The Value of Ongoing Psychological Support for the Bariatric Patient, Surgeon, and Multidisciplinary Team

| June 2, 2007 | 0 Comments

by Carol Bradley, RN, CS, MSN

From the Saint Mary’s Regional Medical Center; Adjunct Clinical Professor, Orvis School of Nursing, University of Nevada, Reno, Nevada


There is increasing consensus that bariatric surgery is superior to medical intervention for long-term weight loss in morbidly obese persons.[1] Most postoperative patients are able to lose a significant amount of weight, profit from reduced or resolved comorbidities, and have an improved quality of life (QOL).

Despite these anticipated benefits from bariatric surgery, studies indicate that 5 to 30 percent of patients either lose little weight or are unable to maintain their weight loss over the long term.[2] Aside from medical or surgical complications, postoperative weight loss success depends upon the patient’s abilities and willingness to follow the prescribed nutritional and lifestyle guidelines. Whereas the surgery provides the “tool” for weight loss, the patient must provide the motivation and ability to obtain the ultimate long-term success.

Numerous experts agree that psychopathology and various psychological difficulties existing prior to the surgery can have direct adverse effects on the postoperative outcome. However, findings of studies investigating underlying psychopathology or other emotional obstacles have yielded inconsistent results.

Whereas earlier studies gave little indication of higher incidence of psychopathology in obese persons, more recent studies suggest that morbidly obese patients may have significant symptoms of depression, evidence of eating disorders, negative body image, low QOL, and other coexisting mental disorders.[3-10] Moreover, various studies of bariatric surgery candidates have identified a variety of psychiatric and behavioral problems, including but not limited to anxiety, depression, eating disorders, and history of sexual abuse.[8,9,11-13]

In addition to the lack of identified factors predicting postoperative success, there are inconsistencies in the nature of the clinical interview, as well as the lack of a standardized protocol for postoperative assessment. The value of particular symptom inventories or other structured tests is continuing to be considered in the literature.[14, 15] Whereas results of the Mental Status Exam (MSE) and various structured psychological tests may prove valuable, there is concern that such might only give a circumscribed and “limited” view of the patient’s readiness for bariatric surgery. These inconsistencies yield questions regarding the usefulness of the preoperative psychological assessment.[16]

The Problem in Clinical Practice

These varied research findings and interview inconsistencies have led to differing conclusions and diverse clinical practices by surgeons and other policy-making groups. With the adolescent population, preoperative evaluation seems to be a more common practice.[17] On the other hand, with evaluation of adult patients, various attitudes and practices abound. Although many may recognize the value of having a behavioral expert or mental health professional (MHP) available to the multidisciplinary team, there is some disagreement as to whether the MHP should be part of the team. Furthermore, there is a lack of agreement as to whether it should be required for the patient to receive a psychosocial assessment prior to surgery and what the nature of the behavioral/psychosocial evaluation should be.[2, 18, 19] Such diversity in opinion has resulted in an equivalent diversity in practice ranging from the position that a routine psychosocial evaluation of any surgical candidate is not necessary to the position that all preoperative patients should be required to obtain a preoperative evaluation.[8, 14-16, 18, 20] This diversity in opinion and in preoperative practice makes it less likely that the patient will obtain ongoing postoperative support from a MHP.

The Proposal for Clinical Practice

It is not the purpose of this article to evaluate the methodology of previous studies or debate the merits of specific structured tests or symptom surveys. Rather, the purpose is to recognize the relevance of pre-existing cognitive, psychological, social, or emotional issues as possible obstacles for postoperative success. This article also seeks to emphasize the value of a comprehensive and population-specific preoperative assessment of the obese patient seeking bariatric surgery.

Determining the patient’s cognitive, psychological, social, and emotional capabilities, as well as assessing motivation for undertaking the necessary postoperative lifestyle and nutritional changes, is critical prior to undergoing bariatric surgery. This assessment should be performed by an experienced MHP with extensive knowledge of the bariatric surgery experience, the surgical procedure, and postoperative outcomes. Only with this extensive knowledge base and expertise in bariatrics can the MHP sufficiently evaluate the myriad number of important issues for the bariatric patient, including but not limited to realistic expectations for postoperative weight loss, understanding of possible postoperative complications, motivation to undertake the necessary nutritional and lifestyle changes, and proclivity toward emotional or psychological obstacles to postoperative success.

