Amy Windover

Brief, four-session group CBT reduces binge eating behaviors among bariatric surgery candidates.

BACKGROUND The objective of this study was to evaluate the effectiveness of a brief, 4-session cognitive behavioral, group psychotherapy for binge eating among bariatric surgery candidates at an academic medical center. Binge eating behaviors have been linked to poorer outcomes among bariatric surgery patients, and binge eating disorder have be considered a contraindication in surgery programs, some of which have mandated preoperative binge eating treatment. However, no previous studies have examined whether a preoperative binge eating intervention could successfully reduce binge eating behaviors among severely obese bariatric surgery candidates. METHODS A total of 243 bariatric surgery candidates completed a brief cognitive behavioral group treatment for binge eating behaviors and were administered the Binge Eating Scale and reported the number of weekly binge eating episodes at the initial psychological evaluation and again after the group sessions. The study used a pre-post intervention design. RESULTS The results suggested significant reductions in both binge eating behaviors and cognitions and binge eating episodes after the group intervention. The interventions effectiveness did not differ according to gender or ethnicity (black versus white). CONCLUSION A brief cognitive behavioral intervention can reduce binge eating behaviors among bariatric surgery candidates. Given the potential influence of binge eating on outcomes, bariatric surgery programs could benefit by treating binge eating before surgery.

Mood disorders in laparoscopic sleeve gastrectomy patients: does it affect early weight loss?

BACKGROUND Research has demonstrated that laparoscopic Roux-en-Y gastric bypass patients with a lifetime history of a mood disorder have a lower percentage of excess weight loss (%EWL) compared with patients without this lifetime history. No studies have examined the effect of psychiatric history on postoperative outcomes among laparoscopic sleeve gastrectomy (LSG) patients. The objectives of the present study were to determine whether mood disorders relate to the first year of weight loss for patients undergoing LSG at an academic medical center. METHODS A total of 104 patients (78.6% white and 71.2% women), with a median body mass index of 60.35 kg/m(2) (range 31.37-129.14) underwent LSG. The patients were prospectively followed up at 1, 3, 6, 9, and 12 months. The semistructured preoperative psychiatric evaluations demonstrated that 43.1% had a current, and 62.5% a lifetime, diagnosis of a mood disorder. RESULTS LSG patients with current mood disorders had a significantly lower %EWL than patients without a psychiatric diagnosis at the 1-, 3-, 6-, and 9-month follow-up visits. LSG patients with a lifetime history of a mood disorder had a significantly lower %EWL than patients without psychiatric diagnosis at the 1-, 9-, and 12-month follow-up examinations. However, after removing patients with bipolar disorder from the analyses, no significant differences were found in the %EWL between patients with and without a lifetime history of depressive disorders. CONCLUSION Consistent with the laparoscopic Roux-en-Y gastric bypass findings, a lifetime history of mood disorders appears to be associated with significantly less weight loss in LSG patients. These findings highlight the importance of the psychiatric assessment in bariatric patients. Additionally, patients with a current or lifetime history of mood disorders might need additional pre- and postoperative care to improve their outcomes.

Positive response to binge eating intervention enhances postoperative weight loss

BACKGROUND Binge eating disorder has been suggested as a predictor of negative outcomes, including weight regain and poorer weight loss, particularly if the symptoms (e.g., loss of control eating) remain after surgery. Binge eating disorder has been viewed by some as a contraindication for weight loss surgery, and preoperative treatment has been recommended to help reduce binge eating behaviors. The objective of the present study was to evaluate whether the response to a preoperative binge eating intervention related to differential postoperative weight loss at an academic medical center. METHODS A total of 128 bariatric surgery candidates completed a brief cognitive behavioral group treatment for binge eating behaviors. The patients were categorized as positive responders or nonresponders according to the postintervention outcomes, including binge eating symptoms and episodes. The percentage of excess body weight loss (%EBWL) was measured at 6 and 12 months after surgery. RESULTS Across all bariatric procedures, the positive responders to the brief binge eating intervention had lost significantly more weight at 6 months (46% EBWL versus 38% EBWL) and 12 months (59% EBWL versus 50% EBWL) postoperatively. The results for a subsample of Roux-en-Y gastric bypass patients (n = 89) were also significant, with 53% EBWL for the responders and 42% EBWL for the nonresponders at 6 months and 68% EBWL versus 54% EBWL at 12 months postoperatively, respectively. CONCLUSION The response to binge eating treatment could be an important predictor of postoperative weight loss. The results from the present study provide support for patients who respond to preoperative binge eating treatment having enhanced surgical outcomes.

