Psychosocial Needs of the Bariatric Patient: Expanding the Role of Mental Health Professionals

by Andrea Bauchowitz, PhD, and Linda Gonder-Frederick, PhD

Behavioral Medicine Center, Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, Charlottesville, Virginia

INTRODUCTION

Research on psychosocial aspects of bariatric surgery has proliferated over the past 15 years, and today there is little disagreement that psychosocial issues significantly contribute to postoperative outcome. When the 1991 NIH consensus conference recommended that a psychological evaluation be part of the overall screening of bariatric surgery candidates,1 much effort went into examining psychosocial issues within the bariatric population. These efforts have been essential in developing preoperative screening guidelines and in defining the role of mental health professionals working with preoperative patients.2-5 Although weight reduction surgery has been very successful for most people, up to one fifth of patients do not see the desired weight loss results.6 Behavioral or psychological issues, such as nonadherence to the postoperative diet and overeating, play a large part in suboptimal postoperative weight loss.6-7 It appears that mental health professionals could play an important role during the postoperative phase, yet their role in the postoperative patient care phase remains only vaguely defined.

This article aims to review some of the central psychosocial issues within the preoperative and postoperative stages with a goal of identifying additional roles of the mental health professional working with this population.

PSYCHOSOCIAL ISSUES IN THE PREOPERATIVE PHASE

Significant progress has been made identifying psychosocial issues common within this population, such as overeating, increased rates of psychopathology, and a generally reduced quality of life.8 Bariatric surgery candidates present with a higher lifetime prevalence of psychiatric diagnoses than the general population. Mood disorders, including major depression and bipolar disorder, have a national prevalence rate of 17.1 percent and 1.6 percent respectively, but are elevated to 49.3 percent and three percent in bariatric surgery patients.9 Increased prevalence of anxiety disorders, binge eating disorder, and personality disorders within the bariatric population have also been identified.10-14 For instance, binge eating behaviors are suspected in about 30 percent of preoperative bariatric surgery patients, and it has been shown that these behaviors persist after surgery.11-12 One study found that 46 percent of postoperative patients reported a loss of control when eating, and those patients also showed significantly more weight regain following maximum postoperative weight loss than patients who did not report such a loss of control.10

Aside from psychiatric diagnoses, other psychological, cognitive, and behavioral factors are also essential components related to patients’ readiness for surgery and ultimate outcome. Only very limited data are available on these “non-psychiatric” variables.15 One of these variables is patient knowledge. We believe that patient knowledge is essential in obtaining informed consent for surgery. Awareness of not only the immediate surgical risks, but also the extent of postoperative behavioral changes, is essential for postoperative success. However, it is likely that the latter often does not receive as much consideration by patients as would be desirable.

By the time patients consider bariatric surgery, they have endured multiple failed diet attempts, are struggling with medical comorbidities, and have lived with the stigma and discomfort of severe obesity for many years. Patients often have contemplated whether or not to undergo bariatric surgery for months, if not years. When attending their first meeting with the surgery team, patients are hopeful about this potentially life-altering procedure and eager to move ahead with the process. Weighing the risks of surgery with the risks of obesity-related comorbidities is emotionally taxing. In light of this, comprehending the plethora of information presented before surgery can be easily overwhelming. Patients are required to learn about the essentials of the procedure, necessary insurance coverage, necessary time off work, and the immediate preoperative and postoperative period, but patients also need to digest a significant amount of information on postoperative lifestyle changes and emotional wellbeing. Since it is difficult to learn such a vast amount of information during a brief period, it is likely that patients will pay more attention to the issues immediately at hand, as opposed to focusing on information about necessary long-term changes.16 At this point, no research exists on how much of the information presented preoperatively can be retained by patients. Yet aspects about longer-term psychosocial and behavioral changes are likely to have a greater impact on postoperative success and patient satisfaction. For instance, missed information about nutritional guidelines can result in physical discomfort, less than ideal weight loss, or worse, postoperative complications.

Unfortunately, the impact of the psychosocial variables addressed above on medical outcome, postoperative psychological adjustment, or satisfaction with surgery has received little scientific attention. There appears to be some evidence that preoperative binge eating disorder limits postoperative success.10 Nevertheless, support for these potential factors and their impact on postoperative outcome is inconclusive, and thus can only cautiously guide the decision-making process following the psychosocial evaluation and preoperative screening process.

