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A. Al-Ozairi and H. Alshatti168
anxiety, might have a negative effect on post-surgery weight loss but not mildmoderate in nature [34]. Recent studies have linked the effect of having multiple
psychopathologies preoperatively on increasing the risk of having intermediate
weight loss after the surgery [35–37].
It is believed that cognitive function has a direct effect on post-surgical weight
loss, due to the influence of the cognitive function to develop an appropriate eating
behavior and coping mechanisms later on.
Most studies have concluded that post-surgical eating behaviors influence the
postoperative weight loss outcome. It is also believed that the impact of the preoperative mental status, cognitive function and personality of the participant on the
total weight loss is linked to the postoperative eating behavior. Other psychiatric
disorders may affect the weight loss outcome through the same previous principle,
as seen in major depressive disorder among gastric sleeve participants [38].
In depression, there is a persistent depressed mood, loss of interest, feelings of
guilt, and disturbed sleep and appetite [39]. Those symptoms may affect the eating
behavior of the participant which includes dietary constrains and results in suboptimal weight loss. Also, depression affects the cognitive functions of the individual
leading the participant focus on the negative sides of the circumstances [40]. This
negative interpretation may interfere with participant’s post-surgical adjustments
and developing new cooking methods with weight loss and diet constrains.
10 Mental Health Preoperative Assessment
Psychiatric disorders and mental illness are prevalent among bariatric surgery participants, as was established earlier. Furthermore, the weight loss outcome relies
not only on a successful procedure alone, but also on the behavioral, and the psychological status of the participant. Therefore, the psychological assessment prior
the surgery is recommended. The goal of the assessment is not diagnostic, rather
than screening. The screening must take place to reveal any contraindications such
as current substance use disorder, recent suicidal attempt, or active psychosis [22].
The assessment should be done by mental health providers such as a psychologist,
a psychiatrist.
It is important to emphasize that the psychiatrist role here is to enhance surgical
outcomes and not just weight loss. For example, a patient with excellent weight
loss post gastric sleeve, may still have psychosocial difficulties and challenges,
ranging from disruptions in interpersonal relationships and body image dissatisfaction to concerns as serious as suicidal behaviour and substance abuse. The aim
of the preoperative assessment is to improve all domains of surgical outcomes.
In this part, we will discuss the psychiatric evaluation of the bariatric surgery
candidate, and the necessary tools should be used with considerations to certain
psychopathologies, such as depression, and eating disorders.
Psychiatric Evaluation: Pre and Post Sleeve
169
11 Outline of Domains of the Evaluation
Guidelines published by the American Society for Metabolic and Bariatric Surgery
(ASMBS 2016), show a systematic method to conduct a preoperative interview for
bariatric surgery participants by psychiatrists. The interview contains four main
elements to evaluate, including the current life, psychiatric, behavioral, and cognitive and emotional status.
Despite the previous published guideline, there are various protocols used
across the globe tackling the issue of mental preoperative evaluation. Most of the
protocols and guidelines agree on certain domains to be included in the evaluation,
those are [22, 26, 41, 42]:
• history of weight loss and previous attempts
• physical activity
• medical history
• pathological eating behavior
• psychiatric history and screening of substance use
• patient’s mental capacity (understanding the surgery, the outcome, possible
complications, and expectations)
• support system
12 Psychiatric Contraindications for Bariatric Surgery
Having a psychiatric disorder, by itself, is not a contraindication per se, but there
are psychiatric elements that prompt delay or cancellation of the surgery.
According to the American Psychaitric Association (APA), and the ASMBS,
the most common elements considered as high risk, or contraindication, to
undergo a bariatric surgery are:
• significant psychopathology such as active psychosis (including thought disor-
der symptoms),
• current substance dependence,
• untreated eating disorders (specifically anorexia nervosa or bulimia nervosa),
• untreated depression
• active suicidal ideation
Those mentioned contraindications, when present, the surgery either is canceled
or delayed till the psychopathology is resolved, treated or reduced to a subclinical
level.
A. Al-Ozairi and H. Alshatti170
Lastly, there are other elements considered as contraindications because they
will interfere with the optimal weight loss after the surgery. Although they are not
psychiatric in nature, they have to be evaluated by a mental health provider. Those
elements are: unrealistic expectations for the goal weight, lack of knowledge of
the surgery and the possible complications, and lack of social and family support
[20, 29, 43, 44].
