Bariatric Psychological Testing – Another Form of Prejudice?

By Sally Singer Horwatt, Ph.D

 

David Ashton, et al. (2008) lists the argument for psychological screening as consisting of four premises:

1) A significant minority of obese patients will not lose weight after surgery (“failure group);

2) A significant minority of patients will exhibit abnormal psychological profiles during preoperative testing;

3) The majority of individuals in group two will be found in group one. That is, abnormal pre-surgical psychological profiles identified preoperatively predict less favorable weight loss outcomes postoperatively;

4) Identifying patients, preoperatively, would allow either exclusion of those at high risk of failure or provide a more secure rationale for targeted pre-and post-operative support. Therefore, the reasoning goes, psychological screening should be part of the routine preoperative assessment for patients undergoing obesity surgery.

 

Reviewing the literature for each premise, they find no evidence to suggest that preoperative psychological screening can predict postoperative outcomes and no justification for using such testing as a means of discriminating between candidates presenting themselves for bariatric surgery.

In fact, Santry, et al (2007) found that 820 surgeons reported that patient age, BMI, and social support were the most influential predictors of patient selection in bariatric surgery. Associated with decreased odds of selection were younger age, older age, limited functional status, poor social support, and public insurance. Diabetes and hypertension increased the odds of selection more than sleep apnea alone. Patient sex and race did not influence surgeons’ decisions to operate. Interestingly, self-pay status did not increase the odds of selection; private insurance rather than public insurance also increased surgical selection. That is, it appears that, in many cases, presurgical psychological screening has little or no influence on who is actually selected for surgery.

Further, Ashton, et al (2008) noted that many findings of “psychopathology” did not specify the diagnostic criteria; whether the results were based on current and lifetime disorders combined; or, if similar rates of psychopathology could be found in other presurgical groups or in nonobese patients. What the findings of psychopathology mean and their relevance to patient care are unknown. The two possible reasons for pre-operative psychological testing are: (1) to weed out those with a psychopathology which would contraindicate surgery and (2) to preselect those in whom the procedure is likely to be a success. “Unfortunately, psychological evaluation has proven of limited value in both situations.”

Surveying the literature through searches on PubMed, MedLine and PsychInfo published between 2003 and 2006, Franks and Kaiser (2008), concluded that bariatric surgery candidates are psychologically heterogeneous. They reported, “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.” Stickle and Weems (2006) concur, reporting that “Evidence is nearly absent in supporting the use of clinical assessment to predict behavior as it relates to treatment response and treatment outcome.” Lanyon and Maxwell (2007) report that the greatest predictor of the success of bariatric surgery was medical in nature. “The greater the impairment through pain and illness, the more difficulty was experienced in losing weight…The measures, however, were of state or current distress.”

“Fabricatore A; Crerand, C.E; Wadden, W; Sarwer, D; Krasucki, J, (2006) noting that “…no consensus exists for guiding mental health professionals in the conduct of [preoperative psychological evaluations]”, surveyed 194 mental health professionals on the assessment methods they use. The most common responses to the open-ended questions about what constitutes a contraindication to surgery involved psychiatric issues (91.1%) Over half of respondents (51.5%) listed a non-specific psychiatric contraindication. About 69.6 ±26% of candidates for surgery, recommend postponing surgery (until specific issues have been addressed or resolved) for 22.8 ± 4.6% of candidates (571). Respondents almost uniformly indicated that psychiatric status was among the most importance domains to assess.

Fabricatore, et al (2006), raise the issue whether the recommendations to postpone or forego surgery might not be harmful. They question whether it is ethical to recommend against surgery in the absence of data based contraindications.

A clinical-educational review (Franks, et al, 2008) of the published data regarding the crucial elements of the preoperative evaluation, surveyed variables such as history of psychiatric inpatient admissions, prior outpatient treatment, childhood sexual abuse and maltreatment, marital status, social support, and psychosocial stress. Studies 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. High levels of preoperative life stress may be positively associated with weight loss, and other patients have been found to experience the same positive physical and psychological well-being after surgery regardless of stress level. Other variables reviewed included body dissatisfaction, self-esteem, personality traits, current psychiatric status, binge eating disorder, somatization and hypochondrias, and personality disorder found results inconsistently associated with post-surgical outcome.

