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nature publishing group

Intervention and Prevention

Behavioral and Psychological Care in Weight
Loss Surgery: Best Practice Update
Isaac Greenberg1, Stephanie Sogg2 and Frank M. Perna3
The objective of this study is to update evidence-based best practice guidelines for psychological evaluation and treatment of weight loss surgery (WLS) patients. We performed a systematic search of English-language literature on WLS and mental health, quality of life, and behavior modification published between April 2004 and May 2007 in
MEDLINE and the Cochrane Library. Key words were used to narrow the search for a selective review of abstracts, retrieval of full articles, and grading of evidence according to systems used in established evidence-based models.
Our literature search identified 17 articles of interest; 13 of the most relevant were reviewed in detail. From these, we developed evidence-based best practice recommendations on the psychological assessment and treatment of
WLS patients. Regular updates of evidence-based recommendations for best practices in psychological care are required to address the impact of mental health on short- and long-term outcomes after WLS. Key factors in patient safety include comprehensive preoperative evaluation, use of appropriate and reliable evaluation instruments, and the development of short- and long-term treatment plans.
Obesity (2009) 17, 880–884. doi:10.1038/oby.2008.571

Introduction

Evidence-based best practice guidelines for psychological assessment and care in weight loss surgery (WLS) have been previously described (1). Earlier recommendations focused on patient selection/screening, preoperative evaluation, the relationship between binge eating and outcome, the role of the mental health practitioner in the WLS team, and postoperative support. This report covers key updates in these areas, and information in some additional areas.
Data show that WLS patients have a higher prevalence of mental health disorders compared with other surgical patients or obese patients who do not seek surgery, and that these problems are associated with a greater degree of obesity (2–5).
The latest studies suggest that psychosocial factors, including psychiatric disorders and disturbed eating, affect both shortand long-term WLS outcomes (2,6). This report is based on a review of the most recent empirical literature. It establishes best practice guidelines for psychosocial assessment and care in WLS, with a focus on long-term efficacy and patient safety.
Methods And Procedures
We searched MEDLINE and the Cochrane Library for articles published on WLS and patient selection, psychological evaluation, mental illness, psychiatry, binge eating, depression, and mental health published between April 2004 and May 2007; 17 relevant articles were identified, and 13 were reviewed in detail. These included randomized

controlled trials, prospective and retrospective cohort studies, metaanalyses, case reports, prior systematic reviews, and expert opinion.
The system used to grade the quality of the evidence has already been described, as has the focus of the recommendations and the process used to develop them (1).
Results
Patient selection and preoperative evaluation

Multiple studies have documented numerous physiological benefits of WLS for the severely obese (7,8). However, WLS is not without risk, and not all patients benefit from the procedure to the same degree. There is significant short- and longterm variability in weight loss outcomes after surgery (6,9). For example, 20% or more of patients who undergo WLS either fail to achieve significant weight loss (2) or regain much of the lost weight over time (9). Determining the psychosocial factors that may enhance or impede a patient’s surgical outcome can be challenging, but it is also critically important (10–12).
WLS patients are an emotionally vulnerable population. The past 3 years have seen increasing recognition of the need to not only screen patients for psychiatric disorders severe enough to contraindicate surgery, but also to identify and address p ­ sychosocial factors that may not be clear contraindications to surgery, but may compromise its outcomes.
The 1991 National Institutes of Health Consensus
Development Conference on Gastrointestinal Surgery for

1
Department of Psychiatry, Tufts School of Medicine, Boston, Massachusetts, USA; 2MGH Weight Center, Massachusetts General Hospital, Harvard Medical School,
Boston, Massachusetts, USA; 3Health Promotion Research Branch Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda,
Maryland, USA. Correspondence: Isaac Greenberg (igreenberg@tufts-nemc.org)