The Benefits of Ongoing Support

Beginning with this preoperative connection with an informed MHP, the benefits of ongoing support for many patients can be ascertained. With preoperative contact with a MHP, the MHP is more likely to anticipate and intervene with any emotional, psychological, or social obstacles that might occur prior to surgery. Continued MHP support will provide the patient with structured postoperative contacts and allow the MHP to more immediately identify obstacles to postoperative success. With the ready access and ongoing relationship with the MHP, family obstacles to postoperative success can be more readily identified and effectively dealt with, either directly by the MHP or as result of referral by the MHP to other professionals. Equally important, in addition to the myriad patient and family benefits, the expert MHP can be a valuable support to the surgeon and multidisciplinary team in providing both preoperative and postoperative consultation, collaboration, and intervention.

The Value of Preoperative Assessment, Interventions, and Support

Identifying psychopathology in the bariatric patient’s preoperative assessment is critical. The value of the preoperative assessment by a MHP to identify such pre-existing psychopathology or other psychiatric issues may already be recognized by the surgeon. Even so, a short-sighted surgeon may only see need for the psychiatric assessment as merely providing a “yes” or “no” answer to the question of appropriateness for surgery. Assessment, however, is not only looking at this dichotomous variable, but is also providing a richer source of data. It is important to identify severe psychopathology in order to possibly avert a postoperative psychiatric crisis or to possibly deter legal proceedings in the event of an adverse outcome. It may be obvious that the chances for an adverse outcome with increased proclivity for litigation would be more likely if questions regarding preexisting psychopathology, inadequate cognition, or poor motivation were not adequately answered prior to the surgery.

As one example, the patient with untreated bipolar illness may not have the judgment or readiness to commit to the lifestyle changes necessary for a successful postoperative outcome. However, the MHP can be helpful in ways beyond the evaluation of frank psychopathology. A legal proceeding can unfortunately be driven for a myriad number of reasons, ranging from an adverse surgical outcome to ineffective communication. Such possible occurrences are mentioned regularly at bariatric conferences and within the literature.[27-32] The prudent clinician is undoubtedly cognizant of such a possibility. Claims that consistently emerge against surgeons who perform bariatric procedures result not only from adverse surgical outcomes, but from issues related to improper patient selection, lack of informed consent, and lack of adequate postoperative follow-up.[31] Such an unfortunate circumstance pertaining to these last three issues could possibly be prevented by the interventions and ongoing relationship with a MHP sensitive and knowledgeable in bariatrics. Specifically, a comprehensive preoperative assessment by such a MHP can evaluate the patient’s postoperative expectations, adequate cognition, and degree of motivation to undergo the surgery. As part of the assessment, the MHP can refute myths and reinforce education for nutritional and lifestyle changes toward postoperative success. As examples, the patient who believes that the “weight will just fall off without exercise” or thinks that she “will never have to think about food intake again” after a laparoscopic gastric banding procedure has unrealistic expectations and needs reinforcement of the necessary postoperative lifestyle and nutritional requirements. Likewise, the patient who chooses the laparoscopic gastric banding procedure “in order to lose the weight and then have the band removed within a couple of years” or the patient who believes that bariatric surgery “is a cosmetic surgery that really isn’t as serious as other surgeries” lacks important detail in order to truly give informed consent. In these ways the evaluating MHP can assist the surgeon with proper patient selection, reinforce the patient’s knowledge base, and ensure a more informed patient.

Moreover, the relationship and the documentation maintained by the MHP provides the surgeon with another professional’s opinion, expertise, and investment in the surgical outcome for clinical follow-up as well as in the event of a legal proceeding. Equally important regarding follow-up, the ongoing relationship with the experienced MHP will help to reinforce the patient’s knowledge base and lifestyle changes, anticipate emotional obstacles for postoperative success, and provide a valuable resource to the patient and support system during postoperative visits. Finally, in varied ways the MHP can assist the surgeon in identifying collaborative strategies and implementing preventative measures to reduce risk exposures in the bariatric program.[29] The MHP can be invaluable in identifying the preoperative patient at risk for miscommunication or psychological distress, in circumventing possible emotional obstacles to postoperative success, and in intervening in the event of an adverse postoperative outcome. In summary, the ideal outcome would be the prevention of legal claims, rather than the need for another professional’s support and testimony with a legal event. Regardless, the communication skills and clinical expertise of the MHP knowledgeable in bariatrics could be crucial in reducing both the frequency and severity of claims or in sitting with the surgeon at counsel’s table if the situation warranted.

