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Preoperative Psychological Testing—Another Form of Prejudice

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Abstract

Preoperative psychological screening of bariatric surgery candidates has become routine, and a significant proportion of patients have their surgery deferred as a consequence. If psychological testing is being used as a form of preoperative triage, both patients and surgeons are entitled to know whether there is sufficient evidence to justify its use in this way. We define the argument for psychological screening as consisting of four premises (p1–p4) and a conclusion (C) as follows: (p1) A significant minority of obese patients will not be successful in losing weight following bariatric surgery—the “failure” group; (p2) A significant minority of patients will exhibit abnormal psychological profiles during preoperative testing; (p3) The majority of individuals referred to in (p2) will be found in group (p1) i.e., abnormal psychological profiles identified preoperatively predict less favorable weight loss outcomes postoperatively; (p4) Identifying patients with adverse psychological profiles preoperatively would allow either exclusion of those at high risk of failure or provide a more secure rationale for targeted pre- and postoperative support; (C) Psychological screening should be part of the routine preoperative assessment for patients undergoing obesity surgery. We reviewed the literature to find evidence to support the premises and show that (p1) can be justified but that (p2) is problematic and can only be accepted in a heavily qualified version. We find no evidence for (p3) and since (p4) and (C) are predicated on (p3), the argument clearly fails. There is no evidence to suggest that preoperative psychological screening can predict postoperative outcomes and no justification for using such testing as a means of discriminating between candidates presenting themselves for bariatric surgery.

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References

  1. McTigue KM, Harris R, Hemphill B, et al. Screening and intervention for obesity in adults: summary of the evidence for the US Preventive Services Task Force. Ann Intern Med. 2003;139:933–49.

    PubMed  Google Scholar 

  2. O’Brien PE, Dixon JB, Laurie C, et al. Treatment of mild to moderate obesity with laparoscopic adjustable gastric banding or an intensive medical program: a randomized trial. Ann Intern Med. 2006;144:625–33.

    PubMed  Google Scholar 

  3. O’Brien PE, McPhail T, Chaston TB, Dixon JB. Systematic review of medium-term weight loss after bariatric operations. Obes Surg. 2006;16:1032–40.

    Article  PubMed  Google Scholar 

  4. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, Schoelles K. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292:1724–37.

    Article  PubMed  CAS  Google Scholar 

  5. Dixon JB, O’Brien PE. Changes in co-morbidities and improvements in quality of life after LAP-BAND placement. Am J Surg. 2002;184:51S–4S.

    Article  PubMed  Google Scholar 

  6. Dixon JB, O’Brien PE. Lipid profile in the severely obese; changes with weight after lap-band surgery. Obes Res. 2002;10:903–10.

    Article  PubMed  Google Scholar 

  7. Busetto L, Sergi G, Enzi G, et al. Short-term effects of weight loss on the cardiovascular risk factors in morbidly obese patients. Obes Res. 2004;12:1256–63.

    Article  PubMed  Google Scholar 

  8. Dixon JB, O’Brien PE. Bariatric surgery provides unparalleled metabolic benefits. Obes Surg. 2007;17:193.

    Article  PubMed  Google Scholar 

  9. Phelan S, Wadden TA, Berkowitz RI, et al. Impact of weight loss on the metabolic syndrome. Int J Obes. 2007;31:1442–8.

    Article  CAS  Google Scholar 

  10. Sjostrom L, Narbro K, Sjostrom CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;23:741–52.

    Article  Google Scholar 

  11. Adams TD, Gress RE, Smith SC, et al. Long-term mortality after bypass surgery. N Engl J Med. 2007;357:753–61.

    Article  PubMed  CAS  Google Scholar 

  12. Favretti F, Segato G, Ashton WD, et al. Laparoscopic adjustable gastric banding in 1,791 consecutive patients; 12-year results. Obes Surg. 2007;17:168–75.

    Article  PubMed  Google Scholar 

  13. Christou NV, Sampalis JS, Liberman M, et al. Surgery decreases long-term mortality, morbidity and health care use in morbidly obese patients. Ann Surg. 2004;240:416–24.

    Article  PubMed  Google Scholar 

  14. Sugerman HJ, Londrey GL, Kellum JM. Weight loss with vertical banded gastroplasty and Roux-y gastric bypass with selective vs random assignment. Am J Surg. 1989;157:93–102.

    Article  PubMed  CAS  Google Scholar 

  15. Brolin RE, Kenler HA, Gorman RC, Cody RP. The dilemma of outcome assessment after operations for morbid obesity. Surgery. 1989;105:337–46.

    PubMed  CAS  Google Scholar 

  16. Hsu LKG, Benotti PN, Dwyer J, et al. Nonsurgical factors that influence the outcome of bariatric surgery; a review. Psychosom Med. 1998;60:338–46.

    PubMed  CAS  Google Scholar 

  17. Lanyon RI, Maxwell BM. Predictors of outcome after gastric bypass surgery. Obes Surg. 2007;17:321–8.

    Article  PubMed  Google Scholar 

  18. Devlin MJ, Goldfein JA, Flanebaum L, et al. Surgical management of obese patients with eating disorders: a survey of current practice. Obes Surg. 2004;14:1252–7.

    Article  PubMed  Google Scholar 

  19. Hubbard VS, Hall WH. Gastrointestinal surgery for severe obesity. Obes Surg. 1991;1:257–65.

    Article  PubMed  Google Scholar 

  20. LeMont D, Moorehead MK, Parish MS, et al. Suggestions for the pre-surgical psychological assessment of bariatric surgery candidates. Allied Health sciences section ad hoc Behavioural Health Committee 2004. American Society for Metabolic and Bariatric Surgery.

  21. Fabricatore AN, Crerand CE, Wadden T, et al. How do mental health professionals evaluate candidates for bariatric surgery? Survey results. Obes Surg. 2006;16:567–73.

    Article  PubMed  Google Scholar 

  22. Van Hout GC, Leibbrandt AJ, Jakimowicz JJ, et al. Bariatric surgery and bariatric psychology: general overview and the Dutch approach. Obes Surg. 2003;13:926–31.

    Article  PubMed  Google Scholar 

  23. Bauchowitz AU, Gonder-Frederick LA, Olbrisch ME, et al. Psychosocial evaluation of bariatric surgery candidates; a survey of present practices. Psychosom Med. 2005;67:825-32.

    Article  PubMed  Google Scholar 

  24. Sarwer DB, Cohn NI, Gibbons LM, et al. Psychiatric diagnosis and psychiatric treatment among bariatric surgery candidates. Obes Surg. 2004;14:1148–56.

    Article  Google Scholar 

  25. Pawlow LA, O’Neil PM, White MA, et al. Findings and outcomes of psychological evaluations of gastric bypass applications. Surg Obes Relat Dis. 2005;1:523–9.

    Article  PubMed  Google Scholar 

  26. Mason EE, Maher JW, Scott DH, et al. Ten years of vertical banded gastroplasty for severe obesity. Probl Gen Surg. 1992;9:280–9.

    Google Scholar 

  27. Halverson JD, Zuckerman GR, Koehler RE, et al. Gastric bypass for morbid obesity: a medical-surgical assessment. Ann Surg. 1981;194:152–60.

    Article  PubMed  CAS  Google Scholar 

  28. Dixon JB, McPhail T, O’Brien PE. Minimal reporting requirements for weight loss: current methods not ideal. Obes Surg. 2005;15:1034–9.

    Article  PubMed  Google Scholar 

  29. Sarwer DB, Cohn NI, Gibbons LM, et al. Psychiatric diagnoses and psychiatric treatment among bariatric surgery candidates. Obes Surg. 2004;14:1148–56.

