Revising the Boston Interview: incorporating new knowledge and experience

Mental Health in Bariatric Surgery: Selection, Access, and Outcomes

Severe obesity has many psychiatric consequences that can be influenced by bariatric surgery. The goal of this article is to review these challenges, including the mental health status of patients with severe obesity, the evaluation of surgical candidates, and the early and late effects of the operations, and to offer some recommendations to manage these challenges. The failure of the insurance-mandated preoperative psychosocial evaluation is also discussed.

Ethical issues in the psychosocial assessment of bariatric surgery candidates

Psychosocial evaluation is recommended prior to bariatric surgery. Practice guidelines have been published on assessment methods for bariatric surgery candidates, but they have not emphasized ethical issues with this population. This review outlines ethical and professional considerations for behavioral healthcare providers who conduct pre-surgical assessments of bariatric surgery candidates by merging ethical principles for mental health professionals with current practices in pre-surgical assessments. Issues discussed include the following: (a) establishing and maintaining competence, (b) obtaining informed consent, (c) respecting confidentiality, (d) avoiding bias and discrimination, (e) avoiding and addressing dual roles, (f) selecting and using psychological tests, and (g) acknowledging limitations of psychosocial assessments.

Revisiting the revised master questionnaire for the psychological evaluation of bariatric surgery candidates

BACKGROUND

This study aims to evaluate the Revised Master Questionnaire (MQR), a measure of cognitive and behavioral difficulties related to weight management, for use in bariatric surgery evaluations. The MQR's five domains include stimulus control, hopelessness, motivation, physical attribution, and energy balance knowledge, all of which are relevant to bariatric surgery evaluation.

METHODS

Participants were 790 bariatric surgery candidates presenting for psychological evaluation in an urban medical center. Internal consistency reliability analyses were performed on the overall scale and subscales. Confirmatory factor analysis using principal components analysis was performed and the results compared with the original behavioral weight loss sample. Convergent validity with the Beck Depression Inventory (BDI) and Binge Eating Scale (BES) were evaluated. Differences in normative data for subgroups of the bariatric sample (by obesity category and by surgery type) were also evaluated.

RESULTS

Alpha coefficients and mean inter-item correlations were largely acceptable and similar to the original behavioral weight loss sample. Factor analyses supported the consistency of the underlying factor structure. Convergent validity between the BDI and BES and relevant subscales was obtained. Overall, bariatric surgery candidates had significantly more adaptive scores than behavioral weight loss patients on three of the five scales; however, scores on physical attribution and energy balance knowledge were significantly lower. Candidates for gastric banding surgery had significantly more adaptive scores on all five subscales than candidates for gastric bypass surgery.

CONCLUSIONS

The MQR evaluates important but under-assessed weight control-related constructs and has acceptable psychometric properties. Based on these findings, it is recommended for use as a component of the psychological evaluation for bariatric surgery.

Psychological factors and weight loss in bariatric surgery

PURPOSE OF REVIEW

Morbid obesity is associated with a high prevalence of psychopathological conditions that might have an impact on postsurgery outcomes. This review summarizes recent data about psychological disorders in obese patients before and after bariatric surgery as well as the assessment and impact of these factors on postsurgery outcomes.

RECENT FINDINGS

Psychological health and quality of life were found to improve after bariatric surgery. Weight loss could not be clearly related to any specific psychological condition prior to surgery, but the presence of more than one psychiatric condition might play a role. A multi-intervention treatment, including approaches for lifestyle changes after bariatric surgery showed positive long-term results in term of weight loss and weight loss maintenance. Recent studies focused on eating behavior changes following bariatric surgery providing important information on the topic of eating disorders after bariatric surgery.

SUMMARY

Psychological assessment before bariatric surgery and systematic follow-up are necessary to guarantee optimal weight loss and weight loss maintenance. The field of psychological factors in bariatric surgery is still in need of controlled randomized prospective trials to better understand relation between psychological presurgery conditions and surgical outcomes. Self-monitoring and cognitive behavioral programs could prevent weight regain.