Additional problems can be identified by the MHP experienced in bariatrics that could pose additional challenges for postoperative weight loss success. The list of possible reactions typically experienced postoperatively can be viewed in the subsequent section, “Usual Postoperative Issues Benefiting From MHP Support.” Equally important, if the preoperative assessment is limited to identification of pre-existing psychopathology alone, with a “yes” or “no” verdict, then the completion of the assessment will most likely signify the “end” of the relationship with the MHP with no expectation for follow-up or structure for continued support or interventions.

Even if preoperative or postoperative psychiatric treatment is indicated, it may not be with the initial assessor, but rather with an independent practitioner pre-designated by insurance for mental health services only. This insurance-mandated MHP may not have knowledge of bariatric surgery or expertise in dealing with the usual postoperative challenges faced by the bariatric patient with its required nutritional or lifestyle changes. Again, this limits the postoperative patient from benefiting from the expertise and continuity with a MHP experienced in the field of bariatrics. Moreover, the surgeon may not be in a team situation or have complete compliance from the patient for postoperative office visits in order to early identify emotional challenges or to provide long-term follow-up for his or her bariatric surgery patients.[2, 21]

The value of the preoperative psychosocial assessment of the bariatric surgery candidate should not be “the end in itself,” but rather the “means to an end.” Rarely should the outcome of a preoperative psychosocial assessment be limited to the statement, “Patient is not appropriate for the surgery” without more detail. The MHP should be in a position to make specific recommendations for treatment, either as a preoperative condition for the surgery, or as a postoperative intervention if an identified problem surfaces. Preexisting psychopathology may require preoperative treatment either as a prerequisite for the surgery and/or as a means of helping the patient deal with his or her psychological impairments. As an example, a history of childhood sexual abuse may prompt the MHP to educate the patient regarding possible emotional obstacles to postoperative success. With increasing weight loss, the patient with a history of abuse may discover that he or she is increasingly uncomfortable, even feeling vulnerable, as a result of the typically increased attention and compliments from others. If such issues have been resolved, education alone by the MHP with encouragement for regular support group attendance and follow-up visits with the MHP may be all that is indicated. However, with a history of untreated sexual abuse, perhaps in the face of guilt and anxiety following the death of the abuser, the MHP may discuss the need for beginning therapy preoperatively in order to recognize unresolved issues that might interfere with the patient’s postoperative progress.

Also, a patient with diagnosed bipolar disorder may need further evaluation for medication management. Another example would be the spouse in need of grief counseling following the unexpected death of her husband. In each instance, the patient may be too psychologically or emotionally impaired to grasp the nutritional principles or lifestyle changes necessary for effective postoperative outcome.

Exploring a history of abuse, psychiatric treatment, psychotropic medications, coping style, depression, and suicidal behavior can yield a wealth of information regarding the probability of patients making the dramatic postoperative changes that bariatric surgery requires. Moreover, knowledge about the surgery and postoperative expectations for lifestyle and nutritional changes can ensure a more comprehensive evaluation by the MHP. With knowledge of the surgery, the MHP should be able to evaluate the patient’s responses to ensure that the patient is truly making an informed decision, has realistic expectations for the postoperative outcome, and is motivated to make the necessary lifestyle and nutritional changes for postoperative success.

In order to adequately evaluate the patient’s knowledge base and to assess the patient’s willingness and readiness to make postoperative changes, the MHP should ask open-ended questions in a semi-structured interview. This type of interview might cover the following:

1. The patient should be able to describe the surgery. The patient should also be able to compare it to other surgical choices if they are available. The knowledgeable MHP might ask, “Describe the surgery for me . . . Tell me why you chose the Lap-Band over the gastric bypass surgery. How are the two surgeries different? What are the pros and cons of each?” Specific questions regarding the “best” and “worst” outcomes can reveal deficits in the patient’s knowledge base and unrealistic expectations for postoperative outcome. The patient who says, “I don’t want the Lap-Band because I don’t like the idea of a tube hanging out of me!” does not have correct information in order to make an informed