From this they argue that “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.”

Note, however, Franks, et al (2008) seem to be convinced that there are psychological predictors of surgical weight loss. Throughout the literature, authors who find little to no support for the psychological variables they were examining, continue to advocate the necessity for further research.

Ashton et al (2008), suggest that the question-begging assumption of necessity for presurgical evaluation of bariatric surgery, unlike for cosmetic surgery, say, stems from “long-standing societal attitudes toward obesity” which has been described as the ‘last socially acceptable form of prejudice’.” The unstated assumption is that obesity is primarily a psychological disorder when obesity does not have a primarily psychological pathogenesis.

But, then, without a psychological evaluation, most candidates for bariatric surgery will be rejected. And so, mental health professionals do them. But, presurgical evaluations should be done with the understanding that severe obesity is a chronic, frequently progressive, life threatening disease.

In summary, insofar as serious obesity is a complex medical condition, composed of genetic, metabolic, social and behavioral components, presurgical psychological evaluations have limited value. The seriously obese are a heterogeneous group; there is no consistency in measurement tools; there are no consistent criteria for a “go-no go recommendation and there is no relationship between “psychopathology” and successful weight loss. Instead, there seems to be an unwavering belief that there are critical psychological traits that preclude success. Yet, for plastic surgery, or other elective procedure, not so. They are, however, most often required if a patient is to have bariatric surgery.

Because the patient is usually not coming to the mental health professional with psychological complaints, the mental health professional is well-advised to dispense labels of psychopathology with extreme parsimony. Additionally, it is important to keep on top of the literature, remembering that we are one small part of a treatment team.

 
References

 
1. Alger-Mayer, S; Rosati, C; Polimeni, JM; Malone, M. (2009). Does comorbid psychiatric disorder argue for or against surgical treatment of obesity? http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2732582/pdf/nihms122504.pdf Retrieved 2-3-11.

2. Ashton, D; Favretti, F; Segato, G. (2008). Preoperative Psychological Testing—Another Form of Prejudice. Obes Surg. Oct;18(10):1330-7.

3. Bauchowitz, A; Gonder-Frederick, A; Olbrisch, M-E; Azarbad, M-Y; Woodson, M; Miller, A; and Schirmer, B (2005). Psychosocial evaluation of bariatric surgery candidates: a survey of present practices. Psychosom Med. Sep-Oct;67(5):825-32

4. Fabricatore, A; Crerand, C; Wadden, T; Sarwer, D; Krasucki, J. (2006). How Do Mental Health Professionals Evaluate Candidates for Bariatric Surgery? Survey Results. Obesity Surgery, 16, 567-573.

5. Franks, S; and Kaiser, K. (2008). Predictive Factors in Bariatric Surgery Outcomes: What is the Role of the Preoperative Psychological Evaluation? Primary Psychiatry, 15 (8): 74-83.

6. Lanyon, R; Maxwell, B. (2007). Predictors of Outcome after Gastric Bypass Surgery. Obesity Surgery, 17, 321-328.

7. Madan, A; Dhawan, D; Coday, Mace; Tichansky, D. (2008). Patients Who are Delayed from Undergoing Bariatric Surgery Do Not Have Improved Weight Loss. Obesity Surgery, Volume 18, Number 3, Pages 278-281.

8. Santry, H; Lauderdale, D; Cagney, K; Rathouz, P; Alverdy, J; and Chin, M, (2007) Predictors of Patient Selection in Bariatric Surgery. Annals of Surgery, January; 245 (1): 59–67.

9. Stickle, T and Weems, C. (2006). Improving Prediction from Clinical Assessment: The Roles of Measurement, Psychometric Theory, and Decision Theory in Bootzin, R and McKnight, P., Eds. Strengthening Research Methodology, Psychological Measurement and Evaluation. Washington, DC: American Psychological Association.

10. Rutledge, T; Adler, S; Friedman, R. (2010). A Prospective Assessment of Psychosocial Factors Among Bariatric Versus Non-Bariatric Surgery Candidates. Obesity Surgery, September 25, 2010. 
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