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Psychological Exams for Obesity Surgery Revisited

Thursday, February 05, 2009 Posted by Travis Saunders

Photo by Boliston

Last week I wrote a post discussing whether or not candidates for obesity surgery should be required to undergo a psychological exam prior to treatment. My post was in response to a recent editorial in The Guardian by Dr David Ashton which can be found here, which described the psychological exam for obesity surgery candidates as prejudiced and unjust. A few days later I received a detailed response from our friend and colleague Danielle Gabert, who works in obesity research and management at the University of Alberta, and who is much more familiar with this type of treatment than either Peter or I. I found her email so informative that I have posted excerpts below (with her permission), in the hopes that others will find it as useful as I did.

“I don’t feel that a mental health evaluation needs to act as “gate-keeper” for Bariatric surgery, but given the number of candidates for surgery, it seems quite reasonable to determine if a pre-operative psychiatric status has any impact on post-operative success. Dr Ashton made it seem that these psychological evaluations are pass/fail, and that if you “fail”, you get no medical help. The reality is that even if a patient has a psychiatric diagnosis, they can still undergo surgery at the discretion of a health professional, as was demonstrated in a study by Sarwer et al. in 2004:

[out of 90 total patients]Almost two-thirds of patients received a psychiatric diagnosis, the most common of which was major depressive disorder. Nearly two-fifths of all participants, and more than half of those given a psychiatric diagnosis, were engaged in some form of psychiatric treatment at the time of the evaluation. Nevertheless, 64% of patients were unconditionally approved for [bariatric] surgery; 31% were recommended for additional psychiatric or nutritional counselling prior to surgery [note: still eligible]. Three patients [out of 90] were not recommended for surgery.”

Thus I would never imagine that if someone does have a mental health concern or illness that they should be deprived of any obesity treatment, including Bariatric surgery. However, I would say that if someone is diagnosed with a psychiatric condition, that this could be seen as a barrier that must be addressed prior to placing any expectations of program adherence on that individual (Especially given the often rigorous post-op guidelines). Rather than give the patient bariatric surgery and then hope to address the mental health issue, it would make more sense to address the mental health issue and then approve the surgery. And to know if there are any mental health issues, it seems rather appropriate to administer psychological testing (which sounds more daunting that it is, since this can be anything from the MMPI – Minesota multiphasic personality inventory – or even patient interviewing by trained professionals).

That being said, I believe that guidelines, as useful as they are, are only that – guidelines. “Research is useful and Instructive, but it is not a substitute for clinical sensitivity to the unique situation of each individual patient.” -Alejandro R Jadad.

-Danielle”

Thanks again to Danielle for taking the time to inform us on this issue. As Peter mentioned yesterday, we urge all of our readers to vote for their favorite blog topics to ensure that our future posts are as informative and useful as possible.

-Travis

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5 Response to "Psychological Exams for Obesity Surgery Revisited"

  1. Anonymous Said,

    It could also be argued that allowing ones' self to reach a state of obesity is in itself a mental health issue. Whether it be compulsive eating, spite eating, boredom, or self-pity, being consciously aware that ones' health, fitness, and body composition are compromised by excessive eating (or poor diet) and allowing it to happen constitutes self-destructive behaviour. That, if nothing else, should be addressed prior to surgery.

    Posted on May 20, 2009 at 11:48 PM

     
  2. Travis Saunders, MSc Said,

    It could be argued, but I think it's a pretty weak argument, and one which is gradually being abandoned by most people in the health field. Obesity is affected by the choices that an individual makes, but it is equally, if not more affected by environmental and personal factors over which they have little control. Things like genetics, socioeconomic status, and ethnicity are just a few factors which have a strong influence on obesity, and which are mainly outside of the influence of the individual.

    I don't know anyone who chooses to be obese, but I'm sure we all know many people who have struggled to attain or maintain a healthy body weight. There are numerous other diseases (breast and many other types of cancer, any number of diseases related to smoking, STD's, etc) which are influenced by lifestyle factors, yet we would never generalize that all individuals with cancer have a mental health issue.

    To suggest that millions of individuals are "allowing" themselves to become obese is naive, and just plain untrue.

    Travis

    Posted on May 21, 2009 at 10:57 PM

     
  3. Anonymous Said,

    Granted, issues such as genetics and ethnicity are outside of ones' control, but I fail to see how those like socio-economic status influences obesity. Less affluent populations do tend to eat less nutrient-rich foods, but they also tend to eat less food in general.

    What do we make then of the individuals that are compulsive eating, spite eating, boredom-eating, or self-pity-eating? Do we ignore the mental health component here?

    Indeed, there are a host of other diseases linked to smoking and STDs, and various other lifestyle factors - but again, no individual is forced to smoke or partake in unsafe sexual practice. On the contrary, many health practitioners are denying service to smokers on the argument that treating these individuals is moot.

    I think it's more naive to believe that people are not responsible for their own health by the choices they make and indeed their lifestyle choices. It seems obesity research is taking a reactive approach rather than a proactive one, which is proven time and time again to be costly and ineffective in the long run. We need to focus on preventing obesity and promoting healthy lifestyles. In doing so, we treat not only obesity itself, but most other co-morbids associated with it.

    Posted on May 25, 2009 at 10:41 AM

     
  4. Travis Saunders, MSc Said,

    In western countries, socioeconomic status is actually a pretty good predictor of obesity (the relationship is somewhat reversed in poorer countries - for an interesting paper click herehere). There are a few reasons why that is the case - the cheapest foods tend to be those that are very calories dense, people who have less income may not have the same opportunities for gym memberships or organized sport, or even access to safe parks and playgrounds. They are also likely to have less education, which itself is a predictor of a less healthy lifestyle.

    Of course people who have binge-eating disorder or other conditions should be treated for them, it would be ridiculous to suggest otherwise. But obesity is not itself a mental illness, nor is obesity always caused by mental illness, it is just one of many factors which can predispose someone to obesity.

    Travis

    Posted on May 25, 2009 at 10:28 PM

     
  5. Anonymous Said,

    I appreciate your position, but I personally can not accept all the extraneous factors that research blames for obesity. It takes away the personal responsibility that individuals have for their own person.

    Obesity is not itself a mental illness; nor is cancer - by any means. But smoking is an addictive behaviour that is the root of many cancers. Take away the smoke = reduce the risk. The only mechanism (save for hormonal and genetic disorders) that is the absolute root of obesity is caloric-imbalance. Period. Take away the calories = reduce the weight. Cheaper foods may very well be calorie-dense... so reduce portions.

    I don't have a gym membership. I'm not even all that active. I live in a bad neighbourhood and i'm floating right around the Canadian poverty line. I'm not obese. When I see a little extra belly building over the winter, I watch how much I eat and try to expend a few extra calories in the comfort of the tiny living room.

    By blaming any other extraneous factors other than caloric-imbalance, we take away the inherent power from individuals to take charge of their own weight. It seems were are creating and associating all these superfluous causes and not dealing with the root. Or is there no money in prevention?

    Posted on May 26, 2009 at 11:44 AM

     

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We are PhD students in the School of Kinesiology and Health Studies at Queen's University in Kingston, Ontario. Our research focuses on the relationships between obesity, physical activity, and health risk. This blog is our attempt to consider the many "cures" for obesity that we read about on a daily basis. Enjoy.

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The opinions expressed here belong only to Peter and Travis and do not reflect the views of any organization. Any medical discussion on this page is intended to be of a general nature only. This page is not designed to give specific medical advice. If you have a medical problem you should consult your own physician for advice specific to your own situation.

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