13 Conducting the Assessment
13.1 History of Weight Loss and Previous Attempts
During this part of the assessment, the examiner should review the pattern of
weight changes of the participant, and the previous methods of weight loss was
tried in a chronological manner, with the notion to the biological and environmental factors that may affect the weight change and the failed attempts. Knowing the
age of onset and family history of obesity may reveal a genetic aspect in which
helps the participant understand the factors affecting the obesity and what to
expect after the surgery [42]. Asking about the effect of stressful events on weight
changes may reveal inappropriate coping mechanism, such as emotional eating or
loss of appetite. Such coping mechanisms may affect the post-surgical weight loss
and may be erected later on.
13.2 Medical History
Asking about the medical history is an important part of any medical based interview. It is vital to know the medical diseases, and treatments the participant has
to have an idea about the individual as a whole. Also, it will provide information
that help the weight loss outcome. Certain medical conditions, or medications may
intervene with the rate of post-surgical weight loss.
Furthermore, asking about the medical history reveals the level of adherence
to the current medications, if present. This information will provide a prospective
idea regarding future compliance to the postoperative management plan, such as
respecting follow-ups, regular investigations, taking medications, and recommended behavioral changes [45].
13.3 Pathological Eating Behavior
This section involves two main aspects:
• eating and diet habits
• eating pathology
Psychiatric Evaluation: Pre and Post Sleeve
171
Eating habits of the participant should be known in detail or at least we should
have an idea about this aspect. The eating habits include daily dietary preferences,
number of main meals and snacks, meal portion sizes, and if there is a consistent
timing of the meals. Understanding these habits may reveal inappropriate aspects
of the participants eating behavior that were factors in the obesity or may cause
weight to regain after surgery [46].
Eating pathology is another aspect to be considered in the assessment, besides
eating habits. In this part we will discuss the types of eating disorders should be
screened, and possible management plans prior undergoing with the surgery.
Understanding the eating patterns and detecting any related pathology is crucial for the after-surgery weight loss. As mentioned earlier, one of the factors that
link the mental health status and not achieving optimal weight loss after the surgery is the inappropriate eating behavior. The most important eating disorders to
screen for are (1) anorexia nervosa (2) bulimia nervosa (3) binge eating dis-
order (BED) (4) night eating syndrome (NES). Other non-diagnostic eating
disorders that are important to screen for are: overeating, grazing and emotional
eating.
The use of scales and screening tools are useful to detect eating disorder. An
example of those tools, eating disorder examination questionnaire (EDE-Q), which
is a self-report instrument and it screens for symptoms of eating disorder in the
last month [47, 48].
After screening for any pathological eating behavior, the next step is to determine the treatment and follow-up plan. The candidate should understand that the
first few weeks after the surgery is a stressful period, mentally and physically.
Furthermore, the participant should be educated that having this psychopathology
may interfere with reaching the optimal weight [45].
The choice of therapy should depend on the psychopathology, e.g., cognitive
behavioral therapy (CBT) and interpersonal therapy (IPT) are verified treatment options for BED [49]. The psychological approach found to be superior
to the behavioral approach in treating BED [50]; however, the opposite is true
in treating NES [51]. The basis of treating NES concentrates on the behavioral
aspects [51].
As for the pharmacological aspects, the usual use of antidepressant has shown
significant improvement of eating disorders symptoms and reducing the frequency
of the episodes. As an example, Fluoxetine, a type of selective serotonin repute
inhibitor (SSRI), is the only antidepressant approved by the food and drug administration (FDA) to treat bulimia nervosa with a therapeutic dose from 20 to 60 mg
per day. For BED, antidepressants (SSRI and tricyclic antidepressants (TCA))
were superior to placebo in reducing the symptoms in a meta-analysis of 7 randomized control trails (RCT) [24]. As for NES, Sertraline (mean dose of 126.5 mg/
day) [52], Escitalopram (mean dose of 20 mg/day) [53], and Agomelatine (mean
dose of 50 mg/day) [54] showed superiority in treating NES when compared to
placebo.
A. Al-Ozairi and H. Alshatti172
13.4 Psychiatric History and Screening of Substance Use
The psychiatric history should be brief and concentrate on screening the psychiatric disorders, rather than diagnosing. The screening should include past and current psychiatric history, mental state exam, substance abuse, psychiatric systemic
review, active symptoms of psychosis, mood disorders, and suicidal ideation [43].
The main goal is to check if there are contraindications for the surgery, including suicide ideation, active psychosis, untreated substance use disorder, and
untreated depression. Also, the screening should include other psychiatric disorders that may affect the cognitive functioning, such as schizophrenia, or bipolar disorder. Thus, affecