87.
10.    Favara-Scacco C, Smirne G, Schilirò G, Di Cataldo A. Art therapy as support for children with leukemia during painful procedures. Med Pediatr Oncol. 2001;36(4):474-480.
11.    Walsh SM, Martin SC, Schmidt LA. Testing the efficacy of a creative arts intervention with family caregivers of patients with cancer. J Nurs Scolarsh. 2004;36(3):214-219.
12.    Council T. Art Therapy with pediatric cancer patients. In: Malchiodi C, ed. Medical Art Therapy with Children. 1st ed. New York, NY: Jessica Kingsley Publishers; 1999:91.
13.    Trauger-Querry B, Haghighi KR. Balancing the focus: art and music therapy for pain control and symptom management in hospice care. Hospice J. 1999;14(1):25-38.
14.    Logan T, Roberts A. The effects of different types of relaxation music on tension level. J Music Ther. 1984;21:177-183.
15.    Capeli B, Anastasi JK. A symptom review: nausea and vomiting in HIV. J Assoc Nurses AIDS Care. 1998;9(6):47-56.


Dr. Levenson is professor in the Departments of Psychiatry, Medicine, and Surgery, chair of the Division of Consultation-Liaison Psychiatry, and vice chair for clinical affairs in the Department of Psychiatry at Virginia Commonwealth University School of Medicine in Richmond.

Disclosure: Dr. Levenson reports no affiliation with or financial interest in any organization that may pose a conflict of interest.


This column begins a series reviewing the interface between dermatology and psychiatry. Dermatologists and primary care physicians frequently encounter important psychiatric issues affecting diagnosis and management of patients with dermatologic complaints. Psychiatrists contend with frequent pruritus and rashes in their patients. A study of psychiatric inpatients excluding those with known skin diseases found that 33% of patients reported itching.1 Psychological factors affect numerous dermatologic conditions including atopic dermatitis, psoriasis, alopecia areata, urticaria and angioedema, and acne vulgaris. Some dermatologic conditions are best considered as idiopathic functional disorders such as idiopathic pruritus, which can be generalized or focal (eg, pruritus ani, vulvae, scroti). Some primary psychiatric disorders present with primarily physical symptoms to dermatologists, including body dysmorphic disorder (BDD) and delusional disorder, somatic type (eg, delusions of parasitosis, delusions of a foul body odor). Indeed, most patients with delusions of parasitosis or BDD avoid visiting psychiatrists or other mental health professionals and resist referral. In addition, dermatologists see patients with compulsive behaviors that may be part of obsessive-compulsive disorder or stand alone (eg, trichotillomania, psychogenic excoriation, onychophagia). Factitious skin disorders include factitious dermatitis (ie, dermatitis artefacta) and psychogenic purpura. Another important aspect of the interface between psychiatry and dermatology is the range of dermatologic adverse reactions to psychotropic drugs. More detailed coverage of these topics can be found elsewhere.2,3 This part of the series focuses on atopic dermatitis and psoriasis.


Atopic Dermatitis

Atopic dermatitis (ie, atopic eczema) is a chronic skin disorder characterized by pruritus and inflammation (ie, eczema), starting as an erythematous, maculopapular rash. Scratching is hard to resist and leads to excoriation and secondary infection, resulting in lichenification. Atopic dermatitis is the most common inflammatory skin disease of childhood and remains fairly common in adults. It typically begins in children or adolescents with a personal or family history of atopic dermatitis, allergic rhinitis, or asthma. In most patients, atopic dermatitis is a recurrent, relapsing disorder, with a vicious cycle of itching and scratching that leads to chronicity.


Atopic Dermatitis and Stress

The onset or exacerbation of atopic dermatitis often follows stressful life events.4,5 Divorce or separation of parents and severe disease of a family member have been identified as particularly increasing risk.4 Adults with atopic dermatitis are more anxious and depressed compared with clinical and healthy control groups.6,7 Children with atopic dermatitis have higher levels of emotional distress and more behavioral problems than healthy children or children with minor skin problems.


Psychosocial Morbidity in Atopic Dermatitis

Atopic individuals with emotional problems may develop a vicious cycle between anxiety/depression and dermatologic symptoms. In one direction of causality, anxiety and depression are frequent consequences of the skin disorder. The misery of living with atopic dermatitis may have a profoundly negative effect on health-related quality of life (HRQOL) of children and their families. Intractable itching causes significant insomnia, and sleep deprivation leads to fatigue, mood lability, and impaired functioning. Teasing and bullying by children and embarrassment in adults and children can cause social isolation and school avoidance. The social stigma of a visible skin disease, frequent visits to doctors, and the need to constantly apply messy topical remedies all add to the burden of disease. Lifestyle restrictions in more severe cases can be significant, including limitations on clothing, staying with friends, owning pets, swimming, or playing sports. The impairment of quality of life caused by childhood atopic dermatitis has been shown to be greater than or equal to that of asthma or diabetes.8

In the other direction of causality, anxiety and depression aggravate atopic dermatitis. This may occur via several possible mechanisms, including modulation of pruritus perception,9 perturbation of epidermal permeability barrier homeostasis,10 or acceleration of immune responses.6


Psychiatric and Psychological Treatments for Atopic Dermatitis

A wide variety of treatments for atopic dermatitis have been advocated to interrupt the vicious cycle of itching and scratching. Mental health interventions include psychological, behavioral, and psychoeducational therapies and psychotropic medications. There have been several randomized controlled trials of psychological and educational interventions (eg, relaxation training, habit reversal training, cognitive-behavioral techniques, stress management training) as an adjunct to conventional therapy for children with atopic eczema to enhance the effectiveness of topical therapy, but the evidence base remains limited regarding their efficacy.11 Oral and topical doxepin have been used because its potent antihistaminic effects can reduce itching, and oral doxepin’s sedation can promote sleep. A systematic review of controlled trials12 of 47 different interventions concluded that there was reasonable evidence to support the use of oral cyclosporine, topical corticosteroids, psychological approaches, and ultraviolet light therapy. However, there was insufficient evidence to make recommendations regarding oral or topical antihistamines (eg, doxepin), maternal allergen avoidance for prevention, dietary restriction in established atopic dermatitis, hypnotherapy, and a variety of other orthodox and alternative medical interventions.