Received 23 June 2007; accepted 6 September 2007; published online 19 February 2009. doi:10.1038/oby.2008.571
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Severe Obesity (13) recommended psychological evaluation for WLS patients, and this practice is currently widespread, required by >80% of WLS programs (2,14). Empirical studies have found high current and lifetime prevalence of mental health ­ isturbances among patients with severe obesity. d A recent review found that prevalence of current Axis I disorders in WLS patients ranged from an estimated 20–60%, with lifetime history as high as 70% (12). Mood and anxiety disorders were the most common diagnoses. A “sizeable minority” of patients had also experienced substance use disorders.
Kalarchian et al. (2) reported that 66% of those seeking WLS had a lifetime history of Axis I disorders, with mood disorders the most common diagnosis. They reported 38% prevalence of current Axis I disorders, with anxiety disorders the most common. The lifetime prevalence of substance use disorders was 32.6%, but the figure for current substance use disorder was only 1.7%. Prevalence of personality disorders was 29%, in this sample but estimates have been as high as 72% (12).
Although there is insufficient evidence to conclude that
Axis I or II disorders contraindicate WLS, it is clear that these conditions may impact the outcome of surgery. This makes it important to identify and address mental health symptoms as part of the WLS treatment process.
Observational data show that many patients with psychiatric disorders and subclinical levels of distress benefit psychosocially as well as physically from WLS (15–17). A variety of psychosocial factors and personality variables have been proposed as potentially predictive of postoperative weight loss and emotional adjustment (18), but these have not been systematically investigated. Moreover, many reports have research design flaws that make it inappropriate to draw definitive conclusions.
Sogg and Mori (19) note a lack of standardized protocol for preoperative psychological evaluation for WLS. Inconsistencies in data collection make it difficult to draw conclusions on the relation between preoperative psychological dysfunction and postsurgical outcomes (19). This lack of clarity was evident in our last review and it continues to exist in the current literature. However, it is becoming increasingly clear that certain subgroups of WLS patients may have worse outcomes, especially later in the postoperative period.
Herpertz et al. (20) reviewed 29 studies that examined psychosocial predictors of weight loss and mental health after obesity surgery. Considering both prospective and retrospective reports with a follow-up of >1 year, the authors concluded that it may not be the mere presence or absence of psychopathology that predicts poorer outcomes, but the severity of the disorder. For example, individuals with a prior history of in-patient hospitalization or chronic disorders, such as personality disorders, may have poorer weight and psychosocial outcomes than individuals suffering from milder psychopathology.
Similarly, in a long-term follow-up (50 months postsurgery) of vertical banded gastroplasty patients, Kinzl et al. (6) reported that patients with ≥2 psychiatric diagnoses lost significantly less weight than those with 1 or no psychiatric disorders. Independent of history of psychiatric or eating disorders, patients who reported abuse, emotional neglect, or obesity | VOLUME 17 NUMBER 5 | MAY 2009

