Katherine L. Applegate

Recent Experiences of Weight‐based Stigmatization in a Weight Loss Surgery Population: Psychological and Behavioral Correlates

Objective: This study evaluated the association between experiences of weight‐based stigmatization (e.g., job discrimination, inappropriate comments from physicians) within the past month, psychological functioning, and binge eating among a sample of individuals seeking weight loss surgery.

Changes in depressive symptoms and glycemic control in diabetes mellitus.

Objective: To investigate if changes in depressive symptoms would be associated with changes in glycemic control over a 12-month period in patients with Type 1 and Type 2 diabetes. Methods: Ninety (Type 1 diabetes, n = 28; Type 2 diabetes, n = 62) patients having Beck Depression Inventory (BDI) levels of >10 were enrolled in the study. Of those 90 patients, 65 patients completed a 12-week cognitive behavioral therapy intervention. BDI was assessed at baseline and thereafter biweekly during 12 months. Hemoglobin (HbA1c) and fasting blood glucose levels were assessed at baseline and at four quarterly in-hospital follow-up visits. Linear mixed-model analysis was applied to determine the effects of time and diabetes type on depressive symptoms, HbA1c levels, and fasting glucose levels. Results: Mean and standard deviation baseline BDI and HbA1c levels were 17.9 ± 5.8 and 7.6 ± 1.6, respectively, with no significant difference between patients with Type 1 and Type 2 diabetes. Mixed-model regression analysis found no difference between the groups with Type 1 and Type 2 diabetes in the within-subject effect of BDI score on HbA1c or fasting glucose levels during the study. Depressive symptoms decreased significantly (p = .0001) and similarly over a 12-month period in both patients with Type 1 and Type 2 diabetes, whereas HbA1c and fasting glucose levels did not change significantly over time in either group. Conclusion: Changes in depressive symptoms were not associated with changes in HbA1c or fasting glucose levels over a 1-year period in either patients with Type 1 or Type 2 diabetes. CBT = cognitive behavioral therapy; BDI = Beck Depression Inventory; BMI = body mass index; HAM-D = Hamilton depression scale.

The utility of the Beck Depression Inventory in a bariatric surgery population.

BackgroundThe Beck Depression Inventory (BDI) is commonly used in bariatric surgery psychological assessments. However, several items may be measuring physical consequences of obesity (e.g., sleep disturbance, chronic pain, or sexual dysfunction) rather than depressive symptoms.MethodsBariatric surgery candidates (n = 210) completed a series of assessments including the BDI, a chronic pain assessment, and a semistructured clinical interview. Total BDI scores, subscale scores, and endorsement patterns of somatic versus cognitive-affective items were examined based on (1) the presence or absence of a depressive diagnosis or (2) the presence or absence of chronic pain, and optimal cut points were determined.ResultsBoth the total BDI and cognitive–affective subscale had good discriminating accuracy between participants with and without depression, with an optimal cut point of 12 for the BDI and 7 for the cognitive–affective subscale. Bariatric surgery candidates with chronic pain had significantly higher mean total scores on the BDI (M = 12.5 ± 7.5) than those without chronic pain (M = 9.02 ± 6.7; p < 0.01), and those with chronic pain were significantly more likely to endorse many of the physical items than those without chronic pain.ConclusionsThe BDI, with or without the somatic items, appears to be a reasonable screening measure for depressive symptoms among bariatric surgery candidates and the subpopulation of those with chronic pain, although future investigations may wish to examine whether other measures would have improved discrimination accuracy.

Patient predictors of follow-up care attendance in Roux-en-Y gastric bypass patients

BACKGROUND Multidisciplinary care after bariatric surgery is important for long-term safety and optimal weight loss, yet many patients do not attend follow-up appointments. We sought to identify demographic, psychosocial, and weight-related variables that were associated with medical and behavioral health appointment attendance after bariatric surgery. METHODS A retrospective chart review was conducted with consecutive patients (n=538) obtaining first-time Roux-en-Y gastric bypass surgery between August 2009 and August 2010. Demographic and psychosocial data were compared between high (>50%) and low (≤50%) medical appointment attendees and high (>50%) and low (≤50%) behavioral health group attendees in their first postoperative year. Percentage excess weight loss at 6 months after surgery was evaluated as a predictor of 12-month appointment attendance. RESULTS High medical appointment attendees were more likely to be older, be Caucasian, and have lower phobic anxiety than low medical appointment attendees. High behavioral health attendees had shorter travel distance to the clinic and lower levels of hostility, anxiety, and phobic anxiety compared with low attendees. In multivariate analyses, race/ethnicity and phobic anxiety remained significant predictors of medical attendance, while travel distance to clinic predicted behavioral health attendance. Six-month percent excess weight loss predicted medical appointment attendance at 12 months. CONCLUSION The identified predictors of poor attendance at medical and behavioral bariatric surgery follow-up appointments should inform efforts to increase follow-up and improve surgical outcomes.