Psoriasis is a chronic, relapsing disease with characteristic scaly lesions varying from pinpoint plaques to extensive skin involvement, nail dystrophy, and often arthritis. Psoriasis is an equally common condition among men and women, affecting 1.5% to 2% of the population in industrialized countries, with onset usually in the third decade of life. Most patients with psoriasis experience unpredictable exacerbations throughout life. The pathogenesis of psoriasis appears to involve genetic and environmental factors, influencing the body’s systems of skin repair, inflammatory defense mechanisms, and immunity.2,3


Psoriasis and Lithium

A particular concern for psychiatrists is lithium-induced psoriasis, which typically occurs within the first few years of treatment. Male patients taking lithium appear to be more susceptible to developing cutaneous reactions to lithium than females. Even a very small amount of psoriasis can be distressing to patients and can undermine medication compliance. Lithium-induced psoriasis is sometimes resistant to psoriatic treatments but resolves after discontinuation of lithium.13 There have also been case reports of psoriasis precipitated or aggravated by olanzapine.14,15


Psychosocial Morbidity in Psoriasis

Psoriasis is associated with a variety of psychological difficulties, including poor self-esteem, sexual dysfunction, anxiety, depression, and suicidal ideation. Psoriasis is associated with substantial impairment of HRQOL, negatively impacting psychological, vocational, social, and physical functioning.16 Not surprisingly, appearance-related concerns dominate the experiences of young people with psoriasis.17 A theme running through the psoriasis literature is conveyed in the conclusion from a systematic review of psychosocial burden of psoriasis: “Social stigmatization, high stress levels, physical limitations, depression, employment problems and other psychosocial co-morbidities experienced by patients with psoriasis are not always proportional to, or predicted by, other measurements of disease severity such as body surface area involvement or plaque severity.”18

A recent cross-sectional study19 of 265 adults with prevalent psoriasis found that 32% of subjects screened positive for depression, with a graded relationship between depressive symptoms and impairment of HRQOL. Only 16.5% of those with high depression scores were receiving treatment for the condition. Depression was highly associated with both illness-related stress and dissatisfaction with antipsoriatic treatment. It was not associated with objective measures of psoriasis severity.19 A survey of 2,391 Italian adults with psoriasis using the Center for Epidemiological Studies-Depression Scale questionnaire found 62% of patients presenting depressive symptomatology. There was no difference in gender; however, younger men were more likely to report depressive symptoms than older men as were all subjects with less education.20

The emotional effects and functional impact of the disease are not necessarily proportionate to the clinical severity of psoriasis.21 In general, psychological factors, including perceived health, perceptions of stigmatization, and depression, are stronger determinants of disability in patients with psoriasis than are disease severity, location, and duration.22 It is not surprising that perceived stress in patients with psoriasis as well as numerous chronic diseases predicts poorer quality of life.23

Studies of the relationship between psychological factors and psoriatic disease severity have been primarily focused on depression. Some investigators found the condition correlated with objective measures of psoriasis severity24 and others have not.19 In a large double-blind, placebo-controlled trial of etanercept,25 which is an effective treatment for the clinical symptoms of psoriasis, patients who received etanercept had significant improvement in both fatigue and depressive sympomatology. Improvement in fatigue was correlated with decreasing joint pain, but improvement in depressive symptomatology was less correlated with objective measures of skin clearance or joint pain.

In a recent prospective study of patients with psoriasis,26 the frequency of psychiatric disturbance decreased with improvement in the clinical severity and symptoms of psoriasis. Other predictors of psychiatric improvement included no psoriatic involvement on the face and sex (ie, women were less likely to improve psychologically). However, the authors concluded that “dermatologists should be aware that even in the presence of vast clinical improvement patients may still substantially suffer psychologically.”26

Psoriasis and Suicide

In addition to the effects of depression on possibly triggering psoriasis and certainly reducing disease-related quality of life, suicide is a concern. One study found that 10% of adults with psoriasis reported suicidal ideation during the previous 2 weeks.27 Gupta and Gupta28 reported suicidal ideation in 2.5% of psoriasis outpatients and 7.2% of inpatients. In an earlier study of a different sample, Gupta and colleagues29 found that 9.7% of patients with psoriasis reported a wish to be dead, and 5.5% reported active suicidal ideation at the time of study. Death wishes and suicidal ideation were associated with higher depression scores and higher patient self-ratings of psoriasis severity.


Psoriasis and Stress

Stress has long been reported to trigger psoriasis.2,3 Uncontrolled studies have reported very high rates of stressful life events preceding the onset of the illness (eg, 68% of adult patients in one study,24 and 50% of children and 43% of adults in another).30 However, perception and recall biases influence such rates. A cross-sectional study23 of 141 adults found that approximately 66% strongly believed that stress was a causal factor for their psoriasis. This belief was significantly associated with higher levels of anxiety, depressive symptomatology, and perceived stress, but there was no association between perceived stress objective measures of psoriasis severity. A large case-control study31 comparing 560 patients with psoriasis to 690 patients with a new diagnosis of skin disease other than psoriasis found a high index of stressful life events associated with patients having more than double the risk of psoriasis compared to low scorers. However, the same study found that current and ex-smokers had approximately double the risk of psoriasis. Not all studies have supported the widely held belief that stressful life events precipitate psoriasis. For example, an investigation32 of outpatients experiencing a recent onset or exacerbation of psoriasis found no difference when comparing them to outpatients with skin conditions in which psychosomatic factors are regarded as negligible. Ultimately, however, most patients who report episodes of psoriasis precipitated by stress describe disease-related stress, resulting from the cosmetic disfigurement and social stigma of psoriasis, rather than stressful major life events or nonspecific distress.2,3

In an experimental study, 40 patients with chronic plaque psoriasis and 40 age-matched normal controls were subjected to acute psychological stressors (ie, cognitive, emotional, social). Patients with psoriasis and, in particular, those who believed that their psoriasis was highly stress responsive, were found to exhibit altered hypothalamic-pituitary-adrenal response to acute social stress, specifically lower post-stressor cortisol levels. The implication is that such patients may perhaps be more vulnerable to flares of their psoriasis.33 The mechanism of stress-induced exacerbations of psoriasis has been speculated to involve the nervous, endocrine, and immune systems, but no definitive pathways have been established. A more direct connection may be the effects of anxiety or depressive symptoms in reducing the threshold for pruritus in psoriatic patients.34

The adverse psychological sequelae of psoriasis are often but not always reduced by effective treatment of the disease, as noted in the study of disease-modifying therapy with etanercept cited earlier.25 A study16 that focused on systematic topical treatment for psoriasis found general quality of life significantly improved following treatment. Body image and appearance, self-esteem, and negative feelings were particularly responsive to clinical change. Domains of spirituality, independence and physical health also improved.


Psychiatric and Psychological Treatments for Psoriasis

There have been case reports of dramatic improvement in psoriasis after anxiolytic drug treatment but no controlled studies. The use of psychological therapies for patients with psoriasis has been proposed based on observations that the severity of their disease may correlate with emotional stress. Meditation, hypnosis, relaxation training, cognitive-behavioral stress management, and symptom control imagery training have received support in controlled trials for their effectiveness in reducing psoriasis activity,2,3 but this evidence base is limited by the size and short duration of the studies. A small (n=51) randomized controlled trial35 of a psychological intervention that entailed seven sessions of individual psychotherapy, including stress management, guided imagery, and relaxation, found some evidence of modest benefit on psoriasis activity.

A small (n=40) nonrandomized, age- and sex-matched case-controlled psychological intervention trial36 investigating the effects of a cognitive-behavioral psoriasis symptom management program showed significant reductions in illness identity (ie, the frequency and severity of symptoms that patients associate with their condition), the strength of belief in severity of consequences of their illness, and patients’ attributions for emotional causes of their psoriasis. PP



1. Mazeh D, Melamed Y, Cholostoy A, Aharonovitzch V, Weizman A, Yosipovitch G. Itching in the psychiatric ward. Acta Derm Venereol. 2008;88(2):128-131.
2. Arnold L. Dermatology. In: Levenson JL, ed. The American Psychiatric Publishing Textbook of Psychosomatic Medicine. 1st ed. Washington, DC: American Psychiatric Publishing; 2005:629-646.
3. Arnold L. Dermatology. In: Levenson JL, ed. Essentials of Psychosomatic Medicine. 1st ed. Washington, DC: American Psychiatric Publishing; 2007:237-260.
4. Bockelbrink A, Heinrich J, Schäfer I, et al. Atopic eczema in children: another harmful sequel of divorce. Allergy. 2006;61(12):1397-1402.
5. Picardi A, Abeni D. Stressful life events and skin diseases: disentangling evidence from myth. Psychother Psychosom. 2001;70(3):118-136.
6. Hashizume H, Horibe T, Ohshima A, Ito T, Yagi H, Takigawa M. Anxiety accelerates T-helper 2-tilted immune responses in patients with atopic dermatitis. Br J Dermatol. 2005;152(6):1161-1164.
7. Gupta MA, Gupta AK. Psychiatric and psychological co-morbidity in patients with dermatologic disorders. Am J Clin Dermatol. 2003;4(12):833-842.
8. Lewis-Jones S. Quality of life and childhood atopic dermatitis: the misery of living with childhood eczema. Int J Clin Pract. 2006;60(8):984-992.
9. Gupta MA, Gupta AK. Depression modulates pruritus perception. A study of pruritus in psoriasis, atopic dermatitis and chronic idiopathic urticaria. Ann N Y Acad Sci. 1999;885:394-395.
10. Garg A, Chren MM, Sands LP, et al. Psychological stress perturbs epidermal permeability barrier homeostasis: implications for the pathogenesis of stress-associated skin disorders. Arch Dermatol. 2001;137(1):53-59.
11. Ersser SJ, Latter S, Sibley A, Satherley PA, Welbourne S. Psychological and educational interventions for atopic eczema in children. Cochrane Database Syst Rev. 2007;(3):CD004054.
12. Hoare C, Li Wan Po A, Williams H. Systematic review of treatments for atopic eczema. Health Technol Assess. 2000;4(37):1-191.
13. Yeung CK, Chan HH. Cutaneous adverse effects of lithium: epidemiology and management. Am J Clin Dermatol. 2004;5(1):3-8.
14. Latini A, Carducci M. Psoriasis during therapy with olanzapine. Eur J Dermatol. 2003;13(4):404-405.
15. Ascari-Raccagni A, Baldari U, Rossi E, Alessandrini F. Exacerbation of chronic large plaque psoriasis associated with olanzapine therapy. J Eur Acad Dermatol Venereol. 2000;14(4):315-316.
16. Skevington SM, Bradshaw J, Hepplewhite A, Dawkes K, Lovell CR. How does psoriasis affect quality of life? Assessing an Ingram-regimen outpatient programme and validating the WHOQOL-100. Br J Dermatol. 2006;154(4):680-691.
17. Fox FE, Rumsey N, Morris M.”Ur skin is the thing that everyone sees and you cant change it!”: exploring the appearance-related concerns of young people with psoriasis. Dev Neurorehabil. 2007;10(2):133-141.
18. Kimball AB, Jacobson C, Weiss S, Vreeland MG, Wu Y. The psychosocial burden of psoriasis. Am J Clin Dermatol. 2005;6(6):383-392.
19. Schmitt JM, Ford DE. Role of depression in quality of life for patients with psoriasis. Dermatology. 2007;215(1):17-27.
20. Esposito M, Saraceno R, Giunta A, Maccarone M, Chimenti S. An Italian study on psoriasis and depression. Dermatology. 2006;212(2):123-127.
21. Russo PA, Ilchef R, Cooper AJ. Psychiatric morbidity in psoriasis: a review. Australas J Dermatol. 2004;45(3):155-159.
22. Richards HL, Fortune DG, Griffiths CE, Main CJ. The contribution of perceptions of stigmatisation to disability in patients with psoriasis. J Psychsom Res. 2001;50(1):11-15.
23. O’Leary CJ, Creamer D, Higgins E, Weinman J. Perceived stress, stress attributions and psychological distress in psoriasis. J Psychosom Res. 2004;57(5):465-471.
24. Devrimci-Ozguven H, Kundakci TN, Kumbasar H, Boyvat A. The depression, anxiety, life satisfaction and affective expression levels in psoriasis patients. J Eur Acad Dermatol Venereol. 2000;14(4):267-271.
25. Tyring S, Gottlieb A, Papp K, et al. Etanercept and clinical outcomes, fatigue, and depression in psoriasis: double-blind placebo-controlled randomised phase III trial. Lancet. 2006;367(9504):29-35.
26. Sampogna F, Tabolli S, Abeni D. The impact of changes in clinical severity on psychiatric morbidity in patients with psoriasis: a follow-up study. Br J Dermatol. 2007;157(3):508-513.
27. Picardi A, Mazzotti E, Pasquini P. Prevalence and correlates of suicidal ideation among patients with skin disease. J Am Acad Dermatol. 2006;54(3):420-426.
28. Gupta MA, Gupta AK. Depression and suicidal ideation in dermatology patients with acne, alopecia areata, atopic dermatitis and psoriasis. Br J Dermatol. 1998;139(5):846-850.
29. Gupta MA, Schork NJ, Gupta AK, Kirkby S, Ellis CN. Suicidal ideation in psoriasis. Int J Dermatol. 1993;32(3):188-190.
30. Raychaudhuri SP, Gross J. A comparative study of pediatric onset psoriasis with adult onset psoriasis. Pediatr Dermatol. 2000;17(3):174-178.
31. Naldi L, Chatenoud L, Linder D, et al. Cigarette smoking, body mass index, and stressful life events as risk factors for psoriasis: results from an Italian case-control study. J Invest Dermatol. 2005;125(1):61-67.
32. Picardi A, Pasquini P, Cattaruzza MS, et al. Only limited support for a role of psychosomatic factors in psoriasis. Results from a case-control study. J Psychosom Res. 2003;55(3):189-196.
33. Richards HL, Ray DW, Kirby B, et al. Response of the hypothalamic-pituitary-adrenal axis to psychological stress in patients with psoriasis. Br J Dermatol. 2005;153(6):1114-1120.
34. Gupta MA, Gupta AK, Schork NJ, Ellis CN. Depression modulates pruritus perception: a study of pruritus in psoriasis, atopic dermatitis, and chronic idiopathic urticaria. Psychosom Med. 1994;56(1):36-40.
35. Zachariae R, Oster H, Bjerring P, Kragballe K. Effects of psychologic intervention on psoriasis: a preliminary report. J Am Acad Dermatol. 1996;34(6):1008-1015.
36. Fortune DG, Richards HL, Griffiths CE, Main CJ. Targeting cognitive-behaviour therapy to patients’ implicit model of psoriasis: results from a patient preference controlled trial. Br J Clin Psychol. 2004;43(Pt 1):65-82.


