Kasey P. S. Goodpaster, PhD
Psychological testing should play an integral role in the pre-surgical psychological evaluation of bariatric surgery candidates. Generally, such testing involves at least one broad measure of general psychopathology, as well as 2–6 briefer and more specific assessments of depression, anxiety, substance abuse, and cognitive functioning as indicated. Ideally completed prior to the clinical interview, testing allows psychologists to identify key areas for further clinical assessment and evaluate the consistency between test and interview data.
Imagine that you are just starting to collaborate with a local bariatric program at a nearby hospital. They have asked you to provide psychological testing to pre-surgical candidates, prepare a report, and attend bimonthly staff meetings to provide input about whether patients are appropriate to undergo surgery. You must develop your own bariatric testing protocol based on best practices and clinical needs. You have just received your third referral. “Ms. Jones” is a 28-year-old African American woman, with a BMI of 42, and a medical history consisting of hypertension, sleep apnea, and type 2 diabetes. She was treated for depression in her late teenage years, and there were hints of her previously considering suicide, though there were no reported suicide attempts. Her husband reportedly drinks alcohol heavily, a stressor that sometimes contributes to emotional eating. As a stay-at-home mother of two young children, Ms. Jones sometimes has difficulty prioritizing her own self-care in the context of many household responsibilities. She complains of forgetting to attend appointments at times, and is unsure of whether she has a memory problem or is simply too busy to keep up with everything.
Through your research so far, you are aware that rates of psychopathology are significantly higher for bariatric patients compared to the general population. Approximately one third of bariatric candidates meet criteria for a current psychiatric disorder, and two thirds met criteria for a disorder at some point in their lifetime (Mitchell et al., 2012). Specifically, lifetime rates of major depressive disorder are much higher for bariatric surgery candidates (38.7%) compared to the general population (6.7%). The same trend holds true for lifetime anxiety disorders (31.7% in bariatric candidates vs. 18.1% in the general population) and alcohol use disorder (33.2% vs. 4.4%; Mitchell et al., 2012, Kessler, Chiu, Demler, Merikangas, & Walters, 2005).
Though research regarding the impact of psychopathology on postsurgical weight loss outcomes is mixed, psychiatric symptoms that are not well-managed and/or are impairing functioning could impact postsurgical adherence to lifestyle change. In addition, those who experience loss of control eating before surgery may continue to experience eating pathology after surgery, which ultimately interferes with weight loss (White, Kalarchian, Masheb, Marcus, & Grilo, 2010). Furthermore, research suggests that cognitive dysfunction, particularly memory and executive function, is associated with poor weight loss outcomes (Spitznagel, Garcia, et al., 2013).
You know that bariatric surgery is by no means a “quick fix.” Ms. Jones would need to significantly change her lifestyle in order to achieve her weight loss goals and avoid surgical complications. The typical expected post-operative lifestyle generally involves: (1) exercising regularly, (2) eating 5–6 small meals per day, over a period of 20–30 minutes, and chewing each bite 20–30 times, (3) drinking at least 64 ounces of fluid per day, (4) separating eating and drinking by 30 minutes, (4) consuming 60 grams of protein per day, depending on body weight, (5) limiting carbohydrates and high-fat foods, (6) limiting caffeine, eliminating carbonated beverages, and avoiding alcohol, nicotine, and drug use, (7) following a life-long vitamin regimen, and (8) doing regular follow-up with the bariatric team in the post-operative period (and at least annually thereafter). In short, bariatric surgery prompts major changes in the types of food consumed, order and pace of eating, physical activity level, and overall relationship with food. The patient needs to know this, and you need to assess whether or not there is evidence that they can follow and maintain the regimen.
From your previous interactions with the bariatric team, you know that you should assess mood, substance use, eating disorders, and understanding of surgery in the clinical interview. However, you are unsure which psychological tests could best help answer your evaluation questions. Does Ms. Jones currently meet criteria for a psychiatric disorder? Does she struggle with substance use like her husband? Does her emotional eating constitute an eating disorder? To what extent should you assess her memory?
This paper seeks to: 1) provide an overview of the utility of psychological evaluations in bariatric surgery candidates and describe current standards of practice, 2) present assessment instruments commonly used and researched in the bariatric field, and 3) discuss how psychological testing data can be integrated into the clinical interview to shape recommendations for optimal postsurgical outcomes.