    Article  PubMed  Google Scholar 

  30. Gertler R, Ramsey-Stewart G. Pre-operative psychiatric assessment of patients presenting for gastric bariatric surgery (surgical control of morbid obesity). Aust N Z J Surg. 1986;56:157–61.

    Article  PubMed  CAS  Google Scholar 

  31. Onyike CU, Crum RM, Lee HB, et al. Is obesity associated with major depression? Results from the Third National Health and Nutrition Examination Survey. Am J Epidemiol. 2003;158:1139–47.

    Article  PubMed  Google Scholar 

  32. Sarwer DB, Wadden TA, Fabricatore AN. Psychosocial and behavioural aspects of bariatric surgery. Obes Res. 2005;12:639–48.

    Article  Google Scholar 

  33. American Psychiatric Association. Diagnosis and statistical manual of mental disorders: revision, DSM-III. 3rd ed. Washington, DC: American Psychiatric Association; 1980.

    Google Scholar 

  34. American Psychiatric Association. Diagnosis and statistical manual of mental disorders: revision, DSM-III-R. 3rd ed. Washington, DC: American Psychiatric Association; 1987.

    Google Scholar 

  35. Glinksi J, Wetzler S, Goodman E. The psychology of gastric bypass surgery. Obes Surg. 2001;11:581–8.

    Article  Google Scholar 

  36. Herpertz S, Kielmann R, Wolf AM, et al. Does obesity surgery improve psychosocial functioning? Int J Obes. 2003;27:1300–14.

    Article  CAS  Google Scholar 

  37. Gentry K, Halverson JD, Heisler S. Psychological assessment of morbidly obese patients undergoing bypass: a comparison of pre-operative and post-operative adjustment. Surgery. 1984;94:215–20.

    Google Scholar 

  38. Gertler R, Ramsay-Stewart G. Pre-operative psychiatric assessment of patients presenting for gastric bariatric surgery (surgical control of morbid obesity). Aust N Z J Surg. 1986;56:157–61.

    Article  PubMed  CAS  Google Scholar 

  39. Powers PS, Rosemurgy A, Boyd F, Perez A. Outcome of gastric restriction procedures; weight, psychiatric diagnoses, and satisfaction. Obes Surg. 1997;7:471–7.

    Article  PubMed  CAS  Google Scholar 

  40. Powers PS, Boyd F, Blair CR, et al. Psychiatric issues in bariatric surgery. Obes Surg. 1992;2:315–25.

    Article  PubMed  Google Scholar 

  41. Larsen F. Psychosocial function before and after gastric banding surgery for morbid obesity: a prospective psychiatric study. Acta Psychiatr Scand Suppl. 1990;359:1–57.

    PubMed  CAS  Google Scholar 

  42. Rosik CH. Psychiatric symptoms among prospective bariatric surgery patients: rates of prevalence and their relation to social desirability, pursuit of surgery and follow-up attendance. Obes Surg. 2005;15:677–83.

    Article  PubMed  Google Scholar 

  43. Kalarchian MA, Marcus MD, Levine MD, et al. Psychiatric disorders among bariatric surgery candidates: relationship to obesity and functional health status. Am J Psychiatr. 2007;164:328–34.

    Article  PubMed  Google Scholar 

  44. Adami GF, Gandolfo P, Bauer B, Scopinaro N. Binge eating in massively obese patients undergoing bariatric surgery. Int J Eat Disord. 1995;17:45–50.

    Article  PubMed  CAS  Google Scholar 

  45. Kalarchian MA, Wilson GT, Brolin RE, Bradley L. Binge eating in bariatric surgery patients. Int J Eat Disord. 1998;23:89–92.

    Article  PubMed  CAS  Google Scholar 

  46. Kalarchian MA, Wilson GT, Brolin RE, Bradley L. Assessment of eating disorders in bariatric surgery candidates: self-report questionnaire versus interview. Int J Eat Disord. 2000;28:465–9.

