Strategies for early detection of psychopathologies in candidates for post-bariatric plastic surgery

Introduction: The increase in demand for post-bariatric plastic surgery has revealed a high prevalence of psychopathologies in patients undergoing the procedure, requiring the need to diagnose these diseases in the preoperative period. The use of specific psychological screening tools has been promoted; however, a gold-standard method has not yet been fully established. Objective: To carry out a review of the literature for alternatives available for the preliminary psychological evaluation of patients who are candidates for post-bariatric plastic surgery, presenting the method recommended in the Post-Bariatric Plastic Surgery outpatient clinic of the Federal University of Mato Grosso do Sul (UFMS). Methods: We reviewed the clinical trials which employed psychological screening tools preoperatively in patients who were candidates for post-bariatric plastic surgery; the MEDLINE/PubMed database was searched using keywords such as “bariatric surgery”, “body image”, “quality of life”, “obesity”, “plastic surgery” and “psychiatry”, for clinical trials published in the last 20 years. Herein, we discuss the findings and analyze the most common methodologies used. Results: Only four clinical trials used psychopathology screening tools in postbariatric plastic surgeries preoperatively, and one method could not be identified. Conclusion: The use of appropriate strategies to screen for psychopathologies helps prevent significant losses in the postoperative period, but the tools still lack validation in the post-bariatric population. Besides possessing extensive clinical-surgical technical knowledge, the plastic surgeon must remain attentive to the signs and psychopathological symptoms in these patients, referring them for psychological and psychiatric evaluation when indicated. ■ ABSTRACT

Strategies for early detection of psychopathologies in candidates for post-bariatric plastic surgery

INTRODUCTION
In recent years, the increase in demand for post-bariatric plastic surgery has presented new and unique challenges to plastic surgeons in Brazil 1 . With the increasing demands for this procedure, new competencies began to be required and new challenges were presented 2 . In general, the clinical management of these patients, often malnourished and anemic, is delicate and laborious; their surgical plans are generally more extensive and detailed, requiring multiple procedures; their scars are usually extensive and postoperative recovery is more prolonged; and in particular, the results are often idealized by the patients, usually far exceeding what is achievable with surgery, adding to the complexity of this treatment 3 .
To help with this identification, a professional psychological evaluation is essential for understanding the true motivations of the patient, often subconscious, as well as for the detection of possible eating and mood disorders, which can potentially damage the postoperative and long-term results 15,16 . Currently, several authors recommend the referral of patients to a specialized service for the diagnosis of psychological conditions before performing any post-bariatric surgical procedure, a strategy considered as the first line to prevent psychiatric complications in the postoperative period 1,15,17 . Currently, this preoperative evaluation is common in centers of excellence in plastic surgery in order to minimize psychiatric complications in the postoperative period 1 . However, this practice is still far from a reality for most privately practicing plastic surgeons in Brazil, especially those who work outside major surgical centers 1 . Often, the mere mention of the need for a psychological evaluation places significant stress on the ex-obese, undermining the already fragile doctor-patient relationship 17 . This resistance frequently prevents follow-up treatment, or it requires the plastic surgeon to permit the patient to desist referral to a psychologist 1,17 .
One recommended solution is the use of psychological screening tools during the first consultation 1 . With these, the plastic surgeon would be able to more easily identify the patients at risk for psychological disorders and, concomitantly, predict associated complications 1,17 . According to the literature, this process would minimize resistance on the part of patients, as it rationalizes the potential problem, demonstrating the importance of referral to a specialist for assessment 1,5,17 .
The challenge of researchers is to develop a simple, quick, and easily applicable tool which provides an efficient psychological screening to be used in plastic surgery clinics without requiring the presence of a mental healthcare professional such as a psychologist or psychiatrist 9 . Several tools have already been proposed; however, a gold standard has not yet been fully established and the search continues 18 .
The objective of this study is to conduct a review of the literature on the alternatives available for the preliminary psychological evaluation of patients who are candidates for surgery, presenting the process recommended in the Post-Bariatric Plastic Surgery outpatient clinic of the UFMS.

METHODS
Using the MEDLINE/PubMed database, articles in the medical literature which described the psychological evaluation of patients who are candidates for post-bariatric plastic surgery published in the last 20 years were analyzed.
The keywords used were "bariatric surgery", "body image", "quality of life", "obesity", "plastic surgery", and "psychiatry", terms validated by MeSH through various combinations and their respective translations into Portuguese. From the studies found, clinical trials which used preoperative psychological screening tools in candidates for post-bariatric plastic surgery were selected for analysis.

RESULTS
After excluding the articles that did not address the specific psychological evaluation of post-bariatric patients, only 4 publications were included in this study (Chart 1).

DISCUSSION
In the past, post-bariatric plastic surgery was deemed to benefit the emotional component of patients due to the improvement in body esthetics, relieving some pre-existing psychopathology 4 . Unfortunately, several studies show that this is not true 13,14,19 . Although able to offer a significant improvement in quality of life by enhancing body image and increasing self-esteem, the positive influence of plastic surgery on already established mental illness has not yet been fully elucidated and cannot be guaranteed 5,6,14 . In fact, according to some authors, the more prevalent psychopathologies in this population even tend to worsen in a significant portion of the patients in the postoperative period 1,13,19 .
There is no consensus recommendation for plastic surgeries in patients with mental disorders 1,11,13 . According to Ferreira, in 2004 20 , plastic surgery contours the body, leading to more pleasant form, but it does not address the emotional problems that already exist. The academic literature is rich in "disastrous cases" involving plastic surgeries and psychopathologies, associating them with higher rates of postoperative complications, surgical failures, and chronic dissatisfaction 11 Using this combination of methods, the authors did not identify any benefit in psychological screening of patients undergoing postbariatric plastic surgery. Accordingly, during the routine pre-operative consultation, the mere suspicion of the presence of mental disorders, especially mild disorders, should serve as an impasse to the plastic surgeon 11 . The consultation is generally focused on the technical difficulty of the case, the surgical strategies to be proposed, and the clinical evaluation of the patient; all these aspects present a high degree of difficulty in post-bariatric patients 11 . Therefore, the attention towards the detection of psychiatric alterations usually remains in the background, although it is perhaps the greatest paradigm requiring more qualified care in post-bariatric plastic surgery.
A good anamnesis has been believed by most healthcare professionals to identify most psychological problems; unfortunately, although essential, it is much less effective in individuals with psychological disorders who are eager for a surgical procedure 10 . In general, these patients maintain a positive demeanor during the consultation and the discussion of the surgical plan. They usually conceal their complaints and minimize their expectations, deluding even the most attentive and experienced physician 11,17 . Another factor that hampers a psychological screening is that many of the neurovegetative and somatic symptoms caused by mental illness, such as fatigue, insomnia, and weight loss, can be easily confused with symptoms resulting from the condition of being formerly obese 21 .
The diagnostic process of psychiatric disorders is based on the identification of clinical syndromes, which are extremely hindered by the absence of consistent biological markers 22 . Thus, several authors have recommended the use of specific methodologies for psychological screening in the initial consultation: the so-called psychopathology screening tools 17,18 . The purpose of their application would identify the patients more susceptible to mental disorders, sending them for a specialized psychological evaluation 10 . However, as yet the absence of a comprehensive tool to assess a wide range of all possible components. As seen here, the literature on the subject is still emerging, requiring more studies and a greater acknowledgement of its importance in plastic surgery. The literature review is completely different when we analyze obese patients who have not yet had bariatric surgery. In these cases, the literature produced by digestive tract surgery teams is abundant in studies, and the production of knowledge is continuous and well-founded.
One of the tools most commonly used in research evaluating candidates for bariatric surgery is the BDI 10,21,23 . This tool evaluates the intensity of depressive symptoms, and it can be easily executed during pre-operative consultations 9,17 . It is a quick and practical instrument with a high rate of acceptance, credibility, and accuracy in screening for depressive symptoms 22 . Although it does not have diagnostic assertions, its use facilitates the screening of psychopathologies with a high level of sensitivity and specificity 21,22,23 . The patient responds to 21 statements in a questionnaire, correlated with depressive symptoms and attitudes 29 determining the intensity of responses that vary from 0 to 3, suggesting increasing degrees of severity of the disease 30 . The final score is the sum of the responses, with a minimum score of zero and maximum of 63 points 18 . According to the authors, a score ≥ 17 classifies the patient as "at risk" 30 . In 1996, the BDI was significantly revised, which resulted in its second edition (BDI-II), which is more straightforward and easier to understand 31 , approaching the new diagnostic criteria for Major Depression present in 5 th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) 8 .
Another widely used method in studies with prebariatric patients is the Patient Health Questionnaire (PHQ-9). It is a rapid application tool, widely used for the evaluation and screening of depressive disorders. Based on the diagnostic criteria of the DSM-5, it has 9 dimensions, evaluated by a scale that ranges from 0 ("not at all") to 3 ("nearly every day"), corresponding to the frequencies of the signs and symptoms of depression, which could result between 0 and 27 points. When the sum is ≥ 10, it is a positive indicator of the disorder. The PHQ-9 is derived from the Primary Care Evaluation of Mental Disorders (PRIME-MD), which was created to screen for major mental disorders in primary care, such as alcohol abuse, depression, anxiety, eating, and somatoform disorders 32 .
Despite their widespread applications, the PHQ and BDI are not free from criticism 18,22 . Some authors claim that they are too specific to depression, not evaluating the other psychopathologies prevalent in ex-obese patients 22 . In addition, the tools would there is no specific and well-validated tool with utility in plastic surgery clinics for post-bariatric candidates for esthetic procedures 9,10,18,21,23 .
In the literature review presented here, only four clinical trials (Chart 1) used screening methods in pre-operative consultations in candidates for postbariatric plastic surgeries. This extremely low number of studies is surprising and worrying, especially since the results are divergent and insufficient to elect, even if superficially, a gold-standard psychological screening method.
Azin et al. in 2014 24 and Zwaan et al. in 2014 25 used a combination of different tools in post-bariatric candidates for body contouring surgery. The authors claimed that this combination would be useful to more easily diagnose psychopathologies. However, despite using similar methods, the authors obtained contradictory results, weakening the thesis that this combination is the ideal screening method. In addition, this strategy with multiple tests has less clinical applicability, requiring more time for the initial preoperative evaluation, and thus it cannot be recommended as an ideal method for initial evaluation. The laborious applicability of the combination of tests also hinders its reproduction in other studies, tending to make its clinical applicability unfeasible. In their conclusions, both authors honestly refer to the difficulties and the limitations of their studies.
In the article by Song et al. in 2006 26 , the authors used the Beck Depression Inventory (BDI) to focus more on depressive symptoms without identifying differences between the groups studied. According to the literature, the use of the BDI alone can underdiagnose very prevalent disorders in these patients, such as anxiety and somatoform disorders 27 . In this case, the BDI, when applied alone, does not seem to be the best choice for screening patients who are candidates for post-bariatric plastic surgery. still need adaptation for post-bariatric patients, with different cut-off levels and application and control strategies. Some authors even recommend that screening tools less focused on depressive symptoms and more on personal interrelationships and quality of life analysis be associated with these methods 22 . Examples include the Medical Outcomes Study Short Form, the Adaptation Self-Evaluation Scale, the Social Adjustment Scale Self-Report, the Multiple Affective Adjective Check List, the Brief Symptom Inventory, the Hamilton Depression Rating Scale, and the Zung Self-Rating Depression Scale 21,22,23 .
Specifically The development of the ideal tool still seems far from a reality in clinical practice and merits more questions 18 . In the Post-Bariatric Plastic Surgery outpatient clinic of the University Hospital of the UFMS, we utilize a Multiaxial Screening 22 , based on the triad of humanized anamnesis, detection of "risk markers", and the BDI score.
At the first pre-operative consultation, we pay attention to the biopsychosocial aspects of the patients, valuing a humanistic and committed doctor-patient relationship, sharing with patients the complexity of the process and the challenges to be faced 20 . We believe that gaining the trust of this complex patient must occur in this first meeting, and the analysis of technical-surgical aspects, previously the major focus of interest, should now be reserved for the final part of the consultations.
In this initial part of the first consultation, we conduct an anamnesis directed at specific psychiatric aspects, taking a detailed history, highlighting the individual and not the physical symptoms, offering the chance to expose feelings, complaints, and expectations. We investigate the patient's personal and relational life, habits, sources of pleasure, and sorrows 13 . Then we present the BDI, explain its motivations, and ask the patient to respond the inventory.
While the patient analyzes the BDI, we assess the findings of the anamnesis, seeking to identify the so-called "markers of psychopathology", risk factors related to a poor postoperative outcome: a) patients with many unrealistic demands and expectations about the procedure; b) patients very dissatisfied with a prior esthetic surgery (with good results); c) patients with minimal bodily deformities but many complaints; d) patients with intellectual conditions limiting their understanding of the complexities and technical limits of the surgeries; e) patients with vague motivations due to relationship problems; f) patients with extremely low self-esteem; g) patients with a history of depression or psychiatric hospitalizations; h) solitary patients; i) patients with personality disorders; j) and patients with suicidal ideation 29 .
In the presence of at least one of these markers or if the BDI score is ≥ 17, we initially counsel against the procedure and forward the patient to an assessment by a mental health professional 9,13,27 . We explain that the future implementation of the procedure shall be subject to the release of this professional and that this will be attached to the Informed Consent Form (ICF) 17 . Pinho et al. in 2011 1 recommended a complete documentation of the pre-operative psychological/ psychiatric approach, with the presence of reports of specialized professionals, as a measure of protection for the plastic surgeon. Some patients dissatisfied with their post-bariatric plastic surgeries have used their preoperative psychiatric condition in medical error litigation as a justification for not understanding the terms of consent and guidelines about the procedure 1 .
Even in those patients without identified risk factors (markers and/or BDI ≤ 16), we devote substantial time to the consultation, explaining the details of the pre-, trans-, and post-operative periods 33 . Unfortunately, this approach, although very effective, cannot prevent all disappointments. Even with a negative screening and all the care dispensed, some patients develop psychiatric issues during the postoperative period. In these cases, it is essential to refer them immediately to a psychiatrist to minimize losses, controlling the situation as quickly as possible 13 , in addition to psychological, cognitive and behavioral interventions.

CONCLUSION
The use of appropriate strategies for preoperative screening of psychopathologies of postbariatric plastic surgeries can assist in the prevention of significant losses during the postoperative period. The ideal tool still lacks validation in the post-bariatric population, requiring more accurate development and validation by the scientific community. In addition to extensive clinical and technical surgical knowledge, the plastic surgeon must remain attentive to the psychopathological signs and symptoms of these patients, being prepared to refer them to psychiatric and psychological evaluation when indicated.