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A Primer on Bariatric Surgery Assessments

Dene Berman

Recent government estimates indicate that 64.5% of the adult population in the United States is overweight or obese (Weight-control Information Network, 2004a). The Body Mass Index (BMI) is most common way of determining one’s weight status, computed by multiplying one’s weight in pounds (W) by 703 and dividing that number by one’s height in inches (H) squared (BMI=W X 703/H2 ) (Weight-control Information Network, 2004b). Approximately one-third of the population is overweight (BMI: 25-29.9) and an equal number are obese (BMI: >30). Those who are morbidly obese (BMI: >40) constitute 4.7% of the population in the United States (American Obesity Association, 2002). Individuals with a BMI of at least 40 (about 100 pounds overweight for a man or 80 pounds overweight for a woman) or those whose BMI is between 35 and 39.9 with a serious chronic medical disorder such as type 2 diabetes, heart disease, or severe sleep apnea are appropriate for consideration for bariatric surgery (Weight-control Information Network, 2004b).

In 2002, there were nearly 70,000 bariatric surgeries in the United States (Davis, et al., 2006). The surgeries involve restricting food intake and/or the amount of calories and nutrients that the body can absorb. The Roux-en-Y gastric bypass and the Biliopancreatic diversion, involving restriction of both food intake and/or malabsorption were formerly the most widely accepted of the bariatric surgeries (Weight-control Information Network, 2004b). Currently, however, the Lap Band ® is the most common procedure for bariatric surgery worldwide (Angrisani et al., 2003). It is a restrictive procedure that involves laparoscopic surgery to implant a gastric a silicone band around the upper part of the stomach. The inner band is filled, via a port located under the skin of the abdomen, with saline to create a smaller stomach pouch that has been shown to result in significant, long term weight loss even for the mildly obese (O’Brien et al., 2006).

The need for psychological evaluations for prospective bariatric surgeries was recognized by the National Institutes of Health in 1991, even though it acknowledged a lack of sufficient objective clinical data to make recommendations for patient selection (National Institutes of Health, 1991). The National Institutes of Health recommended a multidisciplinary team to include psychiatric expertise to explore potential high risk variable(s) that included, among other things, the extent to which the patient is well informed, properly motivated, and able to participate in treatment and long-term follow-up. Bariatric surgery candidates should understand how their lives may change after surgery, including nutritional needs and mood (National Institutes of Health, 1991). Kral (1992) reviewed surgical procedures for the National Institutes of Health conference and made reference to other pre-surgery variables that could be assessed by a psychologist: history of psychiatric treatment, eating behavior, psychosocial factors, ability to maintain weight losses, and any psychopathology that limits informed consent and cooperation with follow-up treatments.

Two recent surveys (Santry et al., 2006; Bauchowitz et al., 2005) provide indications of common assessment practices. Santry et al. (2006) conducted a national survey to determine the extent to which bariatric surgeons followed the aforementioned National Institutes of Health recommendation with respect to multidisciplinary evaluation teams. Less than half of those responding had required primary care, nutrition, and mental health evaluations as recommended by National Institutes of Health. Bauchowitz et al. (2005) reported in their survey of bariatric surgery programs, that nearly 90% of programs require patients to undergo psychological evaluation, although only half of those used a formal, standardized psychological assessment.

Since the National Institutes of Health (1991) report, there have been more frequent and specific recommendations for presurgery evaluations. Perhaps the most comprehensive recommendations for evaluations have come from the American Society for Bariatric Surgery (2004). This document states from the outset that the lack of empirical data mitigates against the recommendations being used as a statement of consensus or best practices in the field. The purpose of a psychological evaluation for potential surgery patients is to identify certain risk factors and to make recommendations to the patient and surgeon that lead to good outcomes for the patient. Nevertheless, suggestions for assessments include behavioral, cognitive, and emotional factors, developmental history, current life situation, as well as psychological test data (American Society for Bariatric Surgery, 2004). While there are specific recommendations for collecting certain types of information (e.g., eating styles), there are no recommendations about the number or type of psychological tests that should be administered.

More recently, Bauchowitz et al. (2005) found, in their survey, that the most common contraindications for surgery included schizophrenia, mental retardation, and lack of knowledge of the surgical procedure. They advocate for the creation of guidelines for mental health evaluations for bariatric surgery. Fabricatore et al. (2006) found that nearly all mental health professionals use clinical interviews as part of the assessment process, about 2/3 use symptom checklists or objective psychological tests, and only 1/3 use tests for cognitive assessments. Contraindications for surgery that were identified by mental health professionals responding to this survey included “psychiatric issues,” as well as limitations to informed consent and treatment adherence. The authors concluded that there are wide variations in the assessment practices of mental health professions who conduct evaluations of bariatric surgery candidates.