    Article  PubMed  CAS  Google Scholar 

  47. Powers PS, Perez A, Boyd F, Rosemurgy A. Eating pathology before and after bariatric surgery: a prospective study. Int J Eat Disord. 1999;25:293–300.

    Article  PubMed  CAS  Google Scholar 

  48. deZwaan M, Mitchell JE, Howell LM, et al. Characteristics of morbidly obese patients before gastric bypass surgery. Compr Psychiatry. 2003;44:428–34.

    Article  Google Scholar 

  49. Hsu LK, Mulliken B, McDonagh B, et al. Binge eating disorder in extreme obesity. Int J Obes Relat Metab Disord 2002;26:1398–403.

    Article  PubMed  CAS  Google Scholar 

  50. Wadden TA, Sarwer DB, Womble LG, Foster GD, McGuckin BG, Schimmel A. Psychosocial aspects of obesity and obesity surgery. Surg Clin North Am. 2001;81:1001–24.

    Article  PubMed  CAS  Google Scholar 

  51. Maddi SR, Khoshaba DM, Persico M, et al. Psychosocial correlates of psychopathology in a national sample of the morbidly obese. Obes Surg. 1997;7:397–404.

    Article  PubMed  CAS  Google Scholar 

  52. Black DW, Goldstein RB, Mason EE. Prevalence of mental disorder in 88 morbidly obese bariatric clinic patients. Am J Psychiatry. 1992;149:227–34.

    PubMed  CAS  Google Scholar 

  53. Widiger TA, Clark LA. Towards DSM-V and the classification of psychopathology. Psychol Bull. 2000;126:946–63.

    Article  PubMed  CAS  Google Scholar 

  54. Kutchins H, Kirk SA. DSM-III: the conflict over new psychiatric diagnoses. Health Soc Work. 1989;14:91–101.

    PubMed  CAS  Google Scholar 

  55. Sadler JZ, Hulgus YF, Agich GJ. On values in recent American psychiatric classification. J Med Philos. 1994;19:261–77.

    PubMed  CAS  Google Scholar 

  56. Goodwin D, Guze S. Psychiatric diagnosis. 4th ed. New York: Oxford University Press; 1989.

    Google Scholar 

  57. Clark L, Livesley J, Morley L. Personality disorder assessment: the challenge of construct validity. J Pers Disord. 1997;11:205–31.

    CAS  PubMed  Google Scholar 

  58. Kendell R, Jablensky A. Distinguishing between the vaidity and utility of psychiatric diagnoses. Am J Psychiatry. 2003;160:4–12.

    Article  PubMed  Google Scholar 

  59. Buchanan A. Georges Canguilhem and the diagnosis of personality disorder. J Am Acad Psychiatry Law. 2007;35:148–51.

    PubMed  Google Scholar 

  60. Powers PS, Rosemurgy A, Boyd F, et al. Outcome of gastric restriction procedures: weight, psychiatric diagnoses and satisfaction. Obes Surg. 1997;7:471–7.

    Article  PubMed  CAS  Google Scholar 

  61. Vallis TM, Butler GS, Perey B, et al. The role of psychological functioning in morbid obesity and its treatment with gastroplasty. Obes Surg. 2001;11:716–25.

    Article  PubMed  CAS  Google Scholar 

  62. Black DW, Goldstein RB, Mason EE. Psychiatric diagnosis and weight loss following gastric surgery for obesity. Obes Surg. 2003;13:746–51.

    Article  PubMed  Google Scholar 

  63. Averbukh Y, Heshka S, El-Shoreya H, et al. Depression score predicts weight loss following Roux-en-Y gastric bypass. Obes Surg. 2003;13:833–6.

    Article  PubMed  Google Scholar 

  64. Clark MM, Balsiger BM, Sletten CD, et al. Psychosocial factors and 2-year outcome following bariatric surgery for weight loss. Obes Surg. 2003;13:739–45.

