Psychological Evaluation for Bariatric Surgery David X. Swenson PhD LP MSSA 2014

1. Psychological Evaluation for Bariatric Surgery David X. Swenson PhD LP MSSA 2014

2. Agenda • Prevalence of obesity • Risks of obesity & surgical outcomes • Bariatric surgery & how it works • Psychological evaluation • Why evaluation? • History & interview • Test & assessment procedures • Recommendations

4. BMI & Obesity Body Mass Index (BMI), is a number calculated from your weight and height that roughly correlates to the percentage of your total weight that comes from fat, as opposed to muscle, bone or organ. The higher the BMI, the higher the percentage of fat.

5. Alternatives to MBI • BMI is based on body weight rather than composition or where fat is distributed • Waist Circumference: Men >40” Women >35” have increased risk for obesity-related conditions like type 2 diabetes, high blood pressure and high cholesterol. “Apple-shaped” have increased risk for kidney disease. • Bioelectrical Impedance: ordinary scale that measures percentage of body fat composition by sending a low electrical current from footpad electrodes

6. “We’re #1 !”

7. Obesity in the US has increased over the years for all age groups http://perfecthealthdiet.com/category/disease/aging/

9. Obesity is widespread but more prevalent in Central and Southern US http://www.alighterme.com/obesity-in-the-united-states.html

10. How Bariatric Surgery Works • Stomach size is reduced so feel full after smaller meal • Limits the amount of food • Limits absorption of calories • Changes in circulating gut hormones (ghrelin) that affect appetite

11. Weight loss surgery is considered successful when 50% of excess weight is lost and the loss sustained up to five years. 30-60% loss with lapband & 50-75% with gastric bypass. Variability in Results http://www.thinnertimes.com/weight-loss-surgery/gastric-bypass/gastric-bypass-outcomes.html

12. Comorbid Conditions related to Obesity and their Resolution of after bariatric surgery http://asmbs.org/benefits-of-bariatric-surgery/

14. Surgical & Long Term Risks http://www.mayoclinic.com/health/gastric-bypass/my00825/dsection=risks

15. The Psychological Evaluation

16. Why a Psychological Evaluation is Required • In 1991, NIH recommended bariatric surgery patients receive presurgicalpsychological clearance. • Although there are no perfect predictors of success or failure, some mental health conditions are related to more difficulties. • Some habits and addictions such as bad habits (e.g., non-mindful grazing), eating disorders and substance abuse disorders can create serious risks • Some mental health conditions may fluctuate or react to stress such that awareness, support, and treatment can mitigate their adverse impact • Lifestyle and body image changes often require counseling to facilitate adjustment • Evaluation can identify areas for improvement, strengths & support, thereby reducing risk and enhancing likelihood for success • Recommended by the American Society for Bariatric Surgery & often required by insurance companies • Up to 40% of bariatric patients are engaged in some form of mental health treatment and 50 % report a history of mental health treatment

17. Alcohol & Drugs After Surgery • Some forms of bariatric surgery (e.g., gastric bypass) are 2.3x more likely to have alcohol Tx • Alcohol and drugs can get into the blood and to the brain faster, thereby increasing intoxication faster & taking longer to get sober • Losing weight and returning to a high social life may increase alcohol use • More problematic alcohol use reported the second year after surgery • Alcohol use disorders more likely to develop in men, younger people, recreational drug users, smokers, socially isolated, and people who drank two or more drinks per week. http://www.webmd.com/diet/weight-loss-surgery/news/20120618/after-bariatric-surgery-alcohol-abuse-more-likely

18. Alcohol cont’d • Reduced caloric intake can also may the patient more susceptible to alcohol (e.g., effects are much faster on empty stomach). Even one glass of wine can push a person over the legal limit. • Carbonated beverages (including beer) can cause uncomfortable distension of the reduced stomach area • Vomiting from intoxication can strain surgical sutures and devices as well as vitamin and mineral deficits. • Alcohol increases the risk of gastric ulcers and gastric reflux. • Elimination of one compulsive disorder (eating) can shift to other addictions such as gambling and alcohol abuse. Prior abuse risk can become even greater following bariatric surgery: 20-30% deal with new addictions.

19. Testing Considerations • Surveys of bariatric programs show that 98.5% use clinical interviews; 48-85% use psychological testing; • Some patients may feel more comfortable endorsing items on paper than admitting in interview • Some patients withhold or minimize relevant information due to shame or that it might adversely affect their candidacy; 2/3 score >2sd on social desirability • Some patients may exaggerate their condition hoping it will enhance their candidacy • If a profile is inconsistent or invalid, 94% produce a valid profile on retesting when given instructions to repeat the tests with “a mindset of rigorous openness and honesty” • Testing can be used to build rapport for more candid interview • Test norms can help identify responses that are outstanding in some way • Bariatric programs should use data to determine cut-off points Heinberg, L. J. (February 21, 2013). The role of psychological testing for bariatric/metabolic surgery candidates. Bariatric Times, 10(2), 1.

