ABCDDV/1061

ABCD Arq Bras Cir Dig Review Article

2014;27(Suppl. 1):59-62

PSYCHOLOGICAL ASSESSMENT FOR BARIATRIC SURGERY: CURRENT PRACTICES

Avaliação psicológica para cirurgia bariátrica: práticas atuais

Carolina Aita FLORES

From the Programa de Pós-Graduação ABSTRACT – Introduction: The prevalence of obesity on a global scale has alarmed health
em Psicologia e Reeducação do institutions, the general population and professionals involved in its treatment. Bariatric surgery
Comportamento Alimentar, Instituto de has emerged as an effective and lasting alternative for weight reduction and improved general
Pesquisa e Gestão em Saúde do Instituto health. In this context and as part of a multidisciplinary team, psychologists are responsible
de Pesquisa e Gestão em Saúde (Post- for the preoperative psychological assessment of bariatric candidates. Aim: To investigate how
Graduation Program in Psychology and psychological assessments are occurring, including the identification of utilized resources;
Reeducation of Eating Behavior, Research factors that are addressed; the duration of the process; existing protocols; and to evaluate the
Institute and Manage in Health), Porto importance of this practice. Method: A systematic review of national and international literature,
Alegre, RS, Brazil. through PubMed and Scielo’s databases, using “psychological assessment”, “obesity” and
“surgery”, as keywords. Conclusion: There is an agreement about the main factors that should
be investigated during the preoperative assessment, as well as the main contraindications for
the surgical procedure. The importance of the psychological assessment is well established in
HEADINGS - Bariatric surgery. Obesity. the field of bariatric surgery. However, this area needs a standard protocol to guide the mental
Psychology. Evaluation. health professionals that deal with bariatric patients.

Correspondence: RESUMO – Introdução: A prevalência da obesidade em nível mundial tem alarmado as instituições
Carolina Aita Flores de saúde, a população e os profissionais envolvidos no seu tratamento. A cirurgia bariátrica
e-mail: [email protected] aparece como alternativa efetiva e duradoura para a redução do peso e melhora geral da
saúde. Nesse contexto, o psicólogo apresenta-se como parte da equipe multiprofissional,
Financial source: none responsável pela avaliação psicológica pré-operatória do candidato a procedimento bariátrico.
Conflicts of interest: none Objetivo – Verificar como são realizadas as avaliações psicológicas dos pacientes bariátricos,
incluindo a identificação dos recursos utilizados, fatores avaliados, duração do processo,
Received for publication: 16/01/2014 protocolos existentes, bem como verificar a importância dessa prática. Método – Revisão
Accepted for publication: 13/06/2014 da literatura nacional e internacional, nos bancos de dados do PubMed e Scielo, com os
descritores “psychological assessment”, “obesity”, “surgery”. Conclusões – Há consenso sobre
os principais fatores psicológicos a serem investigados durante a avaliação pré-operatória, e
sobre a maior parte das contraindicações para o procedimento cirúrgico. A importância da
avaliação psicológica está bem estabelecida no campo da cirurgia bariátrica. Contudo, esta
DESCRITORES - Cirurgia bariátrica. área necessita de protocolo-padrão para nortear a conduta dos profissionais de saúde mental
Obesidade. Psicologia. Avaliação. que trabalham com o paciente bariátrico.

INTRODUCTION

O
besity, in recent years, has become a global epidemy and has begun to be
the focus of innumerous studies. Alarming data divulged recently by the
World Health Organization revealed that in 2008 more than 200 million
men and 300 million women were obese worldwide. In addition, 65% of the global
population was living in countries where being overweight or obese caused more
deaths than being underweight or suffering from malnutrition26.
The high prevalence of obesity, on a global scale, has alarmed authorities and has
demanded effort by professionals involved in its treatment, including medical doctors
and other health professionals, to find new alternatives to manage this disease13. In
this context, bariatric surgery began to be considered as the only effective alternative
to treat obesity. Benefits of the surgery surpass significant and prolonged weight loss
and include: a reduction of the associated comorbidities; remission of depression and
anxiety symptoms; improvement in sexual functioning; an increase of activity; and
improvement in the general quality of life associated with health1,12.
In Brazil, the number of bariatric surgeries has almost quadrupled, increasing
from 16,000 in 2003, to 60,000 in 2010. For a person to be considered a candidate
for bariatric surgery, it is necessary that his Body Mass Index (BMI) must be higher
than 40 kg/m² or above 35 kg/m² with associated comorbidities (eg. type II diabetes,
sleep apnea, arterial hypertension, dyslipidemia, coronary disease, osteoarthritis and
others). It is also necessary to have a history of unsatisfactory clinical treatment for
at least two years3.
In addition to the weight and comorbidity requirements, in 1991, the National
Institute of Health in the United States, established a multidisciplinary approach to
patient assessment during the preoperative period, which included psychological
evaluation as an essential part of this process17. In the same way, the Brazilian Bariatric
Consensus and the Federal Council of Medicine endorsed this practice, as they require
the presence of a psychologist or psychiatrist, as part of the multidisciplinary team4.