2. The patient should be able to describe the postoperative requirements and anticipated behavioral changes for postoperative success. It is best to begin with general questions, such as, “How will your lifestyle be different after the surgery?” or “What will change after the surgery?” These can lead to more specific questions regarding amounts and categories of food at varying points postoperatively. Questions like the following can be helpful: How big is your stomach pouch after the surgery? How much food can you eat/liquid can you drink on the day after surgery, two weeks after surgery, three months after surgery, one year after surgery? How much protein do you need to have in the course of a day after the surgery? How much water do you need to drink? In response to the question, “How important is exercise?” the unmotivated yet “prepped” patient will tout the value of postoperative exercise, yet may refute the need for preoperative activity. Asking the patient if he or she has already started making any changes in anticipation of the surgery will yield increased clues as to his or her readiness for change. The “last supper” mentality is not unusual and the patient may rationalize the intent to “hit every buffet in town” before going on the preoperative liquid diet.

In my practice, I once assessed a woman who exclaimed with delight, “I can’t wait to have this (gastric) bypass. Once I have the surgery, I won’t have to think ever again about what I eat!” Fighting the impulse to ask her if she had fallen asleep during the educational seminar, I outlined the dramatic postoperative nutritional changes needed, including the need to focus on protein and liquid quality and quantity “for the rest of one’s life.” Needless to say, she was overwhelmed with the information and elected not to have the surgery. Another example of unrealistic expectations regarding postoperative outcomes would be uncovered with a patient’s ignorance regarding the value of exercise. Such patients may refuse to do exercise, expecting the weight to just fall off after the surgery..The patient who states, “Oh, the weight will just come off quickly, maybe 10 pounds a week with the Lap-Band!” has unrealistic expectations for the banding procedure. A similar example would be the patient who claims, “I hate exercise and I hate to sweat. I heard from a Lap-Band patient at the support group last night that he has lost 40 pounds in the last two months and hasn’t exercised a lick!” This patient has unrealistic postoperative expectations and may need to demonstrate willingness and motivation for change prior to the surgery. The MHP is in a position to recommend such interventions and to re-evaluate the patient’s progress prior to the surgery.

3. Questions regarding the patient’s support system can help identify emotional deficits or conflictual relationships. For instance, the MHP may ask, “You say your husband is your best support. How does he feel about the surgery? Does he expect his life to change after the surgery?” The patient might respond, “Oh, sex is going to be wonderful!” Or, “He can’t wait to show me off at the holiday party!” Such statements may indicate that the patient is psychologically unsophisticated or at least unaware of possible postoperative problems. This may be particularly true if, respectively, there is a history of sexual abuse for either party or if neither the patient nor the spouse has considered the likelihood of unsettling reactions to the patient’s changing physical appearance, such as feelings of insecurity experienced by the spouse. The latter instance may be particularly relevant if the spouse is obese and chooses to remain so or is unable to lose weight. In my practice, I frequently quote Barbara Thompson with the following: “What this weight loss surgery (WLS) does for married couples is that it makes a good marriage better and a bad marriage worse.”[22] That quote alone may prompt a barrage of comments about the spouse’s reluctance to change eating or exercise habits or statements already made by the spouse “in humor” about fears that the patient “will fall in love with another and leave.” Information obtained by the MHP regarding body weight and typical activities when the patient and spouse first met can yield projections for postoperative marital adjustment to the patient’s changing body image and lesser size.

As discussed, in addition to referrals for psychiatric treatment, the MHP’s recommendations could involve increased visits with the dietitian, maintaining a “log” of food intake with correlating emotions, enrolling in gym membership, and initiating a regular exercise regimen following clearly spelled out behavioral objectives, such as “a minimum of three days weekly for at least 30 minutes.” The patient’s motivation for postoperative lifestyle change could be called into question with statements such as, “I’ll never be able to do any exercise, even after bariatric surgery, with my bad knees.” In order to validate such a complaint, the MHP might recommend as a prerequisite for the surgery, “Patient must have evaluation by physical therapist or orthopedist.” With any of the above recommendations, the MHP can then re-evaluate the surgical candidate at designated preoperative time intervals to ensure that the patient has benefited, as relevant, from the therapy (e.g., individual or couples) as recommended or that the deficits (e.g., nutritional knowledge base or exercise regimen) have been remedied.