Background: Standards of Practice in Bariatric Psychological Evaluations
Bariatric surgery has demonstrated impressive outcomes with regard to significant, durable weight loss and resolution of weight-related comorbidities (Mechanick et al., 2013; Valezi, Menezes, & Mali, 2013). However, these surgical procedures require substantial lifestyle change with regard to the types of food consumed, order and pace of eating, physical activity level, and overall relationship with food. Thus, psychologists play a key role in evaluating the extent to which patients are able to follow the required postsurgical regimen, and what treatment and support they will need to maintain required health behaviors.
Pre-surgical psychological evaluations have been endorsed since 1991 for the surgical treatment of morbid obesity. They are now required by most insurance companies, and national guidelines have been developed. In 2013, the American Association of Clinical Endocrinologists (AACE), the Obesity Society (TOS), and the American Society for Metabolic and Bariatric Surgery (ASMBS) released clinical practice guidelines recommending psychological evaluation of bariatric surgery, specifying contraindications including current drug or alcohol abuse; uncontrolled, severe psychiatric illness; and lack of comprehension of surgery and the lifestyle changes required (Mechanick et al., 2013).
[T]hese surgical procedures require substantial lifestyle change with regard to the types of food consumed, order and pace of eating, physical activity level, and overall relationship with food.
Sogg, Lauretti, and West-Smith (2016) provide the most recent ASMBS guidelines, including over 300 references of supporting evidence to suggest that the following domains be assessed during the pre-surgical evaluation: 1) current eating patterns, diet history, and eating pathology (i.e., binge eating disorder, night eating syndrome, graze eating, other loss of control eating, and compensatory behaviors); 2) mental health symptoms and severity (including current and past suicidal ideation, current and past mental health treatment, and current stressors); 3) family history, including adverse life events and current social supports, 4) the possible existence of cognitive deficits that could affect ability to consent to surgery and/or ability to adhere to the postsurgical bariatric lifestyle; 5) substance use history; and 6) likelihood of adherence, including the patient’s understanding of the surgical procedure, risks, expected weight loss, and lifestyle changes required.
The Role of Psychological Testing
The majority of psychologists conducting bariatric surgery evaluations use a psychological testing component. The results of a 2007 survey of practices among psychologists indicated that 75% employed psychological testing, with most using at least two measures, (Walfish, Vance, & Fabricatore, 2007), though usage may have changed and likely increased within the past 10 years. Psychological testing serves several purposes within a comprehensive bariatric evaluation. First, testing offers an additional source of data with which to compare information gathered during the face-to-face interview. Any discrepancies between the patient’s reported symptoms in the interview and testing should be explored. Some patients may feel more comfortable self-disclosing via computer or paper forms than to a psychologist, or vice versa. Second, some measures include validity scales that gauge the extent to which the patient is attempting to present in a favorable light. Underreporting is particularly important to explore within the bariatric population, as they may be more motivated than other treatment-seeking patients to present favorably for fear of not “passing” the psychological evaluation (Ambwani et al., 2013). Third, testing allows for a more comprehensive review of symptoms than can be typically gathered in a clinical interview, with any clinically significant testing results prompting further targeted questioning in the interview. For instance, psychologists may not routinely ask about legal history, unless testing suggests behavioral dysfunction, antisocial beliefs, or impulsivity. Finally, testing can provide a more objective measure of patients’ progress toward meeting treatment goals. Brief, repeatable measures of depression or anxiety, for example, can help psychologists assess response to pre-surgical treatment and guide the decision-making process regarding their readiness for surgery.
Which Tests Should be Used?
No consensus exists with regard to which specific tests should be used. The 2016 ASMBS guidelines regarding pre-surgical psychosocial evaluation recommend that psychologists consider
the following: 1) psychometric information, including whether bariatric norms are available; 2) availability of validity indices to gauge degree of over- or underreporting; 3) time and cost burden to the patient of the testing; 4) the degree to which the psychometric testing adds value to information gathered in the clinical interview; and 5) the degree to which the information gathered from the measure has been researched and shown to have a bearing on bariatric surgery outcomes (Sogg, Lauretti, & West-Smith, 2016).
