The Bariatric Psychological Evaluation: A Heuristic for Determining the Suitability of the Morbidly Obese Patient for Weight Loss Surgery

Attachment anxiety predicts poor adherence to dietary recommendations: an indirect effect on weight change 1 year after gastric bypass surgery

BACKGROUND

Weight loss after gastric bypass surgery depends on the adoption of healthy dietary recommendations, which may be influenced by psychological issues and patients' attachment representations (habitual states of mind with respect to interpersonal relations). The present study tests (1) whether attachment representations are associated with dietary adherence, (2) whether dietary adherence and weight loss are correlated and (3) whether dietary adherence mediates the relation of attachment representations with weight reduction after gastric bypass surgery. Besides attachment representations, psychological problems are examined.

METHODS

This longitudinal study included 105 patients who had a laparoscopic Roux-en-Y gastric bypass operation. Current and past psychological problems and attachment representations were assessed before surgery. Dietary adherence was assessed 6 and 12 months postsurgery. Patients' weight and height were collected from medical records. Multiple linear and logistic regression analyses and mediation analyses using bootstrapping resampling procedures were conducted.

RESULTS

Of all examined predictor variables, attachment anxiety, i.e., fear of social rejection and abandonment, was most strongly associated with low dietary adherence at both 6 months (p = 0.009) and 12 months (p = 0.006) postsurgery. Dietary adherence 6 months postsurgery was associated with weight loss 1 year after the operation (p = 0.003). Dietary adherence at 6 months (β = 0.51; 95% confidence interval (CI) = 0.19-1.04) mediated the association between preoperative attachment anxiety and postoperative weight loss.

CONCLUSIONS

The results suggest that more anxiously attached patients are less adherent to dietary recommendations 6 months after gastric bypass surgery, influencing weight loss in a negative way during the first year after surgery.

A comparison of the millon behavioral medical diagnostic and millon behavioral health inventory with medical populations

There is a lack of normative data on broadband omnibus types of personality tests with medical populations. In fact, the only two tests normed on medical populations are the Millon Behavioral Medicine Diagnostic (MBMD) and the Millon Behavioral Health Inventory (MBHI). The internal consistency, test-retest reliabilities, and validity studies of these instruments are reviewed and compared in an effort to aid clinicians in discerning their relative psychometric strengths and weaknesses. Due to the lack of validity studies with the MBMD and the fact that reliability limits the ceiling of validity coefficients, the MBMD has yet to meet the challenges it was designed to meet. Implications for practice are addressed.

Moving beyond dichotomous psychological evaluation: the Cleveland Clinic Behavioral Rating System for weight loss surgery

BACKGROUND

Most bariatric programs require a preoperative psychological evaluation. The criteria for such decision-making and acceptance rates have been well described in published reports. Most programs have made categorical distinctions of accept, reject, or delay, although this limits utility.

METHODS

Bariatric surgery candidates (n = 389; 77.1% women; 74.3% white; mean +/- SD BMI 49.84 +/- 11.51 kg/m(2)) were evaluated using the CCBRS across 8 domains of interest in the psychological bariatric literature. Each domain was graded using a 5-point scale (poor, guarded, fair, good, excellent). A summary assessment was also given. The in-patient length of stay and preoperative, 1-, 3-, 6-, 9-, and 12-month BMI changes were assessed in the subset (n = 241) who had undergone surgery.

RESULTS

The CCBRS had excellent internal consistency (Chronbach's alpha = .88) and good consistency across providers (test-retest for overall determination r = .82). Most candidates were deemed acceptable, but 25.7% were initially considered guarded or poor candidates. Only 2.6% of the sample was unable to achieve the goals to improve their candidacy and undergo surgery. Hierarchical regression analyses on the overall CCBRS score demonstrated that unemployment, less education, greater BMI, smoking, and psychiatric medication use were associated with lower assessment scores. Guarded candidates spent significantly longer in the hospital and fair candidates had less preoperative BMI change than guarded or good candidates, although no significant postoperative BMI changes were demonstrated.