Needs Assessment: Psychosocial interventions that address the needs of the whole person have been shown to provide unique benefits to both patients and their families. This is especially relevant and challenging when treating pediatric patients having particular needs. Horticultural therapy is being increasingly offered as a psychosocial intervention designed to meet a variety of needs for many patient groups.

Learning Objectives:
• Understand the history and uses of horticultural therapy.
• Understand horticultural therapy as a psychosocial intervention.
• Understand the importance of developmentally appropriate interventions for pediatric hematology/oncology patients.

Target Audience: Primary care physicians and psychiatrists.

CME Accreditation Statement: This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the Mount Sinai School of Medicine and MBL Communications, Inc. The Mount Sinai School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.

Credit Designation: The Mount Sinai School of Medicine designates this educational activity for a maximum of 3 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Faculty Disclosure Policy Statement: It is the policy of the Mount Sinai School of Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices. This information will be available as part of the course material.

This activity has been peer-reviewed and approved by Eric Hollander, MD, chair and professor of psychiatry at the Mount Sinai School of Medicine, and Norman Sussman, MD, editor of Primary Psychiatry and professor of psychiatry at New York University School of Medicine. Review Date: June 4, 2008.

Drs. Hollander and Sussman report no affiliation with or financial interest in any organization that may pose a conflict of interest.

To receive credit for this activity: Read this article and the two CME-designated accompanying articles, reflect on the information presented, and then complete the CME posttest and evaluation. To obtain credits, you should score 70% or better. Early submission of this posttest is encouraged: please submit this posttest by July 1, 2010 to be eligible for credit. Release date: July 1, 2008. Termination date: July 31, 2010. The estimated time to complete all three articles and the posttest is 3 hours.

Primary Psychiatry. 2008;15(7):73-77


Ms. Fried is horticultural therapist and Mr. Wichrowski is senior horticultural therapist in the OT/PT Department at the Glass Garden, Rusk Institute at New York University Langone Medical Center in New York City.

Disclosure: The authors report no affiliation with or financial interest in any organization that may pose a conflict of interest.
Please direct all correspondence to: Matthew J. Wichrowski, MSW, HTR, Glass Garden, Rusk Institute, NYUMC, 400 E 34th St, New York, NY 10016; Tel: 212-263-6058; Fax: 212-263-2091; E-mail: matthew.wichrowski@nyumc.org.





Quality psychosocial care for patients undergoing treatment for hematology/oncology disorders and their families serves to reduce the inevitable disruptions in life experienced during treatment. Horticultural therapy, a process through which plants and gardening activities are used as vehicles in professionally conducted programs of therapy, is a program option that can address the psychosocial needs of patients in numerous medical situations. The horticultural therapy program at the Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders of New York University Langone Medical Center is designed to stimulate sensory, cognitive, and communication skills as well as increase knowledge and awareness of nature while providing a stress-reducing diversion during treatment. This program provides a range of benefits that complement other treatment options and serves to help minimize potential challenges in the quality of life for patients and their families.



Current trends in care for patients undergoing treatment for hematology/oncology issues increasingly include programs that address psychosocial needs as part of the treatment regimen.1-3 Various psychosocial interventions have shown potential to help normalize the treatment process,1 decrease the stigma of treatment,4 and help reduce the negative impact of the condition.3 These treatment issues are especially important when the patient is a child or adolescent. Their developmental stages and needs create extra challenges in ensuring positive outcomes.5 Through well-defined psychosocial practices, children and families are better prepared to cope with cancer and become well-adjusted survivors.3 Horticultural therapy is increasingly offered as a program component providing an array of psychosocial benefits for many groups of patients.

Biophilia is described as our predisposition to react positively to natural settings that suggest safety and shelter; offer hope for sources of food, medicine, and tools; and provide aesthetic enjoyment.6 Nature has been utilized as a therapeutic aid for thousands of years. Egyptian court physicians prescribed taking walks in the palace gardens for mentally disturbed members of royalty. Benjamin Rush, MD, founder of Friends Hospital, observed that field labor in a farm setting had a curative effect on patients. After World War I, horticultural activities were used with veterans during their occupational therapy sessions at Menninger’s Clinic.7

Today, horticultural therapy is the process through which plants and gardening are used as vehicles in professionally conducted programs of therapy.7 Horticultural therapy is used with individuals of all ages in a wide variety of applications including work in mental health,8 with people who have developmental disabilities,9 in educational settings,9,10 and in diverse healthcare settings.11-14

Although there is only a modest number of studies describing the clinical effects of horticultural therapy, an increasing body of literature supports the benefits of both passive and active interaction with nature. Ulrich15 reported decreased use of narcotic analgesics when compared to acetaminophen and a slightly shortened length of stay when cholecystectomy patients had a view of a landscaped area compared to patients who had a view of an adjacent building. In other studies, changes in physiologic indicators corresponding with stress reduction, including lowered heart rate,15,16 have been reported. Likewise, cognitive restoration in newly diagnosed breast cancer patients17 and enhanced mood in cardiac rehabilitation patients16 have been documented.

In practice, horticultural therapy provides a wide range of benefits in physical, emotional cognitive and social domains. Gardening is a popular avocational activity, exercising fine and gross motor skills, range of motion, strength maintenance, and endurance.18 Emotional benefits include enhanced self-esteem and mood.16,19 Learning about plants provides cognitive stimulation, as it exercises sequencing memory, and work with plants helps reduce stress.20 In addition, a wide range of social benefits can be achieved by a skilled therapist such as instillation of hope, universality, and imparting information.21


Program Description

The Glass Garden at Rusk Institute is the home base for the horticulture program at the Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders (SDHCC). Since its inception in 1959, the Glass Garden has provided a tranquil respite for patients, families, visitors, and staff of the SDHCC.
Initially, the conservatory was maintained as an amenity for the patients to visit and enjoy. However, the patients wanted more than just a visit; they wanted to work with the plants while they were there. This desire, coupled with the birth of the field of clinical horticultural therapy in the early 1970s, changed the role of the Glass Garden and the Glass Garden staff. Once merely a place for passive enjoyment of nature, the garden, which is now staffed with professional horticultural therapists, became a hub for helping, healing, and empowerment.