The most common symptoms assessed through the use of psychological assessment instruments are depression, eating disorders, anxiety disorders, and general psychopathology, respectively (Fabricatore, Crerand, Wadden, Sarwer, & Krasucki, 2006). A reasonable and typical approach to test selection would be to use one of the most common, broad-band measures of psychopathology (e.g., MMPI-2-RF, MBMD) and to supplement with shorter, more specific scales as indicated. For a thorough review of measures used in bariatric evaluations, including psychometric properties, administration times, and costs, see a review by Marek and colleagues (2016). Here, only the most frequently used measures will be discussed. See Table 1 for a summary of the degree to which the measures meet the ASMBS test selection criteria detailed above.
A survey of psychologists involved in bariatric surgery evaluations indicated that the Minnesota Multiphasic Personality Inventory, second edition (MMPI-2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) was used by 69% of respondents, making it the most commonly used measure overall (Walfish, Vance, & Fabricatore, 2007). The MMPI-2 has been extensively researched, though it carries a significant cost and time burden to the patient, with an administration time of 60–120 minutes. The MMPI-2-RF (Ben-Porath & Tellegen, 2008/2011), the newer and briefer version of the MMPI-2, still takes 45–60 minutes to administer, but appeals to psychologists involved in bariatric surgery evaluation because of strong psychometrics; bariatric surgery candidate norms; multiple personality and clinical symptoms domains assessed; multiple validity scales; and extensive research base, with some subscales shown to correlate with postsurgical outcomes (Marek, Ben-Porath, Merrell, Ashton, & Heinberg; 2014; Marek et al, 2015). For example, research suggests that bariatric surgery candidates scoring higher on scales measuring externalizing dysfunction (i.e., poor impulse control) are at risk of suboptimal weight loss and poor adherence to follow-up one year after surgery (Marek et al., 2015).
Psychologists should also consider the possible impact of psychiatric medication malabsorption after bariatric surgery.
Another of the most commonly used measures of general psychopathology is the Millon Behavioral Medicine Diagnostic (MBMD; Millon, Antoni, Millon, Minor, & Grossman, 2007). Like the MMPI-2-RF, the MBMD contains validity scales and bariatric norms. The MBMD offers the advantage of a shorter administration time (20–25 minutes), and may appear more relevant or have greater face validity to patients because of questions pertaining to health habits such as eating, activity level, and tobacco use. Additionally, optional interpretive reports of MBMD results contain more bariatric-specific details than those of the MMPI-2-RF. Specifically, interpretive score reports rate: 1) the advisability of additional pre-surgical interventions (e.g., counseling, psychiatric consultation) and postsurgical care (e.g., physical rehab, support groups), 2) patients’ likelihood of complying with lifestyle recommendations, and 3) the likelihood that bariatric surgery will improve patients’ quality of life across multiple domains. However, the psychometrics regarding the MBMD are not as strong as that of the MMPI-2-RF, particularly within bariatric populations. Walfish, Wise, and Streiner (2008) cautioned against using the MBMD, particularly if used as the only measure by which to judge overall functioning, given low internal consistency of scales.
Depression and Anxiety
Base rates of depression and anxiety are higher in bariatric surgery candidates than the general population (Mitchell et al., 2012), and could impact ability to adhere to necessary lifestyle changes. For example, patients may engage in emotional eating to cope with unpleasant emotions, they may be unmotivated to exercise in the context of anhedonia, or panic could interfere with leaving the home for follow-up appointments. Psychologists should also consider the possible impact of psychiatric medication malabsorption after bariatric surgery. Research suggests that 35% of bariatric candidates are prescribed antidepressants, and while depression appears to improve in the first two years after surgery, symptoms increase between years two and three (Mitchell et al., 2014). Possible reasons for worsening mood include disappointment in weight loss results and malabsorption of psychiatric medications (Mitchell et al., 2014). For these reasons, careful monitoring and treatment of mood are warranted before and after surgery. Thus, for treatment planning purposes, psychologists may wish to include separate measures of depressive and anxious symptoms above and beyond those captured by measures of general psychopathology. By administering brief, repeatable measures of depression and anxiety, psychologists can evaluate response to any recommended mental health treatment.
Of depression measures, the Beck Depression Inventory-II (BDI-II; Beck et al., 1996) is most commonly used (Walfish, Vance, & Fabricatore, 2007). This inventory gauges depression severity and has been studied in bariatric populations (e.g., Hayden, Brown, Brennan, & O’Brien, 2012). However, its discriminant validity warrants further study due to concerns that it assesses somatic complaints beyond those attributable to depression, and given the medical complexity of bariatric patients, a higher cut-off score may be warranted (Krukowsi, Friedman, & Applegate, 2010).