Creating a credential for bariatric behavioral health professionals: potential benefits, pitfalls, and provider opinion

BACKGROUND

Since the 1991 recommendation by the National Institutes of Health-sponsored consensus development conference, preoperative psychosocial evaluation of weight loss surgery patients has been adopted by >80% of weight loss surgery programs. Although some published suggestions for conducting evaluations exist, no formal guidelines have been published specifying the qualifications, content knowledge, or clinical experience for the behavioral health professionals who conduct them. As a result, the backgrounds of behavioral health professionals working with bariatric surgery patients are varied, and no mechanism exists to ensure consistent quality of care. To obtain expert opinion on this issue, a survey of the American Society for Metabolic and Bariatric Surgery membership was conducted using an Internet-based survey.

METHODS

American Society for Metabolic and Bariatric Surgery members of all disciplines were invited by electronic mail to complete an Internet-based survey. Separate forms were created for behavioral health providers and for members of other disciplines.

RESULTS

A total of 409 American Society for Metabolic and Bariatric Surgery members responded (60 behavioral health and 349 nonbehavioral health). Of the 409 respondents, 95% indicated a belief that it is important for behavioral health providers to have specialty knowledge; 87% indicated a belief that specialty experience is important; and 70.6% favored the development of a specialty credential for bariatric behavioral health providers to regulate the quality of patient care. However, the respondents also reported concerns about creating such a credential.

CONCLUSION

Our results reflect widespread opinion that the provision of bariatric behavioral health services requires specialty knowledge and experience and that a credentialing system would help regulate the standard of care in the field. However, some concerns about credential development remain.

Current psychological assessment practices in obesity surgery programs: what to assess and why

PURPOSE OF REVIEW

The present editorial review examines current psychological assessment practices in obesity surgery programs, reasons for making such assessments and data obtained prior to surgery and during follow-up. It summarizes findings from previous review articles and reports on new research findings that have been published between August 2006 and August 2009.

RECENT FINDINGS

Patients with morbid obesity applying for weight loss are commonly administered extensive psychiatric and psychological assessment prior to surgery. Although the value of psychopathological factors for predicting weight loss and mental health after surgery remains controversial, the presence of psychopathology should be taken into account in the presurgery as well as in the postsurgery management of patients undergoing weight-loss surgery.

SUMMARY

Morbid obesity is associated with high rates of psychopathology, including depression, anxiety, eating disorders, abnormal personality traits and personality disorders. There is a decrease in psychopathology after obesity surgery in many, though not all, individuals. There is some evidence for poorer postsurgery outcome in individuals with significant presurgery psychopathology, but there is a clear need for more substantial information with regard to reliable psychological predictors of weight loss and mental health after surgery. Whatever the predictive value of psychopathology prior to surgery, it is essential to detect patients in need of psychiatric and/or psychological support after surgery.

Psychosocial evaluation for bariatric surgery: the Boston interview and opportunities for intervention

The process of psychosocial evaluation for weight loss surgery (WLS) is one that goes beyond serving the function of information-gathering (Bauchowitz et al. in Surg Obes Relat Dis 3:554-558, 2007; Friedman et al. in Surg Obes Relat Dis 3:376-382, 2007; Lanyon and Maxwell in Obes Surg 17:321-328, 2007; Sogg and Mori in Obes Surg 14:370-380, 2004; Sogg and Mori in Surg Obes Relat Dis 4:455-463, 2008). This process offers myriad opportunities for delivering significant and powerful interventions that can enhance the patient's success in the WLS process. A discussion of the unique opportunities for psychosocial intervention afforded by the pre-surgical evaluation process is presented, using The Boston Interview for Bariatric Surgery (Sogg and Mori in Surg Obes Relat Dis 4:455-463, 2008) as the organizing framework.