Today, the Glass Garden is far more than the original conservatory. When the current director, Nancy Chambers, came on board in 1986 she embraced a mission to develop the garden and its programs to reach far beyond the four glass walls of the original building. Her vision has seen the addition of a fully accessible perennial garden and an award-winning, state of the art, children’s PlayGarden that is regarded as a model to replicate in healthcare garden design.

Programming at the Glass Garden has also taken on new dimensions. In addition to four 1-hour intergenerational groups per day for inpatients at Rusk Institute, the staff runs horticulture programs in the Rusk Pre-school, Tisch Hospital Pediatric Child-Life Program, Psychiatric Unit, Cardiac Rehabilitation Unit, and Epilepsy Unit. The garden hosts programs for schools, senior centers, aphasia community groups, Alzheimer’s and dementia support groups, psychiatric day programs, adult day care, and nursing homes.

One of the most requested services at the Glass Garden is a staff therapist to conduct regularly scheduled horticulture groups at an off-site location. One such program at a senior center has been running for >6 years.

This is the kind of program that is currently running at the SDHCC. In 2006, the Glass Garden’s horticultural therapy team began a pilot program at the center’s New York City location. The team at the SDHCC was committed to adding this component to their innovative treatment milieu so they worked around the limited space and other logistical issues to fit the nature-based activity group into the weekly program. The new location at the upgraded space has really helped develop a vigorous program.



Each week, the horticultural therapist brings a plant or group of similarly themed plants to the center. The participants will plant them using the pots, sterile potting mix, plant labels, saucers, and anything else needed for the project. The Child-Life staff recruits medically cleared patients, their parents, siblings, care givers, and other staff members interested in participating. Class begins with participants’ introductions followed by an overview of the plant or project presented. Country of origin, history, culture, folklore as well as culinary and medicinal uses are topics available for discussion. The group’s theme can center on holidays, seasons, weather, geography, or other science topics. Each class may be different depending on the experiences, interests, and needs of its members. The leader demonstrates the project. Then, each group member completes his or her plant or project to take home.

Care is taken to provide numerous opportunities for decision making. For example, participants may choose which plant they want, how many cuttings they want to take, and what size pot is needed. The participants label the finished project with their name, name of the plant, and date. At the end of the class, participants talk about where they are going to keep their plant when they return home and review how to take care of it. The leader often asks how participants liked the class, but by this time the members are often involved in casual conversation about home, hobbies, and other normal activities.


Program Goals

The first goal of the program is to provide respite for the children and their family members while they receive treatment at SDHCC. Many of the center’s patients are from countries other than the United States. Because most houseplants are from tropical or subtropical countries, the plant is often recognized as something from their home country. This often leads to sharing nostalgic stories about home, family, and friends. The child or parent may even assume the role of teacher, telling other members of the group how the plant is used in their homeland. A once overwhelmed caregiver has transformed into a teacher, sharing knowledge and information while experiencing a sense of empowerment that reaches far beyond the class.

The second goal of the program is to offer hands-on experiences with nature to stimulate sensory, cognitive, and communication skills. Numerous families at the center are there for outpatient treatment after an admission to an acute care hospital. Coming from a setting where gowns and gloves are the norm, they are often apprehensive toward touching anything in the “outside world.” With the center’s safe environment, families are reintroduced to these tactile and sensory experiences while being educated on safe ways to handle soil and plant material when they are at home (Figure 1). As the educational conversation and the planting continue, members tend to let down their guard. The colors, smells, and textures of nature begin to take over. The experience becomes such a total sensory immersion that is so different from the clinical environment that members report momentarily forgetting where they are and why they are together (Figure 2).




A third goal is to introduce horticulture projects that increase knowledge of nature, science, nutrition, and environmental concepts. Each program is designed to be well rounded and rich in content. One class on planting ginger began with a challenge to the group members to see if anyone could recognize the root on the table. Clues of ginger ale and gingersnaps helped those who had trouble. At this point group members may discuss ginger roots in India, how the plant is produced or used in recipes, or medicinal uses from days gone by. Someone usually remembers a parent or grandparent giving him or her ginger ale as a remedy for nausea. If they ask, patients are encouraged to check with their doctor to see if they can use ginger tea or ginger ale as a remedy for the side effects of treatment (Table).



Positive Themes Cultivated in Horticultural Therapy Groups

 One of the favorite groups for children and adults alike is the ketchup class. Tomatoes and other ingredients are put together to make tomato ketchup. The product tastes just like the condiment that they know and love. Many participants are surprised to see what is in ketchup and they can easily create fresh ketchup at home without any chemical additives. In addition, they discuss how they can adjust this recipe to make a more sophisticated version custom flavored to their taste preferences.

Another positive theme occurs when planting a seed, root, or seedling comes with an expectation of change and growth. This implies hope for the future. As the participants complete the planting project they talk about what to expect as the plant grows. Comments like, “when that has roots, we will be done with these treatments” or “this plant will be 6 inches tall by your birthday” convey hope and allow the patient to recognize hope in the voices of a caregiver, parent, or child. Hope can be a powerful psychological factor in cancer treatments influencing prognosis and quality of life (Figure 3).21


One of the benefits of the program was not initially intended. The scope of programs at the Glass Garden touches all areas of the hospital and that means very often the therapist sees patients or their families in acute care, rehabilitation, and outpatient care at the SDHCC. It is very comforting for the patients to see a familiar face when they enter another phase of their treatment. Comments like, “I guess you are one big family,” tell us that this is very settling for patients and their families to have familiarity from place to place on their journey.



While the goals of the horticultural therapy option mesh well with the overall goals of the SDHCC in meeting the needs of patients and their families, there is limited empirical support for this relatively new treatment modality. More research is needed to document the benefits of horticultural therapy. Researching psychosocial interventions presents an array of methodologic challenges, particularly when team treatment approaches are used. Evaluating the effects of horticultural therapy on mood, stress, and distraction from discomfort during treatment, as well as on quality of life and overall satisfaction with treatment, would be helpful in determining the range of benefits that horticultural therapy programming provides and in what settings it is most effective.