A free, faster to administer, and yet reliable alternative is the Patient Health Questionnaire-9 (PHQ-9; Kroenke & Spitzer, 2002). Likewise, the Generalized Anxiety Disorder-7 (GAD-7; Spitzer, Kroenke, Williams, & Lowe, 2006) is free, brief, and has demonstrated good reliability in bariatric research (e.g., de Zwaan et al., 2014). Both the PHQ-9 and GAD-7 are easy to administer at follow-up visits after the initial evaluation to track progress toward improving emotional stability. Versions in many languages are available online.
Disordered eating after surgery can lead to complications, suboptimal weight loss or regain, and poor psychosocial outcomes (White, Kalarchian, Masheb, Marcus, & Grilo, 2010). Brief self-report questionnaires may be administered as an adjunct to the clinical interview to either: 1) screen for the presence of eating disorders, or 2) gauge the frequency or severity of loss of control eating episodes. For the former purpose, The Questionnaire of Eating and Weight Patterns-Revised (QEWP-R; Spitzer, Yanovski, & Marcus, 1993) is most frequently used. This instrument serves as a brief screening tool for binge eating, bulimia, and body image concerns. Now called the QEWP-5, the questionnaire was recently updated to reflect DSM-5 diagnostic criteria for binge eating (Yanovski, Marcus, Wadden, & Walsh, 2015). The instrument is intended to screen for overeating disorders, but diagnoses should be confirmed by clinical interview. By contrast, the Binge Eating Scale (BES) does not include specific diagnostic criteria for binge eating disorder, but can be used to discriminate between minimal, moderate, or severe binge eating behaviors (Gormally, Black, Datson, & Rardin, 1982), which could be helpful in determining the appropriate treatment level and in evaluating response to treatment. As it contains only 16 items, the BES is quick to administer. For a more comprehensive questionnaire of eating disorder frequency and severity, psychologists could consider using the Eating Disorders Examination Questionnaire (EDE-Q; Fairburn & Beglin, 1994), which captures broader eating pathology (beyond binge eating) in the past month. The EDE-Q contains subscales measuring restraint, eating concern, weight concern, and shape concern, and thus, may take slightly longer to administer.
Active alcohol abuse is considered a contraindication for surgery per national guidelines (Mechanick et al., 2013), and alcohol should be used with extreme caution, if at all, after surgery due to pharmakinetic changes that make it more intoxicating and may lead to the onset of alcohol-related problems (King et al., 2012). The Alcohol Use Disorders Identification Test (AUDIT; Babor, Higgins-Biddle, Saunders, & Monterio, 2001), or the briefer version, the Alcohol Use Disorders Identification Test- Consumption (AUDIT-C; Bush, Kivlahan, McDonnell, Fihn, & Bradley, 1998) are publicly available, free tools that can be used to identify problematic alcohol use. A reasonable approach may be to assess alcohol use in all patients using the 3-question AUDIT-C, and for patients scoring in the positive range, administering the full 5-minute AUDIT to better differentiate between alcohol use, abuse, and dependence. Beyond the AUDIT, no other substance abuse measures have been evaluated for reliability and validity in bariatric surgery settings.
Impairments in memory and executive function are common among bariatric surgery candidates and are associated with poorer weight loss outcomes and adherence (Spitznagel, Garcia, et al., 2013; Spitznagel, Galioto, Limbach, Gunstad, & Heinberg, 2013). In addition, cognitive dysfunction could impact patients’ ability to understand the surgical procedure, risks, and necessary lifestyle changes to the extent that they could lack capacity to consent to the procedure. Full cognitive testing batteries are not typically administered in routine bariatric evaluations, but there may be instances when a psychologist should screen for cognitive impairment in order to determine any need for more extensive neuropsychological testing. For instance, older patients, those citing memory concerns, or individuals otherwise suspected of having low cognitive functioning can be administered a brief cognitive screen as part of the decision-making process regarding the need for additional testing.
Unfortunately, most cognitive screening measures were developed for older individuals in order to detect dementia. Therefore, common cognitive screens such as the Mini Mental Status Exam (MMSE; Folstein, Folstein, & McHugh, 1975) have limited sensitivity and specificity in detecting cognitive impairment in bariatric surgery candidates (Galioto et al., 2014). The Montreal Cognitive Assessment (MoCA; Nasreddine et al., 2005) may be a better option due to its utility in detecting mild cognitive impairment in medical populations (e.g., Cameron, Worrall-Carter, Page, Stewart, & Ski, 2013), but warrants further study in bariatrics, specifically.