20. Health and Behavioral History

25. Mahoney, D. (2010). Standardizing presurgical psychological evaluations with the PreBari psychological test. Bariatric Times, 7(9), 18-20.

27. Pre-Surgery Psychological Interview

31. Summary of Factors

32. Pre-Surgical Psychological Tests Listed by the American Society for Bariatric Surgery • Eating Attitudes and Behaviors • Binge Eating Scale (BES) • Binge Eating Questionnaire (BEQ) • Three-Factor Eating Questionnaire (TFEQ) • Eating Inventory (EI) • Questionnaire on Eating and Weight Patterns-Revised (QEWP-R) • Eating Disorder Examination-Questionnaire (EDE-Q) • Eating Disorder Inventory-2 (EDI-2) • Eating Disorder Symptom Checklist (EDI-SC) • Weight and Lifestyle inventory (WALI) • Personality And Psychopathology  • Basic Personality Inventory (BPI) • Personality Assessment Inventory (PAI) • Structured Clinical Interview for DSM-IV-Axis I, Clinical Version (SCID-I:CV) • Beck Depression Inventory-II (BDI-II) • Beck Anxiety Inventory (BAI) • Minnesota Multiphasic Personality Inventory-2 (MMPI-2) • Millon Behavioral Medicine Diagnostic (MBMD) • Rosenberg Self-Esteem Scale (SES)(RSE) • Symptom Checklist 90-R (SCL-90-R) http://www.assessmentpsychology.com/psychtests-bariatric-asbs.htm

34. Health Related Quality Of Life • Quality of Life Questionnaire (QLQ) • Quality of Life Inventory (QOLI) • Impact of Weight on Quality of Life (IWQOL) • Impact of Weight on Quality of Life (IWQOL-Lite) • Impact of Weight on Quality of Life-Kids (IWQOL-Kids) • OMS 36-item Short Form Health Survey (SF-36) • Moorehead-ArdeltQuality of life Questionnaire (M-A QoLQ) • Moorehead-ArdeltQuality of life Questionnaire II (M-A QoLQ II) • Outcome Measures • Bariatric Analysis and Reporting Outcome System (BAROS) • Veterans Administration Bariatric Surgery Workgroup 2007 • Alcohol Use Disorder Test-Core (AUDIT-C) • Drug Abuse Screening Test (DAST) • MillonBehavioral Medicine Diagnostic (MBMD) • Multidimensional Health Locus of Control (MHLC) Scales • Questionnaire on Weight and Eating Patterns-Revised (QEWP-R)

35. Conclusions & Recommendations • 70-90% are unconditionally recommended for surgery • 10-30% recommended for additional mental health or dietary treatment for 3-6 months to better prepare for surgery • Most who follow recommendations and return are accepted

36. Considerations for Excluding Patients for Surgery • Active psychosis present (defined as current evidence of active psychosis and/or mental health hospitalization for psychosis within past 1 year) • History of multiple suicide attempts within the past 5 years • Alcohol use disorder within past 6 months • Other substance use disorder within past 6 months • Borderline personality disorder as indicated by medical record and/or clinical interview • History of poor adherence with medical regimens: appointment keeping, follow-up instructions, and/or evidence on MBMD that patient is very high risk for non-adherence. Standards for Pre-Operative Bariatric Surgery Psychological Evaluation, VA Bariatric Surgery Workgroup

37. Delay consideration for surgery pending response to further psychological treatment • Poorly controlled mental illness(es) or cognitive impairment that may interfere with ability of patient to comply with necessary instructions and follow up (e.g. poorly controlled OCD, severe depression/anxiety, severe bipolar disorder, dementia) • Severe binge eating disorder as measured by QEWP and confirmed by clinical interview • Unstable social environment (homeless, lack of access to a kitchen, lack of social support) as assessed by clinical interview • Very low self-efficacy/self-motivation/personal responsibility as evidenced by low MHLC scores and confirmed by clinical interview. • Other severe behavioral problems as evidenced by scores on MBMD and confirmed by clinical interview.

38. Acceptable for surgery; provide ongoing psychological treatment before and after surgery. • Mild-Moderate Binge Eating Disorder as measured by QWEP and confirmed by clinical interview (Refer to Guide to Using Instruments for further instructions on use of QEWP for bariatric patients) • Other mild or moderate behavioral problems as evidenced by scores on MBMD and confirmed by clinical interview (Refer to Guide to Using Instruments for further instructions on use of MBMD for bariatric patients) • Moderately low self-efficacy/self-motivation/personal responsibility as evidenced by moderately low MHLC scores and confirmed by clinical interview (Refer to Guide to Using Instruments for further instructions on use of MHLC for bariatric patients) • Reasonably well-controlled mental illness, including schizophrenia, depression, bipolar disorder, anxiety disorders, OCD, alcohol or substance use disorders in remission • History of an isolated suicide attempt

39. Q/A “I don’t think this is what your doctor mean by lowering your carbs, honey.”