Despite a lack of consensus in the field regarding bariatric evaluations, some authors make specific recommendations about the contents of such evaluations. Wadden and Sarwer (Wadden, Sarwer et al., 2001; Wadden & Sarwer, 2006) described the procedure used for bariatric surgery evaluations at the Hospital of the University of Pennsylvania, covering biological factors (including BMI, co-morbid medical conditions, and history of obesity), environmental (including information about the patient’s diet, activity level, and weight loss attempts), social-psychological (including psychiatric history, current major psychiatric disorders, and history of abuse) and temporal factors (including the patient’s reason for seeking surgery, knowledge of the surgery, and current levels of stress). This evaluation also determines if the patient’s expectations are realistic and assesses their plan for postoperative care.

The only two tests mentioned by Wadden et al. (2001) are the Weight and Lifestyle Inventory and the Beck Depression Inventory. Other psychologists have recommended standardized tests such as the Minnesota Multiphasic Personality Inventory-2 (Arbisi, 2004) and the Millon Behavioral Medicine Diagnostic (Franks, 2004; Antoni, 2006; Grossman, 2006; Steres, 2006) for inclusion in bariatric surgery evaluations.

This article presents three models for psychologists to consider when conducting bariatric evaluations. The first approach involves responding to the individual needs of the bariatric surgeon, while the second model follows recommendations of national associations. A third approach is suggested that combines the two models, considering both the needs of individual surgeons and national recommendations.

What to Include in a Psychological Evaluation

Given that there appears to be little consensus or data about the contents of a psychological evaluation for potential bariatric surgery candidates, psychologists must consider what to include in a psychological evaluation of bariatric patients. One clearly viable approach is to respond to the content requested by the bariatric surgeon. For example, General Surgery of Central Indiana requires the following topics to be covered in a psychological evaluation ( M. Inman and C. Evanson, personal communication, October 6, 2005):

A second approach is to follow the guidelines specified by previously mentioned sources such as the National Institutes of Health (1991) or the American Society for Bariatric Surgery (2004). The latter suggests the following outline (American Society for Bariatric Surgery, 2004, pp. 2-11):

The third approach is suggested in response to the lack of clinical utility of the former two approaches. Clinical utility refers to the usefulness of an intervention for clinical practice and its utilitarianism – the greatest good for the greatest number (Smart, 2006). Smart (2006) goes on the point out that an integral component to clinical utility is a cost-benefit analysis. Take the first approach, tailoring one’s evaluations to outlines provided by the surgeon. While this approach appears to have great clinical utility in the sense that it would be useful and serve the greatest good if a psychologist only did evaluations for one or two surgeons, it no longer seems practical if one is conducting evaluations for a number of surgeons or if the patient has not yet decided who will conduct the surgery. With respect to the second approach, using an outline like that suggested by the American Society for Bariatric Surgery, questions of clinical utility can be raised over the value of many of the topics outlined. In this vein, it is not clear how one’s legal history is so important as to necessitate it being asked of all patients, especially since the vast majority have insurance, are or have been gainfully employed, need a referral for surgery from their primary care physicians, etc. Further, some of the topics about one’s developmental history – such as perceptions of stability in childhood - are time consuming and add little useable clinical information.

The third approach is one where psychologists take into consideration the guidelines specific surgeons require, pertinent literature on performing bariatric evaluations (e.g., Wadden and Sarwer, 2006), and recommendations made by the government (National Institutes of Health, 1991) and professionals associations (American Society for Bariatric Surgery, 2004), and design an evaluation that best fit their needs, those of their patients, and the surgeons for whom they conduct evaluations. Of course, this latter is approach is somewhat of a compromise in that decisions must be made that are both clinically useful and serve the greatest good. Until there is an accepted standard based on research findings and given the lack of uniformity in bariatric evaluations previously mentioned, this third approach provides psychologists with the flexibility to design bariatric evaluations that meet the needs of their unique settings and are consistent with current best practices in the field.

To provide an example of what this approach might yield, the following is an outline that I use when conducting bariatric evaluations:

I also use three psychological tests: the Minnesota Multiphasic Personality Inventory-2 (Butcher et al., 1989), the Shipley Institute of Living Scale (Zachary, 1986), and the Beck Depression Inventory-II (Beck, Brown, & Steer, 1996). The Minnesota Multiphasic Personality Inventory-2 (Butcher et al., 1989) provides a broad based assessment of personality and psychopathology. The Shipley Institute of Living Scale (Zachary, 1986) yields an estimate of IQ that is helpful in documenting a person’s ability to understand the surgical procedures and post-operative requirements. The Beck Depression Inventory-II (Beck, Brown, & Steer, 1996) yields a depression score that readily allows the psychologist to determine a level from minimal to severe depression.

The evaluation ends with four questions and their answers. These are: “What is the patient’s motivation to have surgery?; Does the patient understand the procedure?; Does the patient understand the aftercare requirements?; Are there any factors which may interfere with compliance with dietary restrictions and postoperative instructions?; Is additional psychological counseling indicated?” The answers to these questions are the summary statements that surgeon’s seem to be most interested in. When preparing reports for surgeons who require information that differs from (this) that covered in the above outline, it is possible to add an addendum or to include the additional information as part of a cover letter.