THE PREOPERATIVE PSYCHOSOCIAL EVALUATION

At present, the preoperative psychosocial evaluation centers on identification of psychopathology that may negatively impact postoperative compliance and ability to implement necessary lifestyle changes.3-5 Because the data on actual predictors of outcome is ambiguous, clinicians have little empirical support to rely on for the decision-making process following the evaluation, and therefore use clinical experience as a guideline. Major uncontrolled psychopathology, such as substance abuse and schizophrenia, are considered contraindications for surgery based on clinical insight. However, the decision- making process becomes more convoluted when milder forms of psychopathology—as well as aspects of adherence, knowledge, and expectations for surgery—need to be taken into account. At that junction, professionals have little empirical guidance about deciding who will likely benefit from weight reduction surgery.

To further complicate matters, patients often present to the preoperative psychosocial evaluation with anxieties that either their surgery will be denied or the process will be significantly slowed down if they admit to past psychiatric struggles. Some data show that patients are more likely to engage in positive impression management in order to get through this final hurdle.17 In the absence of empirically identified predictors of outcome, as well as patients’ potential hesitancy about full disclosure, it is difficult to rest assured that patients will actually succeed postoperatively from a behavioral and psychological perspective. Thus, given these limits of the preoperative psychological evaluation, postoperative follow-up by the mental health professional may be indicated to address potential difficulties with lifestyle changes and to screen for potential reemerging symptoms of psychiatric illness.

PSYCHOSOCIAL ISSUES DURING THE POSTOPERATIVE PHASE

Between 80 to 100 percent of patients report satisfaction with bariatric surgery.18-21 Generally, research on patient satisfaction regarding medical care suggests that patient expectations about procedure outcome as well as patient education are strong predictors of satisfaction.22 Research on satisfaction with bariatric surgery is largely descriptive and does not offer any predictions on which preoperative variables impact postoperative satisfaction. One study found that patients reporting dissatisfaction with laparoscopic banding surgery quoted psychological reasons for their dissatisfaction, such as being unable to tolerate a foreign device in their body,18 while another study determined that satisfaction with bariatric surgery is mostly related to weight loss and proximity to ideal body weight.19

If patient satisfaction is indeed related to weight loss, then behavioral aspects of weight loss would indirectly be related to satisfaction as well. Adherence to postoperative dietary and exercise guidelines is one of the major aspects ensuring postoperative weight loss. Emotional wellbeing may also have an impact on weight loss. One study suggests that negative emotions likely are related to grazing behaviors, thus leading to increased caloric consumption.23 The same study also found that emotional eating was related to poor dietary compliance and poor follow-up with the surgical team.

Findings on postoperative prevalence of psychiatric disorders are less robust, with some studies suggesting resolution of mental illness and others pointing to continued presence or even worsening of overeating and depressed mood.13, 24- 25 For instance, one study points out that although depression improves in a majority of patients, a subset of the bariatric population actually shows an increase in symptoms of depression postoperatively.13 Similarly, while some patients report relief from binge eating behavior after surgery, there is data to suggest that binge eating persists for some patients.10 Specifically, binge eating disorder may manifest itself through grazing behaviors or frequent consumption of high caloric liquid or quick-melting foods.26

Addiction transfer is an additional concept that has recently begun to receive attention within the bariatric literature.27 Even though data currently is still mostly anecdotal, it appears that a portion of postoperative patients develop compulsive and addictive behaviors, such as alcohol dependence, compulsive gambling, or promiscuity. It is hypothesized that these patients are no longer able to act compulsively around food and are thus adapting another compulsive behavior. More research in this area is clearly needed; however, involvement of a mental health professional with these patients is crucial in order to prevent and treat these potentially devastating behavioral issues.

Thus, it can be stated that while improvements in psychological wellbeing are likely postoperatively, there is a subset of patients whose wellbeing actually worsens. Preliminary evidence suggests that negative mood, emotional eating, unrealistic expectations, and poor preoperative knowledge are related to poor dietary adherence. Poor dietary adherence in turn is likely to result in suboptimal weight loss and decreased patient satisfaction. Some note that although psychological improvement following surgery is pronounced, the need for psychological follow-up does not diminish after the operation. On the contrary, additional involvement of a mental health professional in patient care could greatly enhance wellbeing, weight loss, and satisfaction.23–24,26

AN EXPANDED VIEW OF THE MENTAL HEALTH PROFESSIONAL’S ROLE

As discussed previously, little is known about what actually predicts postoperative success. However, we do know that disordered eating and depression persist and even increase in a subset of the population. Furthermore, it appears likely that preoperative patients may have difficulties fully appreciating the behavioral and psychosocial challenges that are involved in longterm weight maintenance.