ABCD Arq Bras Cir Dig 2014;27(Suppl. 1):59-62 59

Review Article

According to the Federal Council of Medicine, al. 2 demonstrated that active symptoms of binge eating
psychologists and/or psychiatrists of the multidisciplinary disorder were considered by approximately 90% of the
team should ensure the absence of substance disorders, health professionals surveyed as a “definite” or “possible”
psychotic disorders and dementia. These professionals are also contraindication to the surgery. Corroborating this idea,
responsible for guarantying that patients have the intellectual Hout et al.10 highlighted that patients with bingeing behavior
and cognitive understanding of the risks associated with the should not be treated surgically until their eating behavior is
surgery and the special care needs that are a consequence of normalized through therapy. Furthermore, Snyder24 mentions
the surgery during both the immediate postoperative period only nervous bulimia as a clear contraindication, but not binge
and in the long term4. eating disorder.
As discussed previously, the high prevalence of obesity Due to the lack of consensus between authors as how
in Brazil has caused an increase in the number of bariatric to manage binge eating, and due to evidence proving that
surgeries. This has led to an expansion in the participation clinically significant binge eating is associated to poorer
of psychologists in the field of preoperative evaluation. Thus, surgical results, some authors suggest that researchers and
the purpose of this study is to review the literature through health professionals come to an agreement on how to better
a narrative description of the main results that is focused on describe and evaluate binge eating in relation to bariatric
how psychological evaluations have been practiced. surgery21.