Overall, horticultural therapy provides a treatment option addressing numerous needs for patients and their families at the SDHCC. Offering a variety of psychosocial interventions as part of the treatment team respects individual preferences and offers choice and some sense of control while battling a serious illness. Optimal cancer care balances the need for scientific knowledge, statistical analysis, and rational thought with the need for wisdom, kindness, compassion, and love.2 Integrated treatment that provides a diversity of options aimed at maximizing treatment effectiveness and minimizing potential complications while enhancing quality of life helps fight disease and promotes well being for all dimensions of a person. A treatment philosophy that honors the complexities of the human condition is a key feature in developing optimal healing environments in cancer care. PP



1.    Kusch M, Labouvie H, Fleisback G, Bode U. Structuring psychosocial care in pediatric oncology. Patient Educ Couns. 2000;40(3):231-245.
2.    Geffen JR. Creating optimal healing environments for cancer patients and their families: insights, challenges, and lessons learned from a decade of experience. J Altern Complement Med. 2004;10(suppl 1):S93-S102.
3.    Zeitzer L. Cancer in adolescents and young adults: psychosocial aspects. Cancer Suppl. 1993;71(10):3863-3868.
4.    Ritchie MA. Sources of emotional support for adolescents with cancer. J Pediatr Oncol Nurs. 1993;18(3):105-110.
5.    Redd WH. Advances in psychosocial oncology in pediatrics. Cancer Suppl. 1993;74(4):1496-1502.
6.    Kellert SR, Wilson EO. The Biophilia Hypothesis. Washington, DC: Island Press; 1993.
7.    Davis S. Development of the profession of horticultural therapy. In: Simpson SP, Strauss MC, eds. Horticulture as Therapy. Binghamton, NY: Haworth Press; 1998:3-18.
8.    Shapiro BA, Kaplan MJ. Mental illness and horticultural therapy practice. In: Simpson SP, Strauss MC, eds. Horticulture as Therapy. Binghamton, NY: Haworth Press; 1998:157-197.
9.    Catlin P. Developmental disabilities and horticultural therapy practice. In: Simpson SP, Strauss MC, eds. Horticulture as Therapy. Binghamton, NY: Haworth Press; 1998:131-156.
10. Morris JL, Zidenberg-Cherr S. Garden-enhanced nutrition curriculum improves fourth-grade school children’s knowledge of nutrition and preferences for some vegetables. J Am Diet Assoc. 2002;102:91-93.
11.    Frazel M. Botanical gardening: design, techniques, and tools. In: Simpson SP, Strauss MC, eds. Horticulture as Therapy. Binghamton, NY: Haworth Press; 1998:355-375.
12.    Wichrowski M, Chambers NK, Ciccantelli L. Stroke, spinal cord, and physical disabilities and horticultural therapy practice. In: Simpson SP, Strauss MC, eds. Horticulture as Therapy. Binghamton, NY: Haworth Press; 1998:71-104.
13.    Strauss D, Gabaldo M. Traumatic brain injury and horticultural therapy practice. In: Simpson SP, Strauss MC, eds. Horticulture as Therapy. Binghamton, NY: Haworth Press; 1998:105-130.
14.    Haas K, Simpson SP, Stevenson, NC. Older persons and horticultural therapy practice. In: Simpson SP, Strauss MC, eds. Horticulture as Therapy. Binghamton, NY: Haworth Press; 1998:231-256.
15.    Ulrich RS. View through a window may influence recovery from surgery. Science. 1984;224(4647):420-421.
16.    Wichrowski M, Whiteson J, Haas F, Mola A, Rey MJ. Effects of horticultural therapy on mood and heart rate in patients participating in an inpatient cardiopulmonary rehabilitation program. J Cardiopulm Rehabil. 2005;25(5):270-274.
17.    Cimprich B. Development of an intervention to restore attention to cancer patients. Cancer Nurs. 1993;16(2):83-92.
18.    Lantz B. Therapeutic gardening with physical rehabilitation patients. Journal of Therapeutic Horticulture. 2006;17:35-38.
19.    Szofram J, Meyer S. Horticultural therapy in a mental health day program. Journal of Therapeutic Horticulture. 2004;15:32-35.
20.    Taft S. Therapeutic horticulture for people living with cancer: the healing gardens program at cancer lifeline in Seattle. Journal of Therapeutic Horticulture. 2004;15:16-23.
21.    Yalom ID. The Theory and Practice of Group Psychotherapy. New York, NY: Basic Books; 1995.
22.    Spiegel B. Love Medicine and Miracles. New York, NY: Harper Row; 1988.


Ms. Anglin is the family health librarian at the Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders in New York City.

Disclosures: Ms. Anglin reports no affiliation with or financial interest in any organization that may pose a conflict of interest.
Please direct all correspondence to: Carlita Anglin, MSInfoStds, Family Health Librarian, Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders, Family Health Resource Center & Library, NYU Health Sciences Consumer Library, 160 E 32nd St, Medical Level, New York, NY 10016; Tel: 212-263-9958; Fax: 212-263-8410; E-mail: anglin@library.med.nyu.edu; Website: www.nyumc.org/hassenfeld.




Focus Points

• Consumer health information services in a pediatric hematology/oncology clinic provide an enriched psychosocial experience for patients and family members.
• A medical librarian can serve a vital role on a patient’s interdisciplinary care team.
• Patients and family members who are better informed about their diagnosis and treatment plan are more engaged in their own health care.
• An interdisciplinary pediatric hematology/oncology care team can work together to reduce patient information barriers and facilitate improved health literacy.



A family health librarian and pediatric patient library can serve an important role as an interdisciplinary service line within a pediatric hematology/oncology outpatient clinic. Patients and families are offered an enhanced psychosocial experience during their clinic visit through patient library resources, programs, and services. As one aspect of integrated psychosocial support to patients and families, the patient library’s role in addressing issues in health literacy, patient education, consumers’ information styles, bibliotherapy, education and school readiness, online access to health information, and collection materials are described and discussed. The success of the Family Health Resource Center and Library at the Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders of New York University Langone Medical Center in New York City is owed largely to its integration within numerous psychosocial programs, an overall approach to holistic patient care within the clinic, and a personalized patient experience.



The primary mission of the Family Health Resource Center and Library at the Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders (SDHCC) in New York City is to provide consumer health information that allows family members, patients, and others who care about them to understand their health condition and treatment path, be engaged in their own health care, and be informed during critical and difficult decision-making processes. The library is staffed by a professional librarian who provides services and programs that address issues in health literacy, patient education, educational enrichment, school readiness, research support, and psychosocial programming. This integrated service line contributes to the clinic’s emphasis on wellness and patient-centered care.



SDHCC’s Family Health Resource Center and Library opened in the fall of 2006 through a generous start-up grant from the Citigroup Foundation. In the new clinic space the Family Health Resource Center and Library was envisioned as a program central to serving the mission of the clinic and as an integrated complement to existing programs such as therapeutic recreation activities, wellness services, psychology services, nutrition programming, patient education, and education initiatives. Members of the clinic’s leadership team, colleagues from the NYU Medical Center’s (NYUMC) Health Sciences Libraries, supporters from the Citigroup Foundation, and numerous other collaborators worked together to draft a vision for implementing educational programming through a new consumer health service line. Through a process of multi-disciplinary discussions and extensive reflection on the needs of patients and families, the Family Health Resource Center and Library was created to provide informational support to patients and their families during times of serious medical problems and illnesses.