In addition to the above, the MHP can be helpful to the patient in dealing with certain preoperative concerns. Such concerns could include anxiety related to anesthesia induction or family questions regarding how best to be of support to their loved one. An ongoing relationship between the MHP and the family can more readily make available interventions and support to the patient. Rather than waiting to make the referral or trusting that the patient will call if problems arise, the enhanced relationship with the MHP from the get-go can provide greater possibilities for more immediate and comprehensive intervention.

The initial MHP contact may offer an additional benefit to the patient, regardless of the assessment outcome. Whereas the content of the interview and the assessment outcome are certainly important, the process between the patient and MHP is equally valuable. The nature of the interview provides an opportunity for a significantly personal and positive connection between the MHP and the patient undergoing bariatric surgery. It is the MHP’s first and possibly only opportunity to “connect” with the patient prior to the surgery. It may be the patient’s first contact with any MHP and thus may allow the only opportunity for the patient to establish a positive experience with any MHP. The knowledgeable MHP who is familiar with the prejudice, discrimination, and usual negative life experiences of the morbidly obese has a unique opportunity to use sensitivity and knowledge with positive results.

These benefits would be reaped postoperatively if the surgery is deemed appropriate. However, even if the patient is deemed inappropriate for the surgery, there may be accompanying benefits in making the patient more amenable to future therapy contacts if such become needed. Depending upon the style and skill of the MHP, this first contact with the surgical candidate can either set the stage for a hastened end to the relationship or yield an opportunity for a continued and productive relationship.

As mentioned previously, in a semi-structured interview format, the MHP should explore information germane to the assessment of the bariatric patient. Incorporating that information and the relevant clinical details into a typewritten report with subcategories, such as Cognitive Abilities, Emotional Capabilities, Motivation, Support System, and Summary or Recommendations, can help to demystify any psychiatric terminology, delineate areas for improvement or treatment, and yield a more “user-friendly” tool for communication with the surgeon and multidisciplinary staff.

The Value of Postoperative Evaluation, Interventions, and Support

Existence of emotional issues, pre-existing knowledge deficits, or psychopathology that could pose obstacles for postoperative success can be identified in the preoperative assessment and dealt with by the MHP either preoperatively or postoperatively. Various studies have identified less successful postoperative outcomes due to nonadherence with behavioral recommendations for postoperative change.[4, 23, 24] The patient’s nonadherence to behavioral recommendations could benefit from interventions with the MHP. Such issues that could compromise postoperative progress include untreated psychiatric illness, eating disorders, or history of abuse. In particular, patients with a history of sexual abuse, even if resolved with years of therapy, may experience feelings of vulnerability that prompt patients to slow down or even sabotage their postoperative success.[25, 26] Regardless of a psychiatric history or pre-existing psychopathology, patients may readily experience unsettling effects from their changing body image and may not always welcome the attention that their more physically appealing bodies receive from others.

Usual Postoperative Issues Benefiting from MHP Support

Discussion continues at conferences regarding the question, “What is success?” following bariatric surgery. The obvious answer would involve sufficient weight loss or improvement or resolution of serious comorbid conditions. However, even if there is initial progress in these areas, the patient and surgeon may not recognize underlying psychological issues or emotional obstacles that may impede continued postoperative success. The patient who initially loses the weight only to then later regain may not seek any professional help until it is too late or until the challenge for reversal becomes a daunting one. Such underlying psychological issues or emotional obstacles may include the following:

• “Normal” depression with loss of the “familiar” body
• “Normal” depression and adjustments with a change in relationships
* As a result of jealousy from coworkers
* As a result of unsettling reactions from friends or family who cannot adjust to the new body or lifestyle of their loved one
* As a result of reactions by the spouse or partner due to feelings of jealousy or insecurity, particularly if the spouse is obese or has never known the patient at a lesser weight
• Anxiety as a result of increased attention from others
* Particularly from the opposite sex
* Especially if there is a history of sexual abuse
• Eating challenges related to “mind hunger” or loss of “comfort” eating.