Weighing the evidence for an association between obesity and suicide risk

Chronic illness is an important risk factor for suicidal behavior. Obesity is perhaps the most prevalent chronic disease at present, although the contribution of obesity to fatal and nonfatal suicide is controversial. Several large population-based studies have shown that obesity is independently linked to an increased risk of suicide. However, this association has been challenged by reports demonstrating a paradoxical relationship between an increasing body mass index and suicide. Recently, it has also been suggested that bariatric surgery patients are at increased risk of death by suicide postoperatively. We reviewed the heterogeneous data concerning the relationship between obesity and suicide. We also critically examined recent reports describing the incidence of fatal suicide events after bariatric surgery. From the present review, it appears that a positive association between obesity and suicide has been observed more frequently than a negative or absent association. This implies that obese individuals are indeed at an increased risk of suicide. This risk seems to persist despite treatment of obesity with bariatric surgery.

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 (Chronbachs 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.

Prevalence and psychosocial correlates of self-reported past suicide attempts among bariatric surgery candidates

BACKGROUND Although research has been limited, suicidal behavior has commonly been identified as a contraindication for bariatric surgery. The present study aimed to determine the prevalence and correlates of past suicide attempts in a bariatric surgery population at an academic medical center. METHODS A retrospective chart review, including the demographic and psychosocial variables, was conducted of 1020 consecutive bariatric surgery candidates presenting during a 32-month period. RESULTS Of the 1020 patients, 115 (11.2%) self-reported ≥ 1 previous suicide attempt. The patients with a positive suicide history were significantly younger (mean 42.9 ± 11.0 years), less educated (mean 13.4 ± 2.4 years), had a greater body mass index (mean 52.3 ± 11.6 kg/m(2)), and were more predominantly single (32.2% versus 20.9%), female (90.4% versus 74.8%), and receiving disability (45.2% versus 21.8%) compared with patients without a suicide history. A positive suicide history was also significantly associated with a history of psychiatric hospitalization, outpatient psychotherapy and/or psychotropic medication, sexual abuse, and substance abuse. CONCLUSION Assessing suicide history is an important aspect of the bariatric preoperative assessment. Additional research is needed to evaluate the effects of suicide history on the postoperative outcomes and adherence.

Psychological risk may influence drop-out prior to bariatric surgery.

BACKGROUND Factors necessitating a delay before psychological clearance for bariatric surgery have been previously identified; however, research has not examined why patients who begin the preoperative evaluation fail to complete surgery or drop-out of bariatric programs. This study sought to explore the potential psychosocial reasons for a failure to reach bariatric surgery. The setting was an academic medical center. METHODS Data were analyzed from 129 patients psychologically evaluated for bariatric surgery who had failed to reach surgery after 15 months. Medical records were reviewed for demographics, body mass index, and psychiatric variables. RESULTS The most common reasons for not reaching surgery included withdrawal from the program, outstanding program requirements, self-canceled surgery, moving out of the area, insurance denial, switching to non-surgical weight management, or death. Patients with outstanding program requirements were psychosocially different from patients who had not achieved surgery for other reasons. They were significantly more likely to be involved in outpatient behavioral health treatment (chi-square = 12.90, P < .05), to be taking psychotropic medications (chi-square = 15.17, P < .05), and to have met the criteria for current or past alcohol abuse/dependence (chi-square = 23.70, P < .01), and there was a trend for previous inpatient hospitalizations (chi-square = 11.59, P < .07). CONCLUSION Patients who failed to complete outstanding program requirements often had significant psychiatric and/or substance abuse/dependence issues that required additional treatment. It is possible that these patients drop-out of the program due to unwillingness to complete psychiatric treatment recommendations. Continued screening of high-risk patients and the education of patients on the importance of managing these risks is indicated. However, patients may choose to leave programs once education has been provided or treatment mandated.