other problems during childhood also had poorer weight loss outcomes than other patients. However, these criteria were vaguely described, and even these patients had significant improvements from preoperative baseline.
The empirical literature has not documented a strong association between preoperative psychological distress and postsurgical outcome, but the reported magnitude of the association most likely underrepresents the actual magnitude. There are two reasons for this: with few exceptions, pre-WLS psychological assessment has not been independent of clinical decisionmaking (2); and preoperative psychological assessment often results in rejection or deferral of patients with more severe p ­ sychological dysfunction. This practice artificially restricts the range of psychological functioning among WLS patients, which, in turn, skews estimates of the relation between preoperative psychological functioning and postoperative outcome.
There is insufficient evidence to consider psychopathology, in and of itself, a contraindication for surgery. However, as psychopathology and other psychosocial factors may impact surgical outcome, presurgical psychological evaluation can identify factors that may affect the safety and efficacy of WLS, and serve as the basis for formulating recommendations about whether, how, and when to address these factors.
When preoperative assessment reveals undiagnosed psychopathology or seriously impaired psychosocial functioning, WLS programs may deny surgery, or defer it until various treatment recommendations are met. Few studies have examined these processes and their impact on treatment. In a 5-year review of 449 Roux-en-Y gastric bypass (RYGB) patients at a large US WLS center, Pawlow et al. (21) reported that 81.5% of patients had no contraindications to surgery, 2.7% were psychologically inappropriate for surgery, and 15.8% were deferred pending psychological treatment. Reasons given for surgical ineligibility included current psychosis and impaired ability to provide informed consent.
The majority of patients deferred for WLS had an inadequately treated mood or anxiety disorder, active substance abuse, or binge eating disorder. Only 10% of these patients returned to the WLS center for reevaluation; all received WLS within 6 months. The remainder either did not undergo WLS, or did so at a center where their psychosocial impairment was not detected or not viewed as a barrier to treatment (21). These data are consistent with an American Society for Metabolic and Bariatric Surgery survey. Members who postponed surgery reported that only 16% of patients always/almost always followed through with treatment for their eating disorders and returned for surgery, and 12% never/almost never did (14).
In another large, long-term cohort study of 837 WLS c ­ andidates (22), 8% had significant psychosocial issues and were given behavioral treatment recommendations before surgery. Of this group, 56% were adherent and subsequently underwent surgery within an average of 3 months. Data showed that adherence differed by gender and complexity of treatment plan (e.g., psychotropic medication referral only vs. compliance with psychotherapy or smoking cessation).
At 2-year follow-up, patients who adhered to the treatment
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These data suggest that rejection for WLS on the basis of psychosocial functioning is rare. The recommendation for additional psychosocial or behavioral intervention prior to surgery is also uncommon, and when it occurs, the delay is relatively brief. However, researchers only reported the outcomes for patients who completed treatment plans and returned for WLS. Thus, the percentage of those who received
WLS at other centers is unknown, as are subsequent mental and physical health outcomes. Postponing surgery for psychosocial intervention is not ­ nconsequential, and it may have the i unintended result of prompting some patients (~3–14% of all
WLS candidates) to abandon their pursuit of ­ urgery or lead s them to other WLS centers.
Recommendation

• Recognition that mental illness, including eating pathology, is not necessarily a contraindication to WLS; evaluations should determine the degree to which psychiatric disorders may jeopardize the safety or efficacy of WLS
(category C).
Mental health provider qualifications

Psychosocial evaluation and pre- and postoperative support are increasingly recognized to be essential in the WLS process, but these are not yet recognized as formal areas of specialization.
The above review suggests that while much is still unknown in this emerging field, understanding the underlying reasons for the large variance in weight loss results, both short- and especially long-term, is essential to improving both the safety and efficacy of WLS programs. This process can only benefit from the input of behavioral health specialists.

continuing education of mental health specialists in the field of obesity and WLS (category D).
Binge eating disorder

Estimates of the prevalence of binge eating disorder in patients seeking WLS vary tremendously, from 2% (24) to
57.5% (25). Methodology for assessment of binge ­ ating e v
­ aries tremendously across studies, with the literature suggesting that the most reliable and valid form of assessment involves the use of a self-report questionnaire based on c ­ riteria from the Diagnostic and Statistical Manual of Mental
Disorders (DSM)-based self-report questionnaire as a screening ­ nstrument, combined with a brief, standardized DSMi based interview (26).
Data are also inconsistent on the impact of preoperative binge eating on surgical outcomes (e.g., psychosocial functioning, maximum weight lost, or amount of weight regained). This inconsistency is likely due to the same methodological factors that underlie inconsistent estimates of prevalence. Overall, evidence suggests that only some patients with preoperative bingeing return to this behavior, but for those who do, there is likely to be more weight regain (2,27–29). Nonetheless, such patients achieve a better outcome than they would have been likely to without surgery (30).
In light of findings that binge eating seems to greatly improve or remit for the first 6–18 months after WLS (31), we recommend patient education on the risks of recurrence, and development of effective treatment protocols to address this problem when it does arise. This would entail making mental health professionals available to WLS patients beyond the point at which they are usually involved in current treatment models.
Recommendations