    Article  PubMed  Google Scholar 

  65. Herpertz S, Kielmann R, Wolf AM, Hebebrand J, Senf W. Do psychosocial variables predict weight loss or mental health after obesity surgery? A systematic review. Obes Res. 2004;12:1554–69.

    Article  PubMed  CAS  Google Scholar 

  66. van Hout GCM, Verschure SKM, van Heck GL. Psychosocial predictors of success following bariatric surgery. Obes Surg. 2005;15:552–60.

    Article  PubMed  Google Scholar 

  67. Wadden TA, Sarwer DB, Fabricatore AN, et al. Psychosocial and behavioural status of patients undergoing bariatric surgery: what to expect before and after surgery. Med Clin N Am. 2007;91:451–69.

    Article  PubMed  Google Scholar 

  68. Ryden O, Hedenbro JL, Frederiksen SG. Weight loss after vertical banded gastroplasty can be predicted: a prospective psychological study. Obes Surg. 1996;6:237–43.

    Article  Google Scholar 

  69. Leombruni P, Piero A, Dosio D, et al. Psychological predictors of outcome in vertical banded gastroplasty: a 6-month prospective pilot study. Obes Surg. 2007;17:941–8.

    Article  PubMed  Google Scholar 

  70. Sallet PC, Sallet JA, Dixon JB, et al. Eating behaviour as a prognostic factor for weight loss after gastric bypass. Obes Surg. 2007;17:445–51.

    Article  PubMed  Google Scholar 

  71. Burgmer R, Grigutsch K, Zipfel S, et al. The influence of eating behaviour and eating pathology on weight loss after gastric resection operations. Obes Surg. 2005;15:684–91.

    Article  PubMed  Google Scholar 

  72. Powers PS, Perez A, Boyd F, et al. Eating pathology before and after bariatric surgery. A prospective study. Int J Eat Disord. 1999;25:293–300.

    Article  PubMed  CAS  Google Scholar 

  73. Bocchieri-Ricciardi LE, Chen EY, Munoz D. Pre-surgery binge eating status: effect on eating behaviour and weight outcome after gastric bypass. Obes Surg. 2006;16:1198–204.

    Article  PubMed  Google Scholar 

  74. Busetto l, Segato G, De Marchi F, et al. Outcome predictors in morbidly obese recipients of an adjustable gastric band. Obes Surg. 2002;12:83–92.

    Article  PubMed  Google Scholar 

  75. Dziurowicz-Kozlowska AH, Wierzbicki Z, Lisik W, et al. The objective of psychological evaluation in the process of qualifying candidates for bariatric surgery. Obes Surg. 2006;16:196–202.

    Article  PubMed  Google Scholar 

  76. Sobal J, Stunkard AJ. Socioeconomic status and obesity: a review of the literature. Psychol Bull. 1989;105:260–7.

    Article  PubMed  CAS  Google Scholar 

  77. National Institute of Health. The practical guide: identification, evaluation and treatment of overweight and obesity in adults. Publication number 00-4084. National Institute of Health, October 2000.

  78. van Gemert WG, Severijns RM, Greve JWM, et al. Psychological functioning of morbidly obese patients after surgical treatment. Int J Obes. 1998;22:393–8.

    Article  Google Scholar 

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Acknowledgment

The authors would like to thank Mr Nick Everitt for his helpful comments on a first draft of this paper.

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Authors and Affiliations

  1. Imperial College School of Medicine, London, UK

    David Ashton

  2. Healthier Weight Centre, 3 Vicarage Road, Edgbaston, Birmingham, B15 3UJ, UK

    David Ashton

  3. Department of Surgery, Regional Hospital, Vicenza, Italy

    Franco Favretti & Gianni Segato

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  1. David Ashton
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Correspondence to David Ashton.

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Ashton, D., Favretti, F. & Segato, G. Preoperative Psychological Testing—Another Form of Prejudice. OBES SURG 18, 1330–1337 (2008). https://doi.org/10.1007/s11695-008-9469-z

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