Facts and Fiction about the Seriously Obese and about Weight Loss Surgery

By: Sally Singer Horwatt, Ph.D., MS Clinical Psychopharmacology
 

 

The performance of a competent presurgical evaluation of the bariatric surgery candidate requires that the evaluator be aware of the empirical literature about obesity and bariatric surgery. First, there is now a broad consensus that, “Bariatric surgery is currently the only treatment that results in sustained (>10 years) and substantial (>15%) weight loss in the obese. The achieved weight loss has profound positive effects on the full spectrum of medical and psychosocial consequences of obesity…In the foreseeable future, surgery will probably be the only really efficient treatment option for patients with severe obesity (BMI >40 kg/m2)” (Torgerson, JS and Sjostrom, L. 2002).

Typically, people who seek bariatric surgery are required to complete a behavioral examination with a mental health provider to determine their appropriateness for surgery. This practice resulted from recommendations of a consensus development conference in 1991 sponsored by the NIH. The panel concluded that patients should be carefully selected after evaluation by a multidisciplinary team with medical, surgical, psychiatric and nutritional expertise. However, no specific behaviors or psychiatric disorders that would contraindicate surgery were indicated. According to Wadden and Sarwer (2006), the lack of well-defined contraindications to surgery has led some surgeons to conclude, prematurely in their opinion, that candidates need not undergo a preoperative behavioral evaluation.

Several researchers hold that the psychological evaluation of the presurgical patient is essential because of the behavioral adaptations required for a successful post-surgical outcome in the face of the combination of psychiatric co-morbidities in people with severe obesity (Kinzl, et al, 2007). The proponents of psychosocial screening list the possibility of occasional identity crises, new relationship demands, prolongation of meals among other post-surgical possibilities as reason for such evaluations. Lanyon and Maxwell (2007) state that information from four categories, physical health, psychological status, interpersonal support and the presence of an eating disorder were “not necessarily predictive.” But they claim that an evaluation encompassing all four areas was “useful.”

To the American Association of Preferred Providers Organizations (AAPPO), the purpose of a behavioral health assessment is to identify and treat behavioral health problems that may impact bariatric surgery outcomes. “The primary purpose is not, as many patients fear, to prevent patients with psychiatric conditions from proceeding with surgery (“Best Practices Brief” Issue 2, www.aappo.org).

Noting that behavioral health specialists “can no more ‘predict’ a particular psychological outcome than a physician can ‘predict’ a surgical or medical complication”, Lemont, et al (2004) claim that “we can identify social risk factors and make recommendations to both the client and surgical group that are aimed at facilitating the best possible outcome for the patient.” The objectives of the assessment are to determine whether the patient has a “secure identity, sound psychological resources, resiliency, effective coping strategies, and willingness to access meaningful support from others.”

Via a review of studies on PubMed, MedLine, and PsychInfo, Franks and Kaiser (2008) concluded, “While initial hopes were to determine a clear set of prognostic indicators serving to screen those who would not be successful, it is increasingly clear that this oversimplifies a more complex phenomenon (p.74)”. According to Franks and Kaiser, there has been a conceptual shift in the role of the preoperative psychological evaluation. In addition to identifying patients who may clearly be unsuitable for the procedure, the preoperative evaluation was designed to identify risk factors and formulate treatment plans to improve postsurgical outcomes.

Boutacoff, Ph.D, (2010) claims that the clinical utility of the presurgery psychological evaluation gains value as the surgeons and allied health clinicians become aware of the behavioral and psychological factors that may interfere with long-term postoperative outcome. She also claims that baseline psychosocial data are invaluable when a patient begins to engage in “symptom substitution” behavior, and a review of his psychological profile may shed light on his motivation to engage in such high-risk behavior. Interestingly, she asks, “Why bother with a time-consuming, costly psychological test, especially when it does not predict surgical outcome?” Her answer: “the justification lies in the objective data-based diagnosis (Pearson’s homepage)”. For that reason, she lists several psychological instruments listed on Pearson’s website.

There is a growing amount of literature, however, that questions the utility of presurgical evaluations. A systematic review of all controlled and uncontrolled trials of the last two decades with either a retrospective or prospective design and a follow-up period of at least one year was conducted by Herpertz, S. et al (2004). Articles published in English and German between 1980 and 2002 were reviewed. They found 29 articles which focused on psychosocial predictors of weight loss and mental health after obesity surgery. The authors found that personality traits have no predictive value for the postoperative course of weight or mental state Apart from serious psychiatric disorders including personality disorders, psychiatric comorbidity seems to be of more predictive value for mental and physical well-being as two essential aspects of quality of life than for weight loss surgery. However, depressive and anxiety symptoms as correlates of psychological stress with regard to obesity seem to be positive predictors of weight loss post surgery…it is also not the consumption of “forbidden” foods, such as sweets or soft drinks, but rather a general hypercaloric eating behavior, either as an expression of the patient’s inadequate compliance or a dysregulation in energy balance which is associated with a poor weight loss post surgery.

Across at least five reviews of the pre-bariatric psychological assessment literature published in the past decade, none suggest that psychosocial factors consistently predict weight-related surgery outcomes. (Rutledge et. al., 2010).

At five-year follow-up, Powers, P. and Rosemurgy. A (1997) found no relationship between the presence or absence of a presurgical psychiatric diagnosis and weight loss at follow-up. There was also no relationship between the presence of a presurgical psychiatric diagnosis and various mental health parameters at follow-up. Satisfaction with surgery was marginally associated with weight loss, but significantly associated with improved mental and physical health.