Recommendations

• Psychosocial evaluation by a credentialed expert in p ­ sychology and behavior change for all WLS candidates
(category C).
• Assessment by a social worker, psychologist, or psychiatrist with a strong background in the current literature on obesity and WLS, and some experience in the preand postoperative assessment and care of WLS patients
(
­ category D).
• An evaluator, who, preferably, is on staff or affiliated with the WLS center; this relationship can facilitate communication, maintain the support network, and provide continuity of care (category D).
• Availability of mental health resources beyond the standard postoperative period of 6 months (category D) to address long-term complications (this recommendation can be met in a variety of ways, e.g., on-staff mental health professional, referral network).
• Institutions that provide education on obesity and WLS
(e.g., The North American Association for the Study of
Obesity) offer continuing education units to mental health providers to facilitate the development of standards for the
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• Standardized, empirically validated assessments
(e.g., screening with Eating Disorder Examination Questionnaire and follow-up with a brief, standardized interview based on DSM-IV-TR criteria) (category C).
• Recognition that eating disorders are not contraindications to surgery, but potential complications that may need to be addressed before or after surgery to ensure optimal outcomes (category C).
• Inclusion of education about recurrence of eating pathology in the informed consent process and as part of the WLS program’s standard educational component
(
­ category C).
Night eating syndrome

Determining the prevalence of night eating syndrome (NES) and its impact on WLS outcome has been hampered by inconsistency in the criteria used to identify the syndrome (26,32).
In addition, literature on effective treatment for NES is also in fairly early stages. There is no clear evidence that NES has any impact on surgical outcome, and assessment and/or treatment should focus on the aspects of NES that cause the most impairment, risk, or distress (32).
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Recommendation

• Recognition that NES is not necessarily a contraindication to surgery, but rather, a potential complication that may need to be addressed before or after surgery to ensure optimal outcomes (category D).
Emotional eating

A narrow focus on formal eating disorders in WLS assessment and research may underestimate the prevalence of eating pathology in the WLS population. It might be more useful to focus on the degree to which the patient relies on eating as his or her main coping strategy rather than the p ­ resence or absence of binge eating per se. Not all binge eating is emotional eating, and not all emotional eating is binge eating. Some investigators have found that there are distinct subtypes of binge eating. Some binge eating is diet-induced, although in other cases, it is emotionally induced. This distinction affects course, treatment, and outcome of the eating disorders (33,34). However, there are no published data on the relation between emotional eating and WLS outcome, and no standardized methods to assess the frequency and degree to which patients rely on emotionally triggered eating as a coping mechanism.
Recommendation

• As with NES, emotional eating should be considered a potentially complicating factor that may need to be addressed before or after WLS to assure optimal outcome
(category D).
Substance abuse

There are few published empirical investigations of the lifetime or point-prevalence of substance abuse among patients seeking WLS. One study (2) found that lifetime prevalence of substance abuse disorders among WLS candidates was 32.6%, much higher than the national rate of 14.6%; however, rates of current substance abuse among patients seeking WLS have been reported to be much lower (2,12). For example, a large prospective study indicated a 1.7% prevalence rate of substance abuse at the time of evaluation for WLS (2), and Pawlow et al. (21) found a 0.7% overall prevalence rate, with alcohol the most commonly abused substance.
Recently, media stories have proliferated regarding alcohol misuse after WLS. However, there are few published empirical reports to date (35). Anecdotal evidence on the prevalence of substance abuse in WLS patients varies widely. Given the lack of data on the subject, there is no basis for making preoperative recommendations that differ from standard practice (i.e., excluding individuals who are currently abusing or dependent upon drugs or alcohol) (10,36).
Recommendation