A comparative analysis of Type 2 diabetes and binge eating disorder in a bariatric sample

An emerging literature has illuminated an important link between Type 2 diabetes mellitus (DM) and binge eating disorder (BED) within obese cohorts. However, prior work has not examined this relationship specifically in a weight loss surgery (WLS) sample or fully explored potential psychosocial factors associated with this co-occurrence. Therefore, the present investigation sought to identify socio-demographic (i.e. age, education, BMI, ethnicity, gender, age of obesity onset) and psychological (i.e. depressive symptoms, hedonic hunger/food locus of control beliefs, severity of binge eating-related cognitions) correlates of the co-occurrence of Type 2 DM and BED among bariatric surgery candidates. An archival sample of 488 patients seeking surgical treatment for clinical obesity completed a standard battery of pre-operative psychosocial measures. The presence of BED was evaluated using a semi-structured clinical interview based on the DSM-IV TR (APA, 2000) and was further corroborated by responses on the Questionnaire on Eating and Weight Patterns-Revised (QEWP-R; Spitzer, Yanovski, & Marcus, 1993). Results indicated that 8.2% of the sample was classified as having both Type 2 DM and BED concurrently. A multivariate logistic regression model revealed that in addition to other psychological (e.g., binge eating-related cognitions, hedonic hunger) and demographic variables (i.e. male gender), African American ethnicity (OR=3.3: 1.41-7.73) was a particularly robust indicator of comorbid status. Findings support and extend previous health disparity research urging greater attention to the needs of traditionally underserved, at-risk populations seeking treatment for obesity complicated by dysregulated eating and metabolism. Additionally, these preliminary results underscore the relevance of considering the potential benefits of providing quality comprehensive pre- and post-operative psychological care among bariatric patients towards optimizing both short- and long-term health and well-being.

Electromyographic (EMG) biofeedback in the comprehensive treatment of central pain and ataxic tremor following thalamic stroke.

Peripheral pain and ataxic tremor can appear suddenly following thalamic stroke and can significantly alter a patients psychological, social, and physical functioning. The present paper reports the case of a 70-year-old Caucasian female who sustained an acute left posterior cerebral artery infarction involving the thalamus and left mesiotemporal regions. She subsequently developed Central Poststroke Pain and ataxic movement of her right arm and hand in addition to a significant right-side claudication. She was treated over 16 weeks (6 weeks of EMG biofeedback and 10 weeks of psychotherapy) with a combination of EMG biofeedback, progressive muscle relaxation, behavioral pain coping skills training, Forced Use Therapy, and Cognitive Behavioral Therap 7 years after her initial cerebral accident. The case demonstrates the utility of biofeedback when combined as part of a comprehensive treatment program to address the multiple complications associated with thalamic stroke.

Bariatric surgery in patients with bipolar spectrum disorders: Selection factors, postoperative visit attendance, and weight outcomes

BACKGROUND As many as 3% of bariatric surgery candidates are diagnosed with a bipolar spectrum disorder. OBJECTIVES 1) To describe differences between patients with bipolar spectrum disorders who are approved and not approved for surgery by the mental health evaluator and 2) to examine surgical outcomes of patients with bipolar spectrum disorders. SETTING Academic medical center, United States. METHODS A retrospective record review was conducted of consecutive patients who applied for bariatric surgery between 2004 and 2009. Patients diagnosed with bipolar spectrum disorders who were approved for surgery (n = 42) were compared with patients with a bipolar spectrum disorder who were not approved (n = 31) and to matched control surgical patients without a bipolar spectrum diagnosis (n = 29) on a variety of characteristics and surgical outcomes. RESULTS Of bariatric surgery candidates diagnosed with a bipolar spectrum disorder who applied for surgery, 57% were approved by the psychologist and 48% ultimately had surgery. Patients with a bipolar spectrum disorder who were approved for surgery were less likely to have had a previous psychiatric hospitalization than those who were not approved for surgery. Bariatric surgery patients diagnosed with a bipolar spectrum disorder were less likely to attend follow-up care appointments 2 or more years postsurgery compared to matched patients without bipolar disorder. Among patients with available data, those with a bipolar spectrum disorder and matched patients had similar weight loss at 12 months (n = 21 for bipolar; n = 24 for matched controls) and at 2 or more years (mean = 51 mo; n = 11 for bipolar; n = 20 for matched controls). CONCLUSION Patients diagnosed with a bipolar spectrum disorder have a high rate of delay/denial for bariatric surgery based on the psychosocial evaluation and are less likely to attend medical follow-up care 2 or more years postsurgery. Carefully screened patients with bipolar disorder who engage in long-term follow-up care may benefit from bariatric surgery.

