Does cognitive behavioral therapy strengthen the effect of bariatric surgery for obesity? Design and methods of a randomized and controlled study

Eating disorder outcomes: findings from a rapid review of over a decade of research

BACKGROUND

Eating disorders (ED), especially Anorexia Nervosa (AN), are internationally reported to have amongst the highest mortality and suicide rates in mental health. With limited evidence for current pharmacological and/or psychological treatments, there is a grave responsibility within health research to better understand outcomes for people with a lived experience of ED, factors and interventions that may reduce the detrimental impact of illness and to optimise recovery. This paper aims to synthesise the literature on outcomes for people with ED, including rates of remission, recovery and relapse, diagnostic crossover, and mortality.

METHODS

This paper forms part of a Rapid Review series scoping the evidence for the field of ED, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/MEDLINE were searched for studies published between 2009 and 2022 in English. High-level evidence such as meta-analyses, large population studies and Randomised Controlled Trials were prioritised through purposive sampling. Data from selected studies relating to outcomes for people with ED were synthesised and are disseminated in the current review.

RESULTS

Of the over 1320 studies included in the Rapid Review, the proportion of articles focused on outcomes in ED was relatively small, under 9%. Most evidence was focused on the diagnostic categories of AN, Bulimia Nervosa and Binge Eating Disorder, with limited outcome studies in other ED diagnostic groups. Factors such as age at presentation, gender, quality of life, the presence of co-occurring psychiatric and/or medical conditions, engagement in treatment and access to relapse prevention programs were associated with outcomes across diagnoses, including mortality rates.

CONCLUSION

Results are difficult to interpret due to inconsistent study definitions of remission, recovery and relapse, lack of longer-term follow-up and the potential for diagnostic crossover. Overall, there is evidence of low rates of remission and high risk of mortality, despite evidence-based treatments, especially for AN. It is strongly recommended that research in long-term outcomes, and the factors that influence better outcomes, using more consistent variables and methodologies, is prioritised for people with ED.

Three- and five-year follow-up results of a randomized controlled trial on the effects of cognitive behavioral therapy before bariatric surgery

OBJECTIVE

Up to 37% of bariatric surgery patients suffer from insufficient weight loss or weight regain and mental health symptoms in the longer term. Cognitive behavioral therapy (CBT) may be an effective adjunct intervention to optimize patients' psychological functioning and weight loss results. To examine the value of adding preoperative CBT to bariatric surgery, three- and five-year follow-up data are presented.

METHOD

In this multi-center randomized controlled trial (RCT; N = 130), a CBT group was compared to a treatment-as-usual (TAU) control group. Measurements were conducted at five time points: pretreatment (T0) and posttreatment/presurgery (T1) and at one- (T2; N = 120), three- (T3; N = 117), and five-year postsurgery (T4; N = 115). The intervention group received a 10-weeks, individual, preoperative CBT focused on self-monitoring, identifying triggers for disordered eating and goal setting for eating behavior and physical exercise, as well as postoperative lifestyle. Outcome measures included weight change, eating behavior, eating disorders, depression, quality of life (QoL), and overall psychological health.

RESULTS

Preoperative CBT was not associated with better three- and five-year results than TAU regarding weight, dysfunctional eating behaviors, eating disorders, depression, overall psychological health, and QoL.

DISCUSSION

Contrary to our hypothesis, three- and five-year postsurgery differences between groups regarding weight change and mental health were not significant.. Further exploration suggested that in both groups weight problems and depressive symptoms worsened at three and five-year follow-up. Future research should focus on long-term postoperative monitoring of weight and mood and on associated postoperative interventions and their specific timing.

PUBLIC SIGNIFICANCE

After bariatric surgery, in the longer term weight problems re-occur in 30% of patients, which is probably partly related to psychopathology. We investigated whether cognitive behavior therapy (CBT) prior to bariatric surgery improved weight maintenance and mental health after surgery. Our study provided definite proof that preoperative CBT is not effective. Long-term postoperative monitoring and prompt psychological intervention after first signs of deterioration, are important to prevent further problems.

Behavioral Interventions After Bariatric Surgery

Purpose of Review

Bariatric surgery is the most effective and durable treatment for severe obesity. Postoperative behavioral weight management approaches are available for optimizing weight change for both short- and long-term outcomes.

Recent Findings

Varying settings such as groups and telemedicine along with techniques such as cognitive behavioral therapy have been assessed in the post-bariatric surgery population. The assessment and application of these programs have been limited due to methodological, financial, and attrition-related constraints.