• Further research to establish the prevalence of substance abuse after WLS, as well as its predictors, its relation to surgical outcome, and effective treatment approaches
(
­ category D). obesity | VOLUME 17 NUMBER 5 | MAY 2009

Psychotropic medications

Three relevant aspects of psychotropic medication use have been mentioned in the literature: association with weight gain, prevalence of use by WLS patients, and the possible impact of
WLS on the efficacy of these medications. Although weight gain is closely associated with many types of psychotropic medications, including antidepressants, antipsychotics, and mood stabilizers, little is known about their effects on weight loss in WLS patients.
A large retrospective study (21) found that 72.5% of WLS patients reported a lifetime history of psychotropic ­ edication m use, with a 47.7% rate of current use; antidepressants and anxiolytics were the most commonly prescribed drugs (87.7 and
9.6%, respectively). This point-prevalence rate of psychotropic medication use is approximately six times higher than in the general population, but it is consistent with the reported prevalence rates of Axis I disorders among WLS candidates.
Alterations in the pharmacokinetics of psychotropic medications after surgery are not well understood, particularly in RYGB patients (37). RYGB patients are typically transitioned from sustained-release to instant-release ­ ormulations, f directed to crush their medication and/or monitored on a case-by-case basis. Seaman and colleagues, noting both the changes surgery produces on the digestive tract and the effects of crushing medication, have modeled dissolution rates of s ­ everal classes of medication (e.g., antidepressants, ­ nxiolytics, a and antipsychotics) and report that dissolution rate can be increased, decreased, or remain unchanged after surgery, with effects being more divergent among antidepressant medications (37). The results of Seaman et al.’s study suggest a need for an in vivo study of serum drug levels after RYGB in patients taking ­ sychiatric medications. p Recommendations

• Further research to determine the relation between various psychotropic medications and their impact on postoperative weight loss and psychosocial adjustment
(category D).
• Close postoperative monitoring of WLS patients, especially after gastric bypass (category D).
Future research

WLS is a complex procedure in which psychosocial factors directly impact physical and emotional outcomes. Psychological evaluation can serve not only as a screening tool, but also as part of the treatment plan to optimize the safety and efficacy of
WLS. However, recommendations on the extent and content of psychological evaluation, and the impact of psychosocial f ­ actors and treatments, are largely based on cohort studies, nonrandomized clinical trials, case series or reports (i.e., categories
B and C), and expert opinion (category D). A need exists for adequately powered and controlled prospective trials to examine the relation between psychosocial factors and surgical outcomes, and randomized controlled trials to test the effectiveness of treatments to reduce the impact of psychosocial risk factors on WLS outcomes.
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Recommendations

• Adequately powered and controlled prospective trials that examine the relation between psychosocial factors and surgical outcomes.
• Randomized controlled trials on the effectiveness of treatments to reduce the impact of psychosocial risk factors on outcomes. Discussion

Regular updates of evidence-based recommendations for best practices in psychological care are required to address the impact of mental health on short- and long-term outcomes after WLS. Key factors in patient safety include comprehensive preoperative evaluation, use of appropriate and reliable evaluation instruments, and the development of short- and longterm treatment plans.
SUPPLEMENTARY MATERIAL
To review task group appendices, go to www.mass.gov/dph and search
“Weight Loss Surgery.”

Acknowledgments
We thank Frank Hu for advice in manuscript preparation, Leslie Kirle for administrative support, and Rita Buckley for research and editorial services. This report on WLS was prepared for the Betsy Lehman Center for Patient Safety and Medical Error Reduction (Commonwealth of
Massachusetts, Boston, MA). Manuscript preparation was supported, in part, by the Boston Obesity Nutrition Research Center grant P30-DK46200 and the Center for Healthy Living, Division of Nutrition, Harvard
Medical School.

Disclosure
The authors declared no conflict of interest.
© 2009 The Obesity Society

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