Who Provides Professional Staffing for the Patient Library?

The Family Health Resource Center and Library is staffed by a professional medical librarian who holds a Master’s degree in information studies, a program of study that is recognized and accredited by the American Library Association. Additionally, the clinic’s Family Health Librarian has experience as a primary school teacher and holds special school library certification earned through a carefully prescribed program of study, field experience in a school library setting, and professional examinations. The clinic’s librarian also has special training and experience related to working with individuals in a healthcare setting and works to connect patients and families to quality information resources while making it clear that she is not qualified to interpret medical information or to give medical advice.

The Family Health Librarian is a faculty member of NYUMC’s Ehrman Medical Library where she, as other library faculty members, serves on various library-related committees and teams. As one of three medical librarians specializing in consumer health information services at NYUMC, the Family Health Librarian works closely with counterpart librarians from the adult cancer center and the main hospital. Each of NYUMC’s three consumer health librarians serves distinct audiences and populations, but they work as a team to accomplish common program goals related to patient-centered care and current issues in consumer health.


How are Library Services Integrated within the Clinic?

As a relatively small hematology and oncology outpatient clinic, the SDHCC provides a special, personalized patient-family experience. In this unique setting the Family Health Librarian is one of the multidisciplinary professionals serving on a patient’s care team. New patients and families are often introduced to the clinic’s librarian during an initial visit and clinic tour. The librarian participates in weekly medical and psychosocial rounds and contributes to psychosocial patient care planning. The librarian’s unique perspective and knowledge of families’ questions and struggles allow her to understand the personal world of the patients and their families1 and to bring that understanding to discussions related to patient care within clinic team meetings. The services of the Family Health Librarian are integrated into the multidisciplinary care team of all patients, both through the outpatient clinic experience as well as during any inpatient hospital stays. The personalized approach and librarian integration into patient care is important; in fact, research shows that clinical library services influence patient health outcomes and can save time for healthcare providers.2


What Library Programs and Services Support Families?

When a family is faced with the news of a child’s life-threatening illness or serious medical condition, all family members need support during this difficult time. Very often parents, grandparents, aunts, uncles, brothers, sisters, family friends, and even the patients seek information about diagnosis or treatment to help them come to terms with an illness or medical condition. At the SDHCC, the interdisciplinary care team works together to provide a wide range of resources and patient education materials for families as they adjust to the medical diagnosis of their loved one. The resources of the Family Health Resource Center and Library include access to specialized electronic and print-based health materials, professional medical literature searches, computer workstations, instructional assistance using searching and informational tools, reading materials for young children and the professional assistance of a medical librarian. Through these services and resources many patients and family members are able to “obtain, process, and understand the basic health information and services they need to make appropriate health decisions,”3 characteristics which commonly define health literacy.


How are Health Literacy Issues Addressed?

Health literacy is an important part of effectively engaging patients in their care; it is a fundamental part of patient and family centered care.3 More than the ability to merely decode health and medical language,4,5 health literacy requires complex skills and critical thinking; it refers to a person’s ability to understand and to act on information that directly affects his or her well being.3,6,7 It is also key to ensuring patient safety.8

Not surprisingly, many patients and families treated at the SDHCC clinic struggle with health literacy issues, as do 50% of the adult American population3 of varying educational and socioeconomic backgrounds. In order to provide the best possible care environment, clinic staff members work together to create opportunities for patients and family members to be engaged, informed, and active participants in their own care. The SDHCC families have interpretive language services available to them, translated patient education materials are provided with side-by-side English translations, written materials are created in jargon-free simplified language,9 a patient advocate helps struggling families navigate the health care maze, and families have the opportunity to work with the family health librarian for learning enrichment. Because of the small size of the clinic, interdisciplinary team members are able to identify patients, parents, or family members who have notable literacy and health literacy issues. Together the team is able to brainstorm possible solutions during psychosocial care plan meetings.


How is Patient Education Supported Through Interdisciplinary Work?

The SDHCC’s Family Health Resource Center and Library provides a centralized collection of materials that supports and assists members of a patient’s care team in educating patients, their family members, and their caregivers about disease and treatment information. Family members normally receive a packet of information about a patient’s medical condition and treatment plan from their physician or nurse practitioner at their initial visit; often the librarian plays a key role in this service by locating resources for the clinical staff. The Family Health Resource Center and Library also provides a place where patients and family members can turn for accurate, reliable patient information that complements the clinical visit. Patients and family members are able to improve their understanding about diagnosis and treatment and to be empowered to communicate better with their physician or healthcare provider.10

Having clearly written information about diagnosis or treatment makes it easier for families to digest the news of a serious medical condition during what is recognized as a naturally distressing event that interferes with a person’s ability to “absorb or remember information.”11 Research shows that a person’s capacity for remembering medical information during times of stress is challenged11; in fact, some estimates claim patients immediately forget 40% to 80% of what they are told by their doctors.12 Certainly, written patient education materials are most effective when they are presented in combination with other educational approaches such as a patient’s oral consultations with a physician or nurse educator.8 Patient education efforts at the SDHCC clinic employ this two-part written and oral approach, and, as much as possible, they are tailored to an individual’s learning and cognitive style.


What Influences a Person’s Information Style?

As information seeker’s parents and family members at the clinic are representative of the larger population, people have different learning styles, tolerances for quantities of information, coping strategies, and levels of interest in being informed.11 Numerous factors can affect a person’s interest in receiving health information and his or her ability to process it. Educational levels, literacy levels, cultural beliefs, presentation styles of health professionals, individual personality characteristics, and experiencing distress all affect a person’s unique informational style.11 By working with a librarian, parents are able to access accurate and reliable information that makes sense to them. A librarian can also help parents and family members gain confidence in communicating during medical appointments.10

Parents, family members, and patients alike benefit from their library experience on numerous levels. For some, being better informed about the latest advances in medical research gives a family satisfaction and an informed approach to treatment choices that is known as “evidence-based patient choice.”8 For others, additional information may ensure they are more compliant with medications and treatment regimens. Still others gain personal confidence and a vocabulary that allow them to communicate better with their physicians. Recently, one mother asked the Family Health Librarian for help accessing medical articles she could present to her daughter’s physician because she said, “I want our doctor to know that I have intelligence.”


How Does a Patient Library Help Consumers Seeking Information On the Internet?

Understandably there are physician concerns about patients getting medical information on the Internet.13 Certainly, families facing a devastating illness or medical problem can easily find themselves intrigued by the promise of a miraculous cure that might seem available online. Often it can be difficult for even the well-educated and sophisticated consumer to discern reliable health sources from those of shrewd advertisers representing products for sale. Because so many people are seeking health information online, it is important to empower patients with resources and skills to ensure they are getting correct and reliable information. The Family Health Librarian works with patients and family members to connect them with trustworthy information and to show them strategies for critically evaluating online health information.

Although all new patients and families are given educational materials and information about community support resources by their care team, many parents and older patients engage in self-directed inquiry often even before their relationship with the SDHCC begins. The Pew Internet and American Life Project has estimated that eight out of every ten Internet users have looked for health information online.14 In households with Internet access among people with a chronic illness or disability, such numbers are even higher.15 Many of the center’s parents are very sophisticated Internet users. They often approach medical research as a way of coping with their child’s illness or a way of making order out of a chaotic process. These parents are able to find reassurance and support by connecting to specialized medical literature resources, by accessing full-text articles, by improving their PubMed searching skills through tutorials with the librarian, and learning about trustworthy consumer Websites such as MedlinePlus. However, other parents and families may not have computers at home and may be unskilled at accessing online information. For them, the SDHCC library is a place where they have access to computers and where they can hone basic computing skills.


How is a Patient Library Collection Built?

In order to build a collection that ably serves the needs of the entire clinic population, the Family Health Librarian identifies and purchases high quality health resources that are written in accessible language on a wide variety of childhood cancers, blood disorders, and vascular anomalies. Many of the print materials available as booklets or brochures are procured from well-respected national health or professional organizations such as the American Academy of Pediatrics, the Association of Pediatric Hematology-Oncology Nurses, the Leukemia and Lymphoma Society or the National Cancer Institute. As part of NYUMC, the Family Health Resource Center and Library shares a wealth of resources from the larger medical center and university communities. Often parents and staff benefit from personalized instruction about specialized databases of academic medical literature and electronic resources that are available through the NYU Health Sciences Libraries. The clinic’s library retains basic medical textbooks, medical dictionaries, and drug manuals to serve as reference materials to medical and nursing staff as well as interested parents.

The SDHCC’s collection also reflects the diversity of the clinic’s patient population and the importance of providing informational help for the psychosocial needs of families facing serious medical diagnoses. Respect for different cultural sensitivities and practices is paramount, as parents and family members of all cultural backgrounds come to the SDHCC library looking for information that can help them handle difficult emotional and parenting situations that arise during the sustained family stress of managing the care for a seriously ill child. The materials held in the library aim to serve the unique heterogeneous needs of all SDHCC patients and families, which is a special challenge in New York City. The clinic’s library serves families representing a wide range of nationalities, religious backgrounds, educational levels, languages spoken, and cultural practices. Young patients influence the library’s collection development policy by making requests. For example, two young school age male patients recently approached the librarian separately to suggest more picture books for leisure reading should be available in Russian and Chinese languages.


What is the Role of Bibliotherapy and Therapeutic Books for Children?

As expected, most often the information seekers served by the Family Health Resource Center and Library are a patient’s parents. Parents look for information related to their child’s diagnosis and treatment, but there are often numerous unexpected turns in the lines of inquiry. Frequently, parents ask the clinic librarian for information about how to address sensitive issues and questions raised by other young children in the family or by a child’s classmates and friends. Topics such as dealing with a serious medical problem, facing fears related to the medical environment, handling bullies or teasing by peers,16 or discussing death are just some of the specialized topics addressed in therapeutic picture books held in the collection. Very often these specialized books are written by psychologists who have special expertise in working with young children. The books interweave storylines and imaginative illustrations that help children internalize a story’s message; in some instances readers can practice cognitive skill-building through the story process by drawing on the experiences and problem solving skills of a story’s characters.

Parents have reported to the Family Health Librarian that through the experience of reading therapeutic picture books with their children, many important conversations occur. As with other kinds of reading, children find comfort in stories that mirror their personal experience. After identifying with a story’s main character and drawing correlations to their lives, children are able to experience emotional catharsis and ultimately gain deeper insight into their own personal psychosocial experience.16 Parents are able to discuss sensitive topics indirectly by asking their children questions about the reading material and the experiences of a story’s characters. During the experience of reading, parents and children are able to spend important time together that facilitates bonding and supports healthy habits for child development. Bibliotherapy, the process of reading for therapeutic value, is an important part of the healing process for many young patients facing illness, disability, or psychosocial challenges to help them process their feelings.16-20


How Does the Library Support Family Literacy and School Readiness?

Family reading and encouragement for early literacy are also emphasized through the clinic’s Reach Out and Read (ROR) program, which is managed through the Family Health Resource Center and Library by the Family Health Librarian. ROR is a national program in which physicians and healthcare providers encourage reading and early literacy among children who are 6 months to 5 years of age. During staged visits that correspond to childhood developmental milestones, patients receive a developmentally appropriate book that is theirs to keep. At the same time, parents receive literacy guidance, modeling, and encouragement from the medical provider who underscores the importance of daily reading to young children.21 For example, healthcare providers give their patients personalized “prescriptions” to read. These interactions are important, not only for the benefit of the young patient but very often they offer encouragement to parents who are non-native speakers of English or who are struggling with their reading abilities. This program is popular among patients and their parents, but it is also a favorite among the physicians and nurse practitioners who are able to have a meaningful non-medical encounter with patients during the ROR interaction.

The SDHCC’s patient library is a natural fit for Reach Out and Read programming. Because the clinic serves a large Medicaid and Medicaid-health maintenance organization population, it meets the ROR program goal of targeting at-risk and underserved families during well-child visits at a time when the SDHCC serves their primary care needs. The ROR program model complements the clinic’s approach to care because it employs an interdisciplinary approach22 to personal wellness and family and child resilience.



The SDHCC’s Family Health Resource Center and Library provides a unique and interdisciplinary service line and programming within the clinic. As one psychosocial component of the SDHCC care team, library services are a vital part of actualizing the clinic’s mission to provide patient and family-centered care. SDHCC’s Family Health Resource Center and Library provides programming and services to enhance the educational experiences of patients and family members, address issues in health literacy, improve patient and physician communication, support patient education, assist parents in having conversations with their children, support family literacy, and reflect individual learning styles. A strength of the Family Health Resource Center and Library program, as with all clinic services, is that families receive very personalized attention and care.

Visiting the library can be a very normalizing experience for many patients and their family members. For example, some patients and siblings make a point of visiting the library during every clinic visit. This familiar and pleasant experience reminds them of visits to their school or public library. Patients, siblings, family members, and caregivers seek out the library, not only for information, resources, homework help, research assistance, and help searching the Internet but also for a quiet place away from the bustling activity of the clinic and the playroom areas. For many of the SDHCC patients and families, visiting the library is a conscious choice. PP



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