In addition to these typical issues outlined above, for a more select sub-population, obstacles may be the loss of the usual way of giving or receiving caring by loved ones. As examples, if the patient no longer needs oxygen, use of a wheelchair, diabetes medications, or other self-management practices, the patient may lose the means or focus by which family members or friends previously demonstrated their “love” or “caring” for the patient. Reactions to such a loss may require family interventions in the immediate or long-term sense to help sustain the patient’s postoperative progress. At the very least, patients who were identified preoperatively with tendencies toward passivity and dependency may need additional support while developing more adaptive coping mechanisms or a new interactional style with others. Again, these tendencies may have been identified in the preoperative evaluation by the MHP. However, the actual “loss” (of coping mechanism or interactional style) may not be experienced or identified by the patient until he or she begins the dramatic postoperative weight loss and related changes. Only at that time might the patient and/or significant others experience their unsettling reactions to the patient’s behavioral or emotional changes. The MHP can help the patient and family to understand that loss of secondary gain, to appreciate how the roles of passivity or dependency had heretofore played in their relationships prior to the surgery.

Finally, there are positive outcomes that may seem to the uninformed observer to be a “given” as welcomed opportunities following WLS. Such outcomes could include increased mobility, a sense of wellbeing, increased self confidence, and increased opportunities for life-changing events, such as with increased fertility and the opportunity to become pregnant. These positives for increased activity and new roles may be accompanied by unfamiliar emotions for patients and their loved ones. Even seemingly less serious activities, such as taking airplane rides (without having to purchase a second seat or requesting a seatbelt extension) or enjoying theme park rides, may yield unexpected emotional discomforts and accompanying emotional challenges as well.

As one such example from my practice, a shy 40-year-old who initially lost 140 pounds following her gastric bypass surgery began to regain her weight. In exploring with her the various reactions she had received at work and in social situations, she was able to describe her preoperative “comfort” with “being invisible.” She had no history of abuse or mental disorder (e.g., symptoms of Avoidant Personality Disorder or similar behaviors) that might contribute to an unconscious need to sabotage her new lifestyle and social activities. However, she was aware of her discomfort with the increasing attention by others and acknowledged that she might have “slipped” in various ways postoperatively in order to recover some of her former “invisible self.” She has identified several behavioral objectives and agreed to work with the MHP and dietitian to get herself back on track (e.g., maintain a food and exercise log with correlating emotions, call with weekly progress reports, meet with the MHP following her monthly dietitian appointments, attend the support group for regular attendance, and identify a “buddy” to accompany her on this renewed weight loss journey). Prior to her surgery, she had attended only one group as the preoperative requirement, stating she was “too shy” to become more involved as “a groupie.”

The Value of a Required Postoperative Visit with the MHP

Any of these issues may be difficult to predict in the initial assessment. For that reason, having at least one “automatic” postoperative appointment scheduled prior to the surgery date can ensure the MHP has the potential to more reliably identify postoperative challenges. In my practice, it seems that the patient can recognize the unsettling reactions of a changing body image or slimming face reflected in the mirror as early as 4 to 6 weeks after the surgery. For this reason, at the preoperative assessment visit, I ask that the patient return for the first postoperative visit at this 4- to 6-week point.

Attempts are made to coordinate the appointment with the patient’s follow-up visit with the surgeon and/or dietitian to make “one stop shopping” a greater convenience for the patient and to ensure better adherence with follow-up appointments. (As a Center of Excellence [COE], having the surgeons, dietitians, and CNS located in the same building at Saint Mary’s makes this “requirement” a more appealing and convenient option for the patient. This geographic handiness makes for more immediate and convenient collaboration among the disciplines as well.) At this visit, it might be easier for the MHP and the patient to begin to identify the previously outlined postoperative issues that could be less recognized or even denied with the “thrill” of the initial postoperative weight loss. Moreover, with a prescheduled postoperative appointment time, reticent patients are more likely to feel continually supported and less intimidated to make that call to the MHP on their own.