Resources employed during psychological assessment

METHOD The psychologist, during the assessment for the surgery,
has to be prepared to investigate emotional, psychiatric
A systematic review of national and international and cognitive issues that can interfere with the result of
literature through PubMed and Scielo’s databases was the operation. For this purpose, clinical interviews and
conducted, without delimitating a time frame. The keywords psychological testing appear to be the most valuable resources
were: “psychological assessment”, “obesity” and “surgery”. in obtaining information about the patient’s psychological
Principally, articles with full text available, articles considered functioning1,5,21,24.
seminal in the field and publications relating directly to the Patient’s behavior, presence of psychiatric symptoms,
study of psychological evaluation for bariatric surgery were understanding of the surgical procedure, eating behavior,
selected. stress level, presence of a stable and supporting environment,
expectations and reasons that lead to the surgery are some of
Relevant factors for psychological assessment the aspects usually investigated during the clinical interview.
In order to determine the readiness of a candidate Therefore, the preoperative psychological assessment is
undergoing bariatric surgery, different aspects of the patient’s unique and differs from other traditional psychological
life are considered by psychologists. Among the psychosocial evaluations2,24.
factors that deserve attention, the most commonly cited were: The aim of the psychological testing is to obtain an
the patient’s understanding of the surgery and the necessary objective measure of the patient’s psychological adjustment
lifestyle changes; expectations regarding the results; the ability and assess their preparation to the surgery. Consequently, the
to adhere to operatory recommendations; eating behavior testing is an indispensable tool used to collect information
(weight history, diet, exercise); psychiatric comorbidities and complement subjective data collected during the clinical
(current and previous); reasons to undergo the surgical interview24.
procedure; social support; substance use; socioeconomic For conducting the formal psychological testing,
status; conjugal satisfaction; cognitive functioning; self- the most cited methods were symptom inventories and
esteem; history of trauma/abuse; quality of life and suicidal personality tests; the Beck Depression Inventory and the
ideation1,2,5,18,20,23,24. Minnesota Multiphasic Personality Inventory represented
Candidates may not be considered psychologically the most utilized in their respective categories2,5,14,21,24. It is
eligible for bariatric surgery as impediments may arise after important to highlight that, currently, the last one is not
the consideration of the psychosocial factors previously approved for use in Brazil4.
mentioned18. A study conducted with 194 mental health Enquiries regarding eating behavior, especially
professionals in the United States listed “psychiatric problems” concerning binge eating disorder and night eating syndrome
as the main contraindication for the surgery, cited by 91,2% are also conducted, but not as frequently and with a greater
of the respondents. The primary problems in this category number of instruments available for this purpose. The Binge
were: substance use/abuse/dependence, eating disorders, Eating Scale, the Questionnaire of Eating and Weight Patterns ,
psychotic disorders, depression and suicide5. the Eating Disorder Inventory, the Eating Disorder Examination
In addition to the contraindications stated above, other – Questionnaire Version and the MOVE! Questionnaire were
factors that can postpone or rescind the surgery are: a lack the most commonly used tools for investigating eating
of understanding regarding the risks, benefits and results disorders2,5,6,21,22.
of the surgical procedure; a reluctance to adhere to the As with the main personality test Minnesota  Multiphasic 
postoperative recommendations; severe mental retardation; Personality  Inventory used internationally, none of the
multiple suicide attempts or a recent suicide attempt; active instruments described above have been approved by the
symptoms of obsessive-compulsive disorder and bipolar Brazilian Federal Council of Psychology and hence their use is
disorder; severe life stressors; and nicotine use1,2,20,21. prevented3. Furthermore, it is important to highlight the fact
Binge eating is a polemic topic in relation to bariatric that these resources were not created focusing on bariatric
surgery, as the authors opinions are divided when it comes patients and their idiosyncrasies. For this purpose, and due to
to this matter. Some authors defend that bingeing can go great inconsistency in the understanding of the psychological
into remission after the surgery and, therefore, should not functioning of bariatric patients, some specific techniques
be seen as a contraindication but as a factor to be evaluated were developed, for example, the Boston Interview25 and
carefully1,11. Other researchers mention that only some of the the PsyBari14. Nevertheless, these instruments have not been
patients with binge eating, prior to the surgery, go back to this translated to Portuguese or adapted for use in Brazilian culture.
behavior afterwards, so again, the compulsion should not be The first approach mentioned above, developed by
a contraindication, but a topic to approach before surgery9. the Medical Psychology Service at the VA Boston Healthcare
In contrast a study conducted by Bauchowitz et System, is a semi-structured interview for pre-surgical gastric