How Should Results be Integrated?
Ideally, psychological testing results are available before the patient is seen for the clinical interview. Such is most often the case if the psychologist employs computerized testing (offering immediate scoring and reporting), and/or quick, easy to score paper-and-pencil assessments. Reviewing testing results prior to the clinical interview offers several benefits. First, assuming that a measure including validity indices was utilized, the psychologist can have a sense of the patient’s likely approach to the interview. If guardedness was noted in formal testing, it may also be evident in the interview, perhaps prompting the psychologist to focus more than usual on establishing a safe, trusting therapeutic environment. Second, the psychologist can clarify any discrepancies between the patient’s report in testing and the clinical interview, and their explanations of such should be noted in the report. Third, critical items endorsed in testing (e.g., suicidal ideation) can be further processed to provide risk management and allow for safety planning if needed. Finally, the psychologist can offer test feedback to the patient within the interview. Elevations noted in testing can be used to obtain buy-in for treatment recommendations. For example, if a patient scored high on a scale measuring depression, the psychologist could use this information as a rationale for a recommendation for pursuing mental health treatment before surgery. Moreover, the integration of results of the clinical interview and testing forms the basis of an informed decision about the patient’s candidacy for surgery and any treatment needed to enhance surgical outcomes.
A Return to the Case Scenario
After learning more about standard practices for psychological assessment of bariatric surgery candidates, you decide to make the MMPI-2-RF part of your standard testing battery. “Ms. Jones,” your most recent referral from the bariatric program, completes the MMPI-2-RF on the computer prior to her appointment with you. Validity scales indicate that she approached the test openly and honestly, and though her overall emotions, thoughts, and behaviors fell within the average range, there were elevations on scales measuring stress, self-doubt, and cognitive complaints. The test report also highlights a “critical item” indicating she endorsed a previous suicide attempt, thus prompting you to discuss suicidal ideation with her more thoroughly.
During the clinical interview, she discusses her family stress, history of suicidal ideation as a teenager, and concentration difficulties, all of which were consistent with testing. She denies depressed mood or current suicidal ideation, but reports some anxiety that she attributes to her parenting responsibilities and to worrying about her husband’s alcohol use. You administer the GAD-7 and see that she falls within the moderate range of anxiety. In addition, you ask her the three-question AUDIT-C, and after learning that she drinks alcohol only on special occasions, decide not to administer the full AUDIT. Ms. Jones endorses infrequent binge eating episodes in the interview, but she does not meet full diagnostic criteria. To better determine the severity of her eating pathology, you administer the BES, and she scores in the moderate range. With further discussion of this discrepancy, Ms. Jones shares that she only engages in binge eating when under extreme stress.
Finally, you administer the MoCA to briefly screen for cognitive impairment, and Ms. Jones scores solidly in the normal range. She then acknowledges that her anxiety could be contributing to concentration problems. At the close of the psychological evaluation session, you opine that in order to become a good surgical candidate, Ms. Jones should treat the underlying anxiety that causes her perceived cognitive difficulties and emotional eating. You ask her to establish counseling treatment and to follow up again in two months, at which time you will administer another GAD-7 and BES to evaluate treatment progress.
Psychological evaluations for bariatric surgery have become a standard of practice, with most psychologists using psychological assessment in conjunction with the clinical interview. Psychological assessment adds incremental value by allowing the psychologist to evaluate a broader range of symptoms, severity of symptoms, approach to the evaluation, and response to treatment. There is no consensus in the field with regard to the optimal battery of measures, but psychologists’ decision-making can be guided by national guidelines for test selection and by their clinical judgment regarding patients’ unique strengths and challenges.
Kasey Goodpaster, PhD, is a clinical health psychologist at the Cleveland Clinic Bariatric and Metabolic Institute. She earned her PhD in Counseling Psychology from Purdue University 2014 after completing a predoctoral internship in health psychology and neuropsychology at St. Vincent Indianapolis Hospital. She completed a postdoctoral fellowship in bariatric psychology at the Cleveland Clinic before joining as staff in 2016. She currently serves as a member of the American Society for Metabolic and Bariatric Surgery (ASMBS) Integrated Health Clinical Issues and Guidelines Committee.
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