Internal consistency and validity assessment of SCL-90-R for bariatric surgery candidates.

BACKGROUND Preoperative bariatric psychological evaluations often use both a clinical interview and psychometric testing. Given concerns regarding the psychometric properties of some measures, the present study explored the internal consistency reliability and validity of the Symptom Checklist 90 Revised (SCL-90-R) and has provided a preliminary set of norms for the instrument within a bariatric population. Although the American Society for Metabolic and Bariatric Surgery has included the SCL-90-R as a suggested measure for the assessment of personality and psychopathology, no known studies have reported on the reliability or validity of the SCL-90-R within bariatric samples. METHODS The present study was completed at a large Midwestern medical center in the United States. SCL-90-R inventories were completed by 322 preoperative bariatric patients as a part of their psychological evaluation. Most patients were women (75.5%), with a mean age of 46.7 ± 10.8 years and a mean body mass index of 50.4 ± 10.9 kg/m(2). RESULTS The internal consistency coefficients for the 9 subscales were .76-.90. Convergent validity was demonstrated by scale correlations with the data gathered in the clinical interview. CONCLUSION Compared with other recently studied measures, including the Millon Behavioral Medicine Diagnostic, the SCL-90-R demonstrated good internal consistency and preliminary validity data for bariatric patients. Providers might want to consider the SCL-90-R as a screening measure for bariatric surgery patients.

Pilot evaluation of a substance abuse prevention group intervention for at-risk bariatric surgery candidates

BACKGROUND Concerns have been raised about an increased incidence of substance abuse after bariatric surgery. Alcohol use after surgery may be particularly problematic because of changes in pharmacokinetics leading to greater intoxication. The present study evaluated a substance abuse prevention group pilot intervention for at-risk bariatric surgery candidates. METHODS Patients with a history of substance abuse/dependence or at-risk substance use applying for weight loss surgery (WLS; N = 86) were referred to a single-session 90-minute intervention (67.4% female; 65.1% Caucasian; mean age 46.2 years; mean body mass index 48.77 kg/m(2)). The session included education about the health effects of alcohol/substances on WLS outcomes, developing alternative coping strategies, identifying warning signs of misuse, and providing treatment resources. Patients completed a preintervention and postintervention questionnaire measuring knowledge of substance use health effects, the Alcohol Use Disorders Identification Test-Consumption Items, and items on motivation for abstinence. RESULTS Patients reported a significant increase in knowledge regarding the negative effects of substance abuse after surgery (t = 42.34; P<.001). Patients also reported more healthy alternative coping strategies after the intervention (t = 18.96; P<.001). In addition, a significant number of patients reported a lower intention of consuming alcohol after surgery (χ(2) = 16.18; P<.001) and were more likely to report health reasons as motivation to abstain (χ(2) = 102.89; P< .001). CONCLUSIONS At-risk patients applying for weight loss surgery may benefit from a substance abuse prevention intervention. More research will be needed to see if such benefits can be sustained over time and if interventions affect postsurgical behaviors.

Psychological Considerations for Bariatric Surgery among Older Adults

Older adults are increasing in weight along with the rest of the United States population. Likewise, their rates of bariatric surgery have been on the rise with changes in insurance coverage, evidence of the safety of surgery, and importance of quality of life during older age. Unfortunately, limited research has addressed the unique experiences of older adults and there are no specific guidelines that provide an effective strategy for presurgical psychological evaluation of this group. Therefore, this review aims to address considerations for psychological evaluation of older adults by adapting the current guidelines available, within the framework of a “patient-centered” approach that emphasizes individual needs. Considerations reviewed include psychosocial (e.g., developmental stage, quality of life, level of stress, and coping ability) and cognitive concerns (e.g., capacity to give informed consent, realistic expectations, and adherence to permanent lifestyle change).