60 ABCD Arq Bras Cir Dig 2014;27(Suppl. 1):59-62

 PSYCHOLOGICAL ASSESSMENT FOR BARIATRIC SURGERY: CURRENT PRACTICES

bypass evaluation. This interview contains seven major areas Corroborating the importance of psychological
that are assessed: 1) weight, diet and nutritional history; 2) assessment to bariatric surgery success, Bauchowitz et al.2
current eating behaviors; 3) medical history; 4) understanding demonstrated that approximately 80% of surgical programs
of surgical procedures, risks and postoperative regime; 5) participating in their study considered psychological
motivation and expectations regarding surgical results; 6) assessment as “very valuable” or “valuable”.
relationships and support system; 7) psychiatric functioning25. Psychological assessment is also considered a
The second approach, known as PsyBari, is a psychological unique opportunity to perform the psychoeducation of
test specifically developed for pre-surgical psychological the patient about the changes resulting from the surgery,
evaluations. The PsyBari consists of 115 items, assessed offer psychological support and prepare the candidate for
according to their frequency, on a Likert scale (from 1 to 5). This behavioral modifications that must occur in the postoperative
test is divided into 11 subscales: 1) faking good/minimization/ period8,20. Accordingly, the psychologist has to act in different
denial; 2) surgical motivation; 3) emotional eating; 4) anger; roles during the assessment: a researcher, collecting data;
5) binge eating; 6) obesity-related depression; 7) weight- an educator, providing information; and also, a therapist,
related impairment; 8) weight-related social impairment; 9) increasing motivation and managing emotions that may arise
knowledge of postsurgical eating behavior; 10) substance/ during the evaluation1,24.
alcohol abuse; 11) surgical anxiety. The majority of items In contrast to most studies, Pull21 cited the literature
included in these scales was based on interviews with bariatric review organized by Ashton et al., in 2008, in which the authors
patients14. described psychological assessment as a form of prejudice
Brazilian developed resources for the psychological and discrimination against candidates, and stated that there
assessment of bariatric patients were not found. was no evidence to prove its clinical validity. However, Pull
challenged this hypothesis presenting four assumptions
Duration of psychological assessment to justify the importance of psychological assessment and
Despite the variety of available information concerning concluded with the suggestion that this process continues
the psychological assessment process, including important to be a part of the general preoperative evaluations that
aspects to evaluate and most used resources, this research did precede bariatric surgery21. It was noted that Ashton’s review
not find references relating to the duration of the preoperative was the only one found in the literature attributing a negative
psychological assessment in the international literature. connotation to psychological assessment.
This lack of clarity regarding duration of the psychological As well as highlighting the importance of psychological
assessment generates uncertainty in relation to the number assessment for surgery success and patient’s well-being, the
of sessions dedicated for this purpose. However, due to references also specified the importance of the qualification
results indicating the necessity of psychological testing and of the psychologist in regards to the performance of the
conducting clinical interviews, it is possible to infer that the assessment. Due to peculiarities of the bariatric population,
process demands more than one session. researchers suggest that mental health professionals who are
Amongst Brazilian publications, some allusions in charge of psychological assessments must have expertise in
regarding the duration of preoperative psychological the field of medical psychology. Only appropriately qualified
evaluation were found, suggesting great variability as to the professionals would be able to detect if a patient had a
number of sessions, with some authors even mentioning problematic relation with food and, also, work with cognitive
that psychological assessments have been conducted in a distortions that the candidate may display, in regards to
single session, or according to the “best judgment” of each weight loss and the psychosocial impact of the surgery2.
professional13,15,19. Another reference to time was found in a
study showing that 67.4% of patients (after surgery) wanted to Lack of protocols for psychological assessment
be better prepared, psychologically, before the surgery, with A recurrent topic, found in the majority of publications
more than one session15. examined, refers to the fact that there are no guidelines
or protocols to orientate the psychological assessment for
Importance of psychological assessment bariatric surgery2,5,8,14,21,24. The absence of a standard protocol
The vast majority of reviewed publications addressed hinders the identification of which domains deserve attention
the importance of psychological assessment, naming different and which evaluative procedures should be employed by
reasons to justify this process. It is argued that surgery success, psychologists 5. Furthermore, without a standardization of
in addition to the operation itself, relies on behavioral changes practices, the value and purpose of psychological assessment is
and that one of the goals of the preoperative assessment is subject to variation according to each professional or bariatric
to prepare the patient for the postoperative period, aiming to team21. As a consequence, a great variability is generated in
optimize surgical results1,2,8,9,18,20,21,24. regards to the approaches used during the assessment and
Even though one of the publications examined showed there is little consent on how to conduct the triage and which
that some patients resisted talking to a psychologist prior to criteria should be observed during patient selection2.
surgery, the information discussed during the assessment Amongst Brazilian publications, two references
served not only to evaluate the candidates’ preparation for concerning protocols for bariatric surgery were found.
the surgery, but also to increase their chances of success in The first one describes the creation of software called
the adjustment after the surgery24. Furthermore, the cited “Multiprofessional Electronic Protocol”, developed at the
author mentioned that many patients, after the psychological Universidade Federal do Paraná. Through this software it is
assessment, reported how valuable it was to discuss different possible to register information about bariatric candidates,
issues during the evaluation. Also, a positive experience collected during their assessments in the areas of Medicine,
during the psychological preoperative evaluation “lays the Nutrition, Psychology and Physiotherapy16.
groundwork” for the candidate to seek help in the future in The second publication illustrates a study organized
case any difficulties emerge after the surgery24. by Felix et al.7, in Paraíba. According to this article, after a
The previously cited study also states that psychological literature review, the team developed a “Nursing care protocol
assessment is a vital process not only to identify possible to the patient before and after bariatric surgery”. This protocol
contraindications for the surgery, but above all, to better consists of a program designed to provide nursing assistance
understand the patient’s motivation, preparation and for bariatric patients and it is divided in 11 requirements. The
emotional factors that can impact the adjustment to life after aim of the protocol is to guide nurses in the implementation
the surgery and the lifestyle changes associated with it24. of their duties7.

ABCD Arq Bras Cir Dig 2014;27(Suppl. 1):59-62 61

Review Article

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