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leslie J. heinberg, phd presurgical Evaluation for Bariatric patients: Balancing science and Clinical Judgment By leslie J. heinberg, phd BAriATrics Bariatric surgery is the most effective treatment for obesity. 1 unlike standard diets that focus on altering energy balance, the permanent physiological changes that result from bariatric procedures yield significant weightloss maintenance and remission of most, if not all, of obesity-related co-morbidities. 1 Although highly effective, bariatric surgery carries significant risk and requires permanent lifestyle change. Patients will need to adhere to a strict diet, daily supplements, regular exercise and frequent follow-ups in order to be successful. Determining the appropriateness of candidates requires a balance of empirically based decision-making and the “art” of clinical judgment. For example, adherence must occur in a population that is at high risk for psychiatric co-morbidity. Seventy percent of bariatric patients have a concurrent Axis I disorder and 20 percent meet criteria for Axis II pathology. 2 It is somewhat unclear whether the co-morbidity is causal in the development of the morbid obesity or whether it is secondary to, exacerbated by or maintained by stigma, isolation and societal prejudice. Individuals interested in bariatric surgery often are surprised to learn that almost all insurers require a pre-surgical behavioral evaluation. For many, this is their first-ever visit with a mental health professional and they are understandably nervous. Conversely, those with a long history of psychiatric care may have concern that this history will disqualify them. Rather than a “pass/fail test,” or a rubber stamp, our evaluation focuses on eight domains (see table) that were selected by Cleveland Clinic’s psychological team. Our selection is based upon a thorough review of the existing literature on psychosocial predictors of outcome, as well as our many years of clinical expertise. Each domain is graded on a five-point scale ranging from poor to excellent. A summary assessment of poor, guarded, fair, good or excellent is given at the conclusion of the assessment. Many patients in lower categories are given specific recommendations that will improve their candidacy. For example, about one-third of bariatric surgery candidates (more in a tertiary care center like Cleveland Clinic) meet criteria for binge eating dis- 8 doMAInS oF ASSeSSMenT 1. Capacity to consent 2. realistic nature of expectations 3. Mental health 4. eating behaviors/disorders 5. Alcohol/substance use, abuse, dependence 6. Social support 7. Adherence 8. Coping and stressors order. 2 Although not a clear contra-indication for surgery, patients with binge eating may not lose as much weight and are at higher risk for weight regain. Cleveland Clinic’s Bariatric Surgery Behavioral Health Service offers a four-session binge eating group that helps prepare such patients for surgery. Other behavioral health groups we offer focus on reducing alcohol/ substance relapse risk and improving expectations and behavioral adherence prior to and after surgery. The use of a “grading” system and assessment across many domains is essential in multi-disciplinary assessments. Individuals considered poor (e.g., acute psychosis, inpatient hospitalization or attempted suicide within the last 12 months) generally are not surgical candidates. Individuals who are fair, good or excellent generally are considered surgical can- 4 INsIghts | ClEvElaNd ClINIC dEpartmENt of psyChIatry aNd psyChology
didates, although they may receive recommendations from our team that are designed to improve outcome. Most complicated are those patients who are guarded. These individuals typically have both significant psychological and medical risk factors. Severe, life-threatening medical co-morbidities may necessitate surgery despite significant psychological risk. Conversely, significant psychological risk in the absence of significant medical co-morbidities may be rejected by the surgical team. An interdisciplinary team effort combined with objective ratings and sound clinical judgment has been effective at Cleveland Clinic in balancing the medical and psychological risks of patients who present for bariatric surgery. Leslie J. Heinberg, PhD, is a clinical psychologist and Director of Behavioral Services for Cleveland Clinic’s Bariatric and Metabolic Institute. She is also an Associate Professor in the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University. Her clinical and research interests are obesity, body image and eating disorders. She can be contacted at 216.445.1986 or heinbel@ccf.org. REFERENCES 1. Brethauer S, Chand B, Schauer PR. Risks and benefits of bariatric surgery: current evidence. Cleve Clin J Med. 2006;73:993-1007. 2. Kalarchian MA, Marcus MD. Bariatric surgery and psychopathology. In: Mitchell JE and de Zwaan M (Eds.). Bariatric Surgery: A Guide for Mental Health Professionals. Routledge: New York, NY. 2005; 59-76. BAriATrics hoW BArIATrIC SUrGery WorKS laparoscopic adjustable gastric banding (illustrated above left) is a restrictive procedure in which a silicone band with an inflatable inner collar is placed around the upper stomach. the band is connected to a port that is placed in the subcutaneous tissue of the abdominal wall. the inner diameter of the band can be adjusted according to weight loss by injecting saline through the port. this surgery is performed laparoscopically, offering less surgical trauma in the wound and to the viscera, improved postoperative pulmonary function and decreased incidence of wound-related complications. the procedure is reversible and, if patients fail to lose adequate weight, it can be converted to a roux-en-y gastric bypass. roux-en-y gastric bypass (depicted below left) is the most common bariatric procedure performed in the United states. It combines a restrictive and a malabsorptive procedure. a small (15-30 cc) gastric pouch is created to restrict food intake and a roux-en-y gastrojejunostomy provides the mild malabsorptive component. at Cleveland Clinic, more than 95 percent of roux-en-y gastric bypass procedures are performed laparoscopically. this procedure results in excellent long-term weight reduction and resolution or elimination of comorbidities. ClEvElaNdClINIC.org/psyChIatry | 866.588.2264 5
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Insights - Cleveland Clinic

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