Introduction to Psychological Consultations for Bariatric Surgery Patients

A preoperative psychological consultation has become the standard of practice among bariatric surgery programs in the United States. During these psychological evaluations, the assessment of areas specific to bariatric surgery is essential to assist with patient preparation for surgery. In this chapter, the most common structured and semi-structured clinical assessment strategies are discussed, as well as specific assessment topics including dieting history, psychopathology, eating behaviors, substance use habits, adherence, knowledge about bariatric surgery, social support, and psychosocial stressors. Key psychometric instruments used with this population, treatment planning/decision-making patterns, and clinician preparation issues also are discussed. The use of empirical literature and sound clinical judgment to inform and justify behavioral treatment planning is critical for the appropriate treatment of bariatric surgery candidates. As this chapter emphasizes, the preoperative psychological consultation serves many purposes including enhancing behavioral preparation for surgery, educating patients about psychosocial aspects of the bariatric surgery experience, and building rapport for future clinical support as needed.

Comment on: Validity of Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) scores as a function of gender, ethnicity, and age of bariatric surgery candidates

Preoperative bariatric surgery assessments can serve several valuable functions for patients and their associated surgical programs. One primary goal is the identification of clinical issues that may benefit from additional attention or structured intervention perioperatively in an effort to maximize the chances of patients’ long-term success after surgery. To advance this aim, bariatric surgery specialists are working to determine: 1) the most relevant preoperative characteristics associated with positive and/or negative outcome, 2) efficient methods of identifying patients with these characteristics, and 3) effective ways of creating change that is associated with improved patient outcome. Behavioral health specialists have actively participated in this investigative process for many years. They have conducted descriptive, cross-sectional, longitudinal, and retrospective studies on the psychological features of bariatric surgery patients and have explored the use of psychological variables in predicting postsurgical outcomes. Although the descriptive efforts have been quite beneficial in clarifying the cognitive, behavioral, social, and emotional characteristics of bariatric surgery patients, the predictive efforts have proved much more challenging. One of the most common psychological assessment instruments that has been used within the bariatric surgery population for both descriptive and predictive purposes is the Minnesota Multiphasic Personality Inventory (MMPI, MMPI-2, MMPI-2-RF) [1–6]. In fact, Bauchowitz et al. [7] found that nearly 30% of bariatric surgery programs that included standardized psychological testing preoperatively included a personality inventory, the most common of which was the MMPI. Fabricatore et al. [8] surveyed 194 behavioral health providers involved in screening candidates for bariatric surgery and found that nearly 43% of these professionals included the MMPI as part of their assessment protocol. Descriptive studies using the MMPI have provided valuable information on this patient population. For example, clinical scale elevations are not uncommon in this patient group. Glinski et al. [9] reported that 71% of the 115

Comment on: The Mini-Mental State Exam (MMSE) is not sensitive to cognitive impairment in bariatric surgery candidates

Data from the Longitudinal Assessment of Bariatric Surgery project continue to provide an excellent source of information on various topics relevant to clinicians working with metabolic and bariatric surgery patients. Analyses from this ongoing multisite research are not only clarifying the surgical and medical outcomes for bariatric surgery patients longitudinally, they are also allowing examinations into important behavioral and cognitive parameters involved in the appropriate selection and preparation of patients for surgery [1–3]. The accompanying article is an example of a clinically useful investigation into the validity of a commonly used cognitive screening instrument for the purposes of identifying possible mild cognitive impairment among applicants for weight loss surgery. As referenced in the accompanying article, studies have shown that approximately 25% of candidates for bariatric surgery show clinically meaningful levels of cognitive impairment (i.e., greater than 1.5 standard deviations below average) on neuropsychological tests. Thus, an appropriate screening measure is needed to identify bariatric surgery patients who may need additional testing on memory/executive function or who may benefit from expanded behavioral treatment plans (targeting preoperative preparation or postoperative factors) to compensate for any recognized deficient. Most mental health providers conducting presurgical psychological screenings for metabolic and bariatric surgery are not trained as neuropsychologists. However, most clinicians functioning in this role are familiar with the Mini-Mental State Examination (MMSE) [4] and could be reasonably expected to select this screening instrument for their psychometric testing batteries on selected patients. This may have been even more likely based on the recently published literature on the prevalence of mild cognitive impairment among bariatric surgery patients (1–3). Unfortunately, as the present study highlights, those clinicians could have been misled by the rate of false negatives resulting from the use of the MMSE in this patient population for the purpose of identifying mild cognitive impairment. The clinical issue emphasized here is not the identification of dementia, which is uncommon among bariatric surgery candidates, but rather the detection of mild