Summary

This review aims to summarize the current evidence for different postoperative behavioral interventions on postoperative outcomes, specifically highlighting weight loss. Future opportunities for study include mechanisms for overcoming some of the barriers to implementing these programs in clinical, non-research settings.

Screening, assessment and diagnosis in the eating disorders: findings from a rapid review

BACKGROUND

Limited screening practices, minimal eating disorder training in the healthcare professions, and barriers related to help-seeking contribute to persistent low rates of eating disorder detection, significant unmet treatment need, and appreciable associated disease burden. The current review sought to broadly summarise the literature and identify gaps relating to the screening, assessment, and diagnosis of eating disorders within Western healthcare systems.

METHODS

This paper forms part of a Rapid Review series scoping the evidence base for the field of eating disorders, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/Medline were searched for studies published between 2009 and mid 2021 in English. High-level evidence such as meta-analyses, large population studies and Randomised Control Trials were prioritised through purposive sampling. Data from selected studies relating to Screening, Assessment and Diagnosis of eating disorders were synthesised and are disseminated in the current review.

RESULTS

Eighty seven studies were identified, 38% relating to screening and 62% to assessment and diagnosis. The majority of screening studies were conducted in university student samples, showing high prevalence but only modest improvements in help-seeking in those studies that followed up post-screen. In healthcare settings, clinicians continue to have difficulty identifying eating disorder presentations, particularly Binge Eating Disorder, Other Specified Feeding or Eating Disorders, and sub-threshold eating disorders. This is preceded by inadequate and frequently homogenous screening mechanisms and exacerbated by considerable personal and health-system barriers, including self-stigma and lack of resourcing. While all groups are at risk of delayed or no diagnosis, those at particular risk include LGBTQ+ and gender diverse individuals, individuals living in larger bodies, and males.

CONCLUSIONS

A majority of individuals with eating disorders remain undiagnosed and untreated despite a high prevalence of these conditions and increased advocacy in recent years. Research into improving detection and clinician diagnostic skill is extremely limited. Innovative empirical research is strongly recommended to address significant individual and health-system barriers currently preventing appropriate and timely intervention for many. Limited screening in healthcare settings and low rates of eating disorder training in the healthcare professions are just some of the barriers to help-seeking which may contribute to delayed intervention and diagnosis in the eating disorders. This has significant impacts, prolonging treatment when it is finally received, and increasing healthcare costs for both the individual and the healthcare system. The current review is part of a larger Rapid Review series conducted to inform the development of Australia's National Eating Disorders Research and Translation Strategy 2021-2031. A Rapid Review is designed to comprehensively summarise a body of literature in a short timeframe, often to guide policy-making and address urgent health concerns. The Rapid Review synthesises the current evidence-base and identifies gaps in eating disorder research and care, in order to guide decision making and address urgent health concerns. This paper gives a critical overview of the scientific literature relating to the current state of screening, assessment, and diagnosis of eating disorders within Western healthcare systems that may inform health policy and research in an Australian context. It covers screening initiatives in both general and high-risk populations; personal, clinician and healthcare system challenges relating to help-seeking; and obstacles to accurate and timely clinical diagnosis across the eating disorders.

The influence of cognitive behavioral therapy on lumbar spine surgery outcomes: a systematic review and meta-analysis

PURPOSE

As more patients undergo lumbar spine surgery, novel interventions may improve physical and mental health outcomes. Few studies summarize the benefit of cognitive behavioral therapy (CBT) among lumbar spine surgery patients. This study collects randomized control trial data to investigate the influence of CBT on patient reported outcomes among lumbar spine surgery patients.

METHODS

Our study used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and a medical library expert assisted in searching PubMed/MEDLINE, Scopus, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO, and Google Scholar. We calculated standardized mean differences (SMD) to evaluate the effect size of CBT versus control groups with a sensitivity analysis.

RESULTS

Our meta-analysis included seven studies with a total of 531 patients. The majority of included studies evaluated lumbar fusion, with preoperative CBT performed by physiotherapists. The largest effects were observed for overall quality of life (SMD = 0.55 [95% CI 0.05, 1.05], p < 0.001, I² = 86.7%) and psychological outcomes (SMD = 0.61 [95% CI 0.28, 0.94], p < 0.001, I² = 89.7%) though disability and pain outcomes also favored CBT intervention. Included studies demonstrated low overall bias but large heterogeneity. Sensitivity analysis demonstrated negligible study design differences and revealed moderators including CBT session frequency and final follow-up duration (p < 0.001).

CONCLUSION

Compared to usual care or alternative therapy control arms, CBT delivered the most improvement with overall quality of life and psychological outcomes. Among appropriately selected patients, CBT could improve perioperative disability, pain, quality of life, and psychological health following lumbar spine surgery.

Cognitive Behavioral Therapy Versus Usual Care Before Bariatric Surgery: One-Year Follow-Up Results of a Randomized Controlled Trial

BACKGROUND

Although early results of bariatric surgery are beneficial for most patients, some patients regain weight later. Cognitive behavioral therapy (CBT) has been suggested as a way to improve patients' psychological health and maintaining weight loss in the longer term. The added value of preoperative CBT to bariatric surgery was examined. Pre- and posttreatment and 1-year follow-up data are presented.

METHODS

In a multi-center randomized controlled trial, CBT was compared to a treatment-as-usual (TAU) control group. Measurements were conducted pre- and posttreatment/pre-surgery (T0 and T1) and at 1-year post-surgery (T2). Patients in the intervention group received 10 individual, weekly sessions of preoperative CBT focused on modifying thoughts and behaviors regarding eating behavior, physical exercise, and postoperative life style. Outcome measures included weight change, eating behavior, eating disorders, depression, quality of life, and overall psychological health.

RESULTS

Though no significant differences between conditions were found per time point, in the CBT, condition scores on external eating, emotional eating, depressive symptoms, and psychological distress decreased significantly more over time between pre- (T0) and posttreatment (T1) pre-surgery compared to TAU. No significant time x condition differences were found at 1-year post-surgery (T2).

CONCLUSIONS

Compared to TAU, preoperative CBT showed beneficial effects on eating behavior and psychological symptoms only from pretreatment to posttreatment/pre-surgery, but not from pre-surgery to 1-year post-surgery. Preoperative CBT does not seem to contribute to better long-term outcomes post-surgery. Recent studies suggest that the optimal time to initiate psychological treatment may be early in the postoperative period, before significant weight regain has occurred.

TRIAL REGISTRATION

https://www.trialregister.nl Identifier: Trial NL3960.

Go with the FLOW: Implementation of a psychological skills intervention in an exercise program for post-bariatric surgery patients

Bariatric surgery is an effective obesity treatment; however, most individuals regain weight following surgery. Following a Lifestyle of Wellness (FLOW) is a psychological skills intervention with strategies designed to increase self-efficacy and promote living a healthy lifestyle including regular physical activity. Eleven participants completed FLOW. Results indicated participants enjoyed the program and intended to continue this lifestyle upon program completion. Interviews indicated FLOW was effective for improving self-perceptions, and exercise motivation. The most effective sessions were goal setting, future planning, and stress management. Suggestions for program improvement were provided. This information can be used to improve the FLOW program and for implementation into other settings.

Cognitive behavioral therapy and predictors of weight loss in bariatric surgery patients

PURPOSE OF REVIEW

Bariatric surgery is the most effective treatment for morbid obesity. However, 20-30% of patients undergoing bariatric surgery experience premature weight stabilization or weight regain postoperatively. We report on the recent literature of predictors of weight loss and the efficacy of cognitive behavioral therapy (CBT) in bariatric patients.

RECENT FINDINGS

Preoperative disordered eating behaviors do not appear to be significantly predictive of postoperative weight loss. Postoperative disordered eating behaviors, eating disorders, and depressive symptoms have been found to be associated with less optimal weight loss results. Recent studies show that CBT can contribute in reducing disordered eating behaviors and depressive symptoms. Some studies also show that pre and postoperative CBT interventions can promote weight loss. New applications of CBT such as by telephone, internet, or virtual reality might contribute to more accessible and low-cost treatments for the large group of bariatric patients worldwide.

SUMMARY

CBT seems to be effective in reducing risk factors for weight regain after bariatric surgery, such as disordered eating behavior and depression. Controlled studies with long-term follow-up and larger sample sizes are needed to investigate the long-term effect of CBT interventions on weight loss results and psychological well-being.

Psychological preparation and postoperative outcomes for adults undergoing surgery under general anaesthesia

BACKGROUND

In a review and meta-analysis conducted in 1993, psychological preparation was found to be beneficial for a range of outcome variables including pain, behavioural recovery, length of stay and negative affect. Since this review, more detailed bibliographic searching has become possible, additional studies testing psychological preparation for surgery have been completed and hospital procedures have changed. The present review examines whether psychological preparation (procedural information, sensory information, cognitive intervention, relaxation, hypnosis and emotion-focused intervention) has impact on the outcomes of postoperative pain, behavioural recovery, length of stay and negative affect.

OBJECTIVES

To review the effects of psychological preparation on postoperative outcomes in adults undergoing elective surgery under general anaesthetic.

SEARCH METHODS

We searched the Cochrane Register of Controlled Trials (CENTRAL 2014, Issue 5), MEDLINE (OVID SP) (1950 to May 2014), EMBASE (OVID SP) (1982 to May 2014), PsycINFO (OVID SP) (1982 to May 2014), CINAHL (EBESCOhost) (1980 to May 2014), Dissertation Abstracts (to May 2014) and Web of Science (1946 to May 2014). We searched reference lists of relevant studies and contacted authors to identify unpublished studies. We reran the searches in July 2015 and placed the 38 studies of interest in the `awaiting classification' section of this review.

SELECTION CRITERIA

We included randomized controlled trials of adult participants (aged 16 or older) undergoing elective surgery under general anaesthesia. We excluded studies focusing on patient groups with clinically diagnosed psychological morbidity. We did not limit the search by language or publication status. We included studies testing a preoperative psychological intervention that included at least one of these seven techniques: procedural information; sensory information; behavioural instruction; cognitive intervention; relaxation techniques; hypnosis; emotion-focused intervention. We included studies that examined any one of our postoperative outcome measures (pain, behavioural recovery, length of stay, negative affect) within one month post-surgery.

DATA COLLECTION AND ANALYSIS

One author checked titles and abstracts to exclude obviously irrelevant studies. We obtained full reports of apparently relevant studies; two authors fully screened these. Two authors independently extracted data and resolved discrepancies by discussion.Where possible we used random-effects meta-analyses to combine the results from individual studies. For length of stay we pooled mean differences. For pain and negative affect we used a standardized effect size (the standardized mean difference (SMD), or Hedges' g) to combine data from different outcome measures. If data were not available in a form suitable for meta-analysis we performed a narrative review.

MAIN RESULTS

Searches identified 5116 unique papers; we retrieved 827 for full screening. In this review, we included 105 studies from 115 papers, in which 10,302 participants were randomized. Mainly as a result of updating the search in July 2015, 38 papers are awaiting classification. Sixty-one of the 105 studies measured the outcome pain, 14 behavioural recovery, 58 length of stay and 49 negative affect. Participants underwent a wide range of surgical procedures, and a range of psychological components were used in interventions, frequently in combination. In the 105 studies, appropriate data were provided for the meta-analysis of 38 studies measuring the outcome postoperative pain (2713 participants), 36 for length of stay (3313 participants) and 31 for negative affect (2496 participants). We narratively reviewed the remaining studies (including the 14 studies with 1441 participants addressing behavioural recovery). When pooling the results for all types of intervention there was low quality evidence that psychological preparation techniques were associated with lower postoperative pain (SMD -0.20, 95% confidence interval (CI) -0.35 to -0.06), length of stay (mean difference -0.52 days, 95% CI -0.82 to -0.22) and negative affect (SMD -0.35, 95% CI -0.54 to -0.16) compared with controls. Results tended to be similar for all categories of intervention, although there was no evidence that behavioural instruction reduced the outcome pain. However, caution must be exercised when interpreting the results because of heterogeneity in the types of surgery, interventions and outcomes. Narratively reviewed evidence for the outcome behavioural recovery provided very low quality evidence that psychological preparation, in particular behavioural instruction, may have potential to improve behavioural recovery outcomes, but no clear conclusions could be reached.Generally, the evidence suffered from poor reporting, meaning that few studies could be classified as having low risk of bias. Overall,we rated the quality of evidence for each outcome as 'low' because of the high level of heterogeneity in meta-analysed studies and the unclear risk of bias. In addition, for the outcome behavioural recovery, too few studies used robust measures and reported suitable data for meta-analysis, so we rated the quality of evidence as `very low'.

AUTHORS' CONCLUSIONS

The evidence suggested that psychological preparation may be beneficial for the outcomes postoperative pain, behavioural recovery, negative affect and length of stay, and is unlikely to be harmful. However, at present, the strength of evidence is insufficient to reach firm conclusions on the role of psychological preparation for surgery. Further analyses are needed to explore the heterogeneity in the data, to identify more specifically when intervention techniques are of benefit. As the current evidence quality is low or very low, there is a need for well-conducted and clearly reported research.