Practical Matters

The diagnosis we render for patients undergoing bariatric surgery evaluations is Psychological Factors Affecting Medical Condition (316: American Psychiatric Association, 1994). This diagnosis is accepted by most, but not all, insurance companies. Sometimes, a phone call to the provider relations department of the insurance company is needed to discuss the acceptability of this diagnosis.

Billing is an important matter for all of us in private practice. We bill for a one hour diagnostic interview and 3 hours of psychological testing. An option is to add an individual therapy session after the assessment in order to have a feedback session. Given the small percentage of patients who are not recommended for bariatric surgery, we have chosen not to include a routine follow-up session; instead, we schedule those follow-up sessions only for patients for whom we are unable to recommend surgery.

Billing is one issue, payment is often a totally different matter. To ensure payment, we contact the patient’s insurance company prior to the first visit. That way we can determine what benefits are covered as well as deductibles and co-payments. Surprisingly, some insurance companies that cover bariatric surgery will not cover testing for the surgery. Conversely, some insurance companies will cover the testing even though they do not cover bariatric surgery. Other companies require two separate authorizations, one for the initial assessment which is covered under patients’ mental health benefits, and a separate authorization for psychological testing which is covered by the medical part of patients’ insurance for the stated reason that the surgery is a medical procedure. Additionally, some insurance companies will allow the initial assessment and testing on the same day, others require that they be performed on different days. In our experience. the frustration caused by the capricious nature of the rules surrounding bariatric surgery evaluations is only exceeded by the fact that the waiting time to talk to a representative from some major insurance companies in order to determine benefits or to secure authorization can be as long as 90 minutes.

To insure that there is no appearance of a conflict of interest, we give patients a list of local providers who can provide individual counseling for patients for whom follow-up care is recommended. We also inform patients of the free monthly support groups for bariatric surgery patients.

Conclusions

Nearly 2/3 of all Americans are overweight or obese. Bariatric surgery offers a viable long-term solution for those whose weight puts them at risk for chronic, debilitating, and life-threatening medical problems. Since the National Institutes of Health (1991) consensus panel met to discuss bariatric surgery 15 years ago there has been a place for psychologists as part of a multidisciplinary team to determine patients’ appropriateness for bariatric surgery. Unfortunately, there is little data that points the way to what should be included in a psychological pre-surgery evaluation for bariatric surgery. There is also not a sufficiently high level of consensus regarding bariatric evaluations to suggest best practices in the field.

For those reasons, psychologists are in the position to use extant recommendations put forth by the government (National Institutes of Health, 1991), professional associations (American Association of Bariatric Surgery, 2004), and individual surgeons (e.g., M. Inman and C. Evanson, personal communication, October 6, 2005), along with the scant findings of research, to guide their own formulation of the contents of bariatric evaluations.

Examples of outlines for bariatric evaluations have been included in this article to provide background information for psychologists wishing to enter this new area of health care. Matters related to diagnosis, billing, and payment were also discussed to provide insight into some of the pitfalls of practicing in this field.

References

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American Society for Bariatric Surgery. (2004). Suggestions for the pre-surgical psychological assessment of bariatric surgery candidates. Author: Gainesville, FL.

Angrisani, L., Furbetta, F., Doldi, S. B., Basso, N., Lucchese, M., Giacomelli, F., Zappa, M., Cosmo, L., Veneziani, A., Turicchia, G. U., Alkilani, M., Forestieri, P., Lesti, G., Puglisi, F., Toppino, M., Campanile, F., Capizzi, F. D., D’Atri, C., Sciptoni, L., Giardiello, C., Lorenzo, N., Lacitignola, S., Belvederesi, N., Marzano, B., Bernate, P., Iuppa, A., Borrelli, V., & Lorenzo, M. (2003). Lap Band® adjustable gastric banding system. Surgical Endoscopy, 17, 409-412.

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Butcher, J. N., Dahlstrom, W. G., Graham, J. R. , Tellegen, A., & Kaemmer, B. (1989). Minnesota Multiphasic Personality Inventory-2. Minneapolis: University of Minnesota Press.

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Smart, A. (2006). A multi-dimensional model of clinical utility. International Journal for Quality in Health Care, 18(5), 377-382.

Steres, L. M. (June 2006). Practical applications of the MBMD with bariatric candidates. Presented at the 23rd Annual Meeting of the American Society for Bariatric Surgery, San Francisco, CA.

Wadden, T. A., Sarwer, D. B., Womble, L. G., Foster, G. D., McGuckin, B. G., & Schimmel, A. (2001). Psychological aspects of obesity and obesity surgery. Obesity Surgery, 81, 1001-1024.

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Correspondence regarding this article should be addressed to Dene Berman, Lifespan Counseling Associates, P. O. Box 340398, Dayton, Ohio 45434-0398. Email: dene.berman@wright.edu

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