This postoperative connection might more readily help the surgeon, dietitian, and other multidisciplinary staff to identify difficult patient behaviors or nonadherence to postoperative treatment guidelines. If needed, the surgeon or multidisciplinary team members can readily contact the MHP for an immediate consultation on the patient. Integrated treatment plans and collaborative interventions can provide the surgeon and team with the added benefit of the MHP’s expertise and proposal for behavioral interventions. Moreover, difficulties for the surgeon with postoperative follow-ups and patient retention issues could more likely be helped by the additional connection and ongoing relationship with the MHP.[24]

The Value of the Support Group

Patients should be referred to an ongoing support group beginning preoperatively and continuing through at least the first year postoperatively. This group of the patient’s peers who have also undergone bariatric surgery with its dramatic lifestyle changes can be very helpful in order to sustain the patient’s self-management practices and to identify any symptoms of adverse outcome. Unfortunately, there may be deterrents to this recommendation. First of all, the surgeon or other treatment providers may have negative expectations regarding the ongoing value of a support group. Second, even with a preoperative requirement by the surgeon to attend at least one support group with encouragement to attend regularly postoperatively thereafter, the patient may hear this as, “I only have to attend one group in order to get the surgery.” Third, if patients attend only one group and that experience is a negative one, the patient is less likely to consider regular attendance. As one example, if in that particular session there are one or more patients who monopolize the group discussion or impart a similarly negative tone, the prospective patient may base the value of group attendance on that one limited experience. The patient may surmise that the group in general is “only a bitch session.” Finally, the patient may refute the need for the group, stating that he or she has “enough supports in my friends and family.” Regardless, the value of the group experience cannot be overemphasized. (Moreover, the MHP who has an ongoing relationship with the patient can further promote the value of regular group attendance for the patient and his or her significant others.


In summary, the MHP knowledgeable in bariatrics offers more than just a preoperative “yes or no” decision regarding a patient’s appropriateness for bariatric surgery. An ongoing relationship with the MHP can provide valuable preoperative education and support to the patient and family, identify emotional and psychological obstacles to postoperative success, intervene with patients’ postoperative difficulties, provide postoperative care to the patient and family, and both preoperatively and postoperatively serve as a valuable resource for the surgeon and multidisciplinary team.