CONCLUSION

The results of our study have shown that the CCBRS is an internally consistent and useful tool for multidimensional psychological assessment of preoperative bariatric candidates.

Psychological correlates of laparoscopic adjustable gastric band and gastric bypass patients

BACKGROUND

To compare psychological characteristics of patients seeking laparoscopic adjustable gastric band (LAGB) and gastric bypass surgery.

METHODS

In the present study, 898 women were assessed as part of a comprehensive presurgical evaluation. Of these 898 patients, 107 (12%) were seeking LAGB surgery and 791 (88%) were seeking gastric bypass surgery. Their scores on a battery of psychological tests were compared with T-tests with Bonferroni correction.

RESULTS

Those patients seeking gastric bypass had greater body mass indices than those seeking LAGB. However, the analyses found no statistically significant differences on measures of IQ, depression, anxiety, anger, self-assessed reasons for weight gain, and psychopathology and personality as indicated by Minnesota Multiphasic Personality Inventory-2 scale scores.

CONCLUSIONS

The psychological evaluation can be helpful in identifying behavioral and emotional issues that merit adjunct psychological attention to optimize long-term surgical outcome. These results suggest that, as a group, no differential treatment planning needs to take place for psychological issues based on surgery performed.

Psychological evaluation of bariatric surgery applicants: procedures and reasons for delay or denial of surgery

BACKGROUND

Psychologists play an important role as members of the bariatric surgery team. The current investigation examined the frequency with which psychologists recommend delay or denial of surgery for psychological reasons, the procedures they use in making their clinical decisions, and the reasons for such conclusions.

METHOD

A sample of 103 psychologists with experience in conducting pre-surgical psychological evaluations responded to a brief survey.

RESULTS

There was significant variability in the number of evaluations psychologists complete and the instruments they use to make their clinical decisions. For most candidates, the evaluation results in psychological clearance for surgery. However, approximately 15%, on average, are delayed or denied for psychological reasons. The most common reasons for delaying or denying surgery were significant psychopathology (including psychosis or bipolar disorder), untreated or undertreated depression, and lack of understanding about the risks and postoperative requirements of surgery, which were reported by 51, 39, and 30% of respondents, respectively. Several other reasons were reported less frequently and many appeared to be idiosyncratic.

CONCLUSION

Psychologists differ in their preoperative evaluation practices. Further research is needed to determine the reasons for the variability in clinical decision making and the long-term medical and psychosocial outcomes associated with the recommendation to delay or deny surgery for psychosocial reasons. When patients receive such a recommendation, they can be encouraged to seek a second opinion from a mental health professional with bariatric expertise.

Reducing Minnesota Multiphasic Personality Inventory defensiveness: effect of specialized instructions on retest validity in a sample of preoperative bariatric patients

BACKGROUND

Because of the possibility of being denied or delayed surgery, bariatric patients might have a motivation to minimize any emotional difficulties in the preoperative psychological evaluation. This study examined changes in the psychometric test scores when extremely defensive patients were asked to repeat the testing.

METHODS

Changes in the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) scale scores were studied in a subsample of patients referred to the author for a preoperative psychological evaluation. After producing defensive MMPI-2 test profiles, these bariatric patients (n = 31) were provided feedback on their defensiveness and asked to be more open and honest on the repeat testing.

RESULTS

The vast majority (94%) of the patients produced valid profiles on the second test. On the second test, significant differences were found on 6 of the 13 MMPI-2 scales, as well as on separate measures of depression, anxiety, and anger.

CONCLUSION

It appears to be important to include a psychometric measure that includes a validity scale in the evaluation process, because patients might be motivated to present in a defensive or overly virtuous light in fear that a negative evaluation from the psychologist would adversely affect a decision regarding their candidacy for surgery. It is recommended that patients who are defensive in their testing be asked to repeat the test battery.