TCRBH: Why is presurgical psychological evaluation important for patients considering bariatric surgery?

Dr. Sogg: Unlike most other surgeries, the outcome of this surgery requires significant input, effort, and change by the patient, and this surgery effects changes that can have a really significant impact on psychosocial functioning. That is one reason why a psychological evaluation is required for this surgery, but not for something like a hip replacement. An analogous procedure would be transplants. Every transplant clinic conducts a preoperative psychological evaluation because in order for the transplant to succeed, the patient has to make behavioral changes, be stable enough to make those changes, understand what they are getting into and make a commitment to doing it.

TCRBH: What is determined by a presurgical psychological evaluation?

Dr. Sogg: The purpose of the presurgical psychological evaluation is not to say whether or not a patient can have surgery, or whether they will do well or poorly. Ideally, we do the assessment to identify psychosocial factors that may pose a challenge or create barriers to safe and effective outcomes of surgery. Once we have identified those factors, we can formulate recommendations to help minimize their detrimental impact on outcomes. By “outcome” I mean not just the amount of weight loss, but also how well people adjust to the surgery and their ability to keep the weight off.

TCRBH: What are the factors that you look for in assessment that might help promote a more successful outcome?

Dr. Sogg: One thing we look at is whether or not the person tends to rely heavily on eating as a strategy for coping with negative emotions such as stress, sadness, anxiety, and loneliness. If that is the case, then we worry that this patient could continue to use eating as a coping strategy after the surgery, which is likely to impact weight loss outcomes. Alternatively, if we assume that the surgery will prompt someone to stop using eating as a coping strategy, then we have to make sure that they have healthy adaptive coping strategies in place, because negative emotions are always going to be a fact of life. Another thing we assess is history of other specific disorders. Specific psychiatric disorders are not in and of themselves contraindications for surgery, but you have to look at the potential impact of the disorder on the outcome after surgery.

TCRBH: How might other disorders impact success of the surgery?

Dr. Sogg: For instance, I have a patient who has a chronic history of depression. The worry with depression is that if someone is too depressed they are not going to engage in the self-care behaviors required as part of their long-term post-surgical regimen. These include eating changes, physical activity, taking supplements, etc. With this patient, while it was clear that depression was a chronic feature of her life, she was able to function and care for herself despite the depression symptoms. However, I have had other patients tell me, “I am so depressed I can’t get out of bed.” I would not recommend that they have surgery until their symptoms are improved enough so they are getting out of bed, able to be active in a consistent way, able to structure their eating, and plan ahead for their meals and snacks.

TCRBH: What about something like attention deficit hyperactivity disorder (ADHD), which often involves impairment in planning and organization?

Dr. Sogg: If we discover in our evaluation that a person has diagnosed or undiagnosed ADHD that is not well controlled, we might recommend that he get extra help with organizational and perhaps impulse control strategies. Being disorganized and having deficits in the ability to plan ahead or control impulses could definitely have an impact on the way one eats after surgery. More than psychiatric diagnoses, we look at the potential impact of symptoms on post-surgical outcome.

TCRBH: Are there other factors that you consider beyond specific disorders?

Dr. Sogg: We are also looking at non-psychiatric features such as social factors; for instance, the dynamics in the patient’s relationships. I have a patient who about 15 years ago lost about 90 pounds non-surgically. After the weight loss she started going out and socializing a lot more. She was out drinking with her friends, but without her husband. This created a lot of tension in her marriage. That is something I have been talking to her about as she has gone through the presurgical process, asking her, “Do you think that might happen again? Why or why not? Is your husband afraid of it happening again? Is he likely to be unsupportive of your choice to have surgery because he is afraid the same thing will happen?”

TCRBH: Are there other worries about challenges patients may face after surgery?

Dr. Sogg: We don’t have a lot of good, solid, scientific data on psychosocial predictors and psychosocial outcomes, but it has been pretty well established that there is an increased risk for suicide after weight loss surgery (Peterhansel C et al, Obes Rev 2013;14(5):369–382). We also know now that there are people who develop alcohol dependence or risky alcohol use after having gastric bypass (Conason A et al, JAMA Surg 2013;148(2):145–150). So we carefully assess for those risks. Now a really smart, well-informed person would say, “But we don’t know what predicts those things, so how is your psychosocial evaluation going to do anything about that?” And the fact is, we don’t really know scientifically, but we can use our clinical judgment and the experiences that we have observed in our post-op patients.

TCRBH: How might a therapist treating a patient for a different issue help that person evaluate the potential fit for bariatric surgery?

Dr. Sogg: You want to refer your patient to a good weight loss surgery center, where there are behavioral health professionals either in-house or that work with the center in an ongoing close relationship. This evaluation is really something that should be done through a specialist in weight loss surgery who has experience and training in this field. One of the things that makes these specialists competent to evaluate patients before surgery is having lots of first-hand experience with both short-term and long-term post-op patients.

TCRBH: How valuable is it to have the exposure to many post-surgery patients?

Dr. Sogg: I have been doing this now for about 15 years, and I can say there is a limit to what our clinical judgment can predict.

I think we have to be humble about our clinical judgments, especially in this case when there is a very pressing medical need. Someone who is quite ill and really needs the surgery might not be optimized psychosocially. However, there is a certain place where you have to say, “Look, they are still going to be better off with the surgery, even if they have lower than average weight loss or more trouble adjusting. It is a matter of life and death for this person.” It is rare that I will make an unconditional recommendation that a person not undergo surgery.

TCRBH: What kinds of patients do you see most likely to achieve successful outcomes?

Dr. Sogg: I have now worked with about 1,000 post-op patients and, based on my own anecdotal observations, I would say the people who have the most success are:

•   Good at creating systems and routines for themselves and sticking with them.

•   Problem-solvers.

•   Persistent in their efforts to maintain healthy behaviors.

•   Good at following directions.

•   Organized or fundamentally disorganized but recognize the importance of creating organizational structures for themselves.

•   Able to maintain an approach to eating and activity that is flexible rather than overly strict or completely disorganized.

TCRBH: How do you characterize the goal for success?

Dr. Sogg: There are a number of different factors, and I think they are all important. Weight loss is the one that is easiest to measure, so that is what is looked at the most. Improvement or resolution of medical comorbidities is not quite as easy to measure as weight loss, but that is the second most researched outcome. Then there are less tangible outcomes that affect the individual: Do they have improved quality of life? Do they have an improved self-image? Do they have improvement in their interpersonal functioning?

TCRBH: What else might be helpful for clinicians to know about assessment for weight loss surgery?

Dr. Sogg: One thing I want to emphasize is that people often make assumptions that if someone is severely overweight it must be a reflection of some kind of psychological problem or failing. While it is true that a number of psychological or psychosocial factors can contribute—sometimes significantly—to obesity, it is really important for behavioral health providers to know how strongly obesity is related to metabolic, genetic, and other biological factors. Even if obesity develops because of a behavioral pattern, once a body is in the metabolic state of obesity it is physiologically very difficult to lose weight and keep it off. Not being able to do so is not necessarily a sign of psychological problems.

TCRBH: Thanks very much for sharing your knowledge of psychological assessment for weight loss surgery, Dr. Sogg.

Editor's note: This article originally appeared in The Carlat Behavioral Health Report with the title, "Psychological Evaluation of Patients Prior to Bariatric Surgery," and has since been updated. At the time of publication in 2014, Dr. Sogg had no financial relationships with companies related to this material. Jay Coburn, who conducted this interview, had  no financial relationships with companies related to this material.