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: firstname.lastname@example.org.
• 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
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
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
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
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.
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
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
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.
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.
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 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
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
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