Lanyon, R. and Maxwell, B. (2007) cited lack of consistency in predictors of outcome. Specifically, there were relatively few findings supported by more than a single study. “The equivocal nature of the findings from previous studies was borne out, in that most of the predictions made from single variables were not significant, even with a relatively large sample size…successful sustained weight loss was related to small contributions from a number of variables.”

Up to six years after Roux-en-Y gastric bypass, Alger-Mayer (2009) found that patients who were severe binge eaters preoperatively had similar weight loss compared to the rest of the group. The patients with significant depressive symptoms as assessed using the BDI had no significant difference in their weight loss outcome over the six year follow-up period.

The particular variables van Hout, Gerbrand, et al (2005) looked at in their review of the literature were relationship between age and postoperative weight loss or between onset of obesity and weight loss. Gender and socioeconomic status were in most cases unrelated to successful weight loss. Preoperative weight might predict the amount of weight lost, but not postoperative psychological success. Some studies found that binge eating was not a negative indication for surgery insofar as the surgery in some cases reduced binge-eating (also found in Bauchowitz, Andrea, et al (2004)). Some authors suggested that the personality of morbidly obese patients differs from that of persons from the normal population, or from morbidly obese people who do not seek treatment. However, others suggest there is no such thing as an obese personality. Variables such as self-esteem, rigidity, self-criticism, history of sexual abuse, marital satisfaction and coping, as you might now expect, produced conflicting results. In general, no substantial psychosocial variables having predictive value have been found. Findings that most or all psychopathology decreases or disappears with successful weight loss after bariatric surgery suggest that, in many cases, psychological disturbances are the consequences, not the causes of obesity.

Van Hout, Gerbrand, et. al.(2005) conclude that “psychological and psychiatric contraindications for bariatric operations may be biased by unproven theories, rather than based on solid evidence” (p. 557). Further, they note that most studies define success as weight loss, whereas outcome from bariatric surgery should include the impact on the patient’s medical co-morbidities, physical and psychological health, and quality of life.

Dziurowicz-Kozlowska, A., et al (2006) states from her clinical experiences and outcome studies reports that “the majority of bariatric patients suffer from mood disorders, primarily various levels of depression: this, however, has no negative influence either on the rate or course of weight reduction. What is more, symptoms of depression seem gradually to subside along with progressing weight loss, which might indicate that obesity is one of the main reasons for the development of depression in bariatric patients.” They do recommend providing appropriate psychiatric and psychotherapeutic assistance for the more seriously depressed in the pre- and post-surgical period. Kinzl, J. et al (2007) report that personality traits seem to have no essential predictive value for the postoperative course of weight and mental state. Psychiatric co-morbidity has more predictive value for mental and physical well-being as two essential aspects of quality of life than for weight loss after surgery.

While reporting that surgery is an important aid for long-term weight loss, but not for other emotional and psychosocial problems, they note that the majority of obese patients show psychological and interpersonal improvements after weight loss and the feeling of having found a solution to their problems.

Insofar as many patients suffer from mood disorders, Kalarchian, M. A., et al (2007), advocate the need for studies to determine causal pathways between obesity and specific disorders, as well as mediators and moderators of the relationships between psychiatric disorder and obesity.

Variables typically associated with the need for presurgical evaluation include the possibility of post-surgical symptom substitution, compulsive behavior, identity crises, new relationship demands, anxiety, depression, binge-eating disorder, avoidant personality disorder and social anxiety. The seriously obese have been thought to have low self-esteem, inter/intrapersonal rigidity, have external locus of control, and a history of sexual, physical or emotional abuse. They are thought to have unrealistic weight loss goals. The mental health professional is to evaluate for secure identity, resiliency, sound resources and effective coping strategies. If the latter are deficient, they should postpone the surgery until these issues have been “resolved”. None of these variables has been shown to predict post-surgical outcomes. Further, there is no empirical basis for widely accepted contraindications to bariatric surgery (Franks and Kaiser, 2008).

According to Walfish (in press), it is unlikely that a psychological evaluation will ever be able accurately to predict who will and who will not benefit from bariatric surgery. First, the success rate of weight loss surgery is high, and it is statistically difficult to predict to a low likelihood event. Second, citing Lanyon and Maxwell (2007), morbid obesity is a complex phenomenon with small contributions from a number of variables.

Brolin, R. (2002) made a cogent observation when he suggested that outcome of obesity operations should be assessed in terms of both absolute weight loss and improvement of obesity-related medical disorders. He notes that, although only a few bariatric surgical patients will achieve ideal weight at the time of stabilization, many experience dramatic improvement in their medical comorbidities with only a modest amount of weight loss. Citing specific improvements in signs associated with much comorbidity, he then concludes, “It is inappropriate to consider a patient who weighs 225 kg and has lost more than 90 kg with complete resolution of sleep apnea, hypertension and diabetes a failure due to a loss of less than 50% of excess weight. Improvement of both medical problems and overall quality of life must be included in assessment of outcome of obesity operations.”(p.2795)

Several investigators have suggested psychologists re-evaluate their roles in the bariatric team from screening for psychopathology to participating in post-surgical care. (Franks and Kaiser, 2008; Van Hout, et al, 2005; Pontiroli, et al (2007). For example, studies have indicated that post-surgical compliance with regularly scheduled visits after surgery positively influence weight loss, “while pre-surgery eating habits have little importance” (Pontiroli, 2007, p. 1495). Continuing, “presence or absence of psychological problems does not predict weight loss, it has been shown that psychological help improves weight loss” (Pontiroli, 2007, p. 1496). A multidisciplinary treatment paradigm for morbid obesity would include supportive non-surgical treatment components. The non-surgical treatment components should be viewed as “essential interdependent facets of a bariatric treatment program” (vanHout, Boekestein, et al. 2006, p 788).

References

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