Although assessment of psychopathology is clearly important, mental health professionals can offer additional services to the treatment team and the patient preoperatively and postoperatively. The preoperative evaluation is one of the only opportunities for the patient to spend a significant amount of time with a professional who is trained in facilitating behavior change and addressing some of the important aspects of long-term success. Patients undergoing bariatric surgery have different needs depending on the stages of preoperative preparation or postoperative recovery. Preoperative patients are likely concerned with insurance coverage, immediate health consequences of having a major surgical procedure, and organizing time off work for preoperative visits and postoperative recovery. Mental health professionals can offer not only extensive screening for psychiatric disorders, but also provide education about the behavioral aspects of bariatric surgery and address expectations for weight loss and realistic goals with the patient.

The psychological evaluation lends itself to an in-depth discussion on how to accomplish behavioral changes given the needs of the patient while considering the possible postoperative barriers which may be unique to each bariatric surgery candidate. Assisting the patient with consolidating information about the behavioral aspects of surgery and addressing expectations about postoperative outcome may be important aspects of preoperative preparation, informed consent, and preparation of postoperative success. Immediately following surgery, patients’ attention is focused on the healing process and getting acquainted with their smaller pouch. Patients then enter the honeymoon period, which entails steady weight loss lasting up to 24 months. During this time, they are learning to tolerate new foods and making healthy food choices, and are beginning to be more active. This period is likely to bring about changes in self image and body image, and the emergence of past psychopathology. As the end of the honeymoon period draws near, patients are more likely to experience prolonged weight loss plateaus and are voicing concerns about being able to maintain weight loss. Old maladaptive eating habits are likely to surface as the patient is able to tolerate larger quantities and types of food. At that point, proper food choices, exercise, and reduction of emotional eating become critical aspects in patients’ weight loss success.

It follows that this would be a critical time to involve a mental health professional who can address these issues with the patient, provide proper education, and establish realistic and attainable goals. With this in mind, it appears prudent to increase the involvement of mental health professionals in the postoperative follow-up of bariatric patients. It seems that brief visits with a mental health professional during the routine follow-up visits with the surgery team could be helpful in assessing for signs of depression and disordered eating. Once patients approach the end of the honeymoon period and are likely to plateau in their weight loss, it will be important to address their diet and exercise goals and provide additional education about long-term maintenance of weight loss. Addressing their expectations about weight loss and body image is important because some patients may feel discouraged if they have not reached their ideal body weight or are struggling with body image issues due to loose skin. It would be easy to speculate that if patients received individual attention as to their weight loss goals and adjustment to the surgery, they would ultimately feel more satisfied with the procedure and more likely to remain persistent in their attempts to maintain difficult lifestyle changes.

CONCLUSION

Clinical experience and some preliminary research suggest that patients could benefit from repeated exposure to a mental health professional throughout recovery from surgery in order to address behavioral and emotional issues that may negatively impact their postoperative weight loss.

In addition to screening for psychopathology, mental health professionals have expertise that can be helpful to bariatric surgery patients during the postoperative period. The mental health professional can address knowledge about psychosocial and behavioral issues related to surgery. Specific interventions could involve addressing emotional eating patterns and grazing behaviors. Because altered anatomy does not address or treat psychological issues associated with eating, it is imperative that patients receive assistance in developing alternative coping skills. Addressing appropriate expectations for weight loss will enable the patient to set realistic, achievable goals and make modifications to lifestyle changes as needed. Unrealistic expectations may lead to disappointment and subsequent reduction of efforts toward behavior change. A mental health professional working with this population should be trained in the use of cognitive therapy techniques, which are important tools for restructuring unrealistic expectations and self-defeating thoughts. In addition to addressing realistic weight goals, setting realistic goals for lifestyle changes and examining expectations about interpersonal and psychological changes are also important interventions for which the expertise of the mental health professional is ideal. These interventions, if provided at various periods during the preoperative and postoperative period, may prevent dissatisfaction and poorer patient outcome in the long run.

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Category: Past Articles, Review