1. Steinbrook R. Surgery for severe obesity. N Engl J Med 2004:350(11):1075–9.
2. Puzziferri N. Psychologic issues in bariatric surgery—The surgeon’s perspective. Surg Clin North Am 2005;85(4):741–55.
3. Simon GE, Von Korff M, Saunders K, et al. Association between obesity and psychiatric
disorders in the US adult population. Arch Gen
Psych 2006:63(7):824–30.
4. Kinzl JF, Schrattenecker M, Traweger C, et al. Psychosocial predictors of weight loss after bariatric surgery. Obes Surg 2006;16(12):1609–14.
5. Carpenter KM, Hasin DS, Allison DB. Relationships between obesity and DSM-IV major depressive disorder, suicide ideation and suicide attempts: Results from a general population study. Am J Public Health 2000;90(2):251–7.
6. Onyike CU, Crum RM, Lee HB, et al. Is obesity associated with major depression? Results from the Third National Health and Nutrition Examination Survey. Am J Epidemiol 2003;158(12):1139–47.
7. Allison KC, Stunkard AJ. Obesity and eating disorders. Psych Clin North Am 2005;28(1):55–67.
8. Greenberg I, Perna F, Kaplan M, Sullivan MA. Behavioral and psychological factors in the assessment and treatment of obesity surgery patients. Obes Res 2005;13(2):244–9.
9. Berkowitz RI, Fabricatore AN. Obesity, psychiatric status, and psychiatric medications. Psych Clin North Am 2005;28(1):39–54.
10. Wadden TA, Butryn ML, Sarwer DB, et al. Comparison of psychosocial status in treatment-seeking women with class III vs. class I-II obesity. Surg Obes Rel Dis 2006;2(2):138-45.
11. Kalarchian MA, Marcus MD, Levine MD, et al. Psychiatric disorders among bariatric surgery candidates: Relationship to obesity and functional health status. Am J Psych 2007;164(2):328–34.
12. Fabricatore AN, Wadden TA, Sarwer DB, et al. Self-reported eating behaviors of extremely obese persons seeking bariatric surgery: A factor analytic approach. Surg Obes Rel Dis 2006:2(2):146–52.
13. Sarwer DB, Cohn NI, Gibbons LM, et al. Psychiatric diagnoses and psychiatric treatment among bariatric surgery candidates. Obes Surg 2004;14(9):1148–56.
14. LeMont D, Moorehead MK, Parish MS, et al. Suggestions for the pre-surgical psychological assessment of bariatric surgery candidates. Presented at the American Society for Bariatric Surgery; October, 2004.
15. Sogg S, Mori DL. The Boston interview for gastric bypass: Determining the psychological suitability of surgical candidates. Obes Surg 2004;14(3):370–80.
16. Fabricatore AN, Crerand CE, Wadden TA et al. How do mental health professionals evaluate candidates for bariatric surgery? Survey results. Obes Surg 2006;16(5):567–73.
17. Helmrath MA, Brandt ML, Inge TH. Adolescent obesity and bariatric surgery. Surg Clin North Am 2006;86(2):441–54.
18. Buchwald H. For the Consensus Conference Panel. Bariatric surgery for morbid obesity: Health implications for patients, health professionals, and third-party payers. J Am Coll Surg 2005;200(4):593–604.
19. Salem L, Jensen CC, Flum DR. Are bariatric surgical outcomes worth their cost? A systematic review. J Am Coll Surg 2005;200(2):270–8.
20. Wadden TA, Sarwer DB. Behavioral assessment of candidates for bariatric surgery: A patient-oriented approach. Surg Obes Rel Dis 2006;2(2):171–9.
21. Saxton JW, Finkelstein MM, Camden SG. Consultant’s Corner: Understanding bariatric risk—A legal, clinical, and customer service focus. Bariatric Times 2007; 4(1):26–7.
22. Thompson B. Weight Loss Surgery: Finding the Thin Person Hiding Inside You! 3rd Edition. Tarentum, PA: Word Association Publishers, 2003.
23. Elkins G, Whitfield P, Marcus J, et al. Noncompliance with behavioral recommendations following bariatric surgery. Obes Surg 2005;15(4):546–51.
24. Sarwer DB, Wadden TA, Fabricatore AN. Psychosocial and behavioral aspects of bariatric surgery. Obes Res 2005;13(4):639–48.
25. Gustafson TB, Gibbons LM, Sarwer DB et al. History of sexual abuse among bariatric surgery candidates. Surg Obes Rel Dis 2006;2(3):369–74.
26. Vaidya V. A study: Body image and sexual functioning in obese patients presenting for bariatric surgery. Bariatric Times 2005;2(6):13–6.
27. Lindstrom W. Professional liability and risk management. Presented as Surgical Support Issue at 19th Annual Meeting of the American Society for Bariatric Surgery; June 2002. Las Vegas, NV.
28. Saxton J, Corboy PH, Sheldon A. Bariatric surgery: What the plaintiff’s lawyers think, the defense lawyers, and most importantly the jurors! Presented at the 23rd Annual Meeting of the American Society for Bariatric Surgery; June 2006. San Francisco, CA.
29. Saxton JW. Reducing your bariatric risk while enhancing your program. Presented at the Adding, Updating and Expanding Bariatric Surgery Centers of Excellence Hospitals and Health Systems Conference; March 2007. San Francisco, CA.
30. Wittgrove AC. An interview with Alan C. Wittgrove, MD. Bariatric Times 2007;4(3):13–6.
31. Wong-Swartz E. Minimizing risk exposure in bariatric surgery. Bariatric Times 2006;3(5):42–4.
32. Eagan MC. Bariatric surgery: Malpractice risks and risk management guidelines—Commentary. Amer Surg 2005;71(5):369–75.

Suggested Reading

1. Alexander CL. The Emotional First+Aid Kit: A Practical Guide to Life After Bariatric Surgery. Edgemont, PA: Matrix Medical Communications, 2006.
2. Browne AF, Browne NT. Bariatric surgery in adolescents. Bariatric Times 2006;3(5):1,10,12-4.
3. Kurian MS, Thompson B, Davidson BK, Roker A. Weight Loss Surgery for Dummies. Hoboken, NJ: Wiley Publishing Inc., 2005.
4. Moorehead MK, Alexander CL. Transfer of addiction and considerations for preventive measures in bariatric surgery. Bariatric Times 2007;4(1):22–5.
5. Sarwer DB, Thompson JK, Cash TF. Body image and obesity in adulthood. Psych Clin North Am 2005;28(1);69–87.

Category: Past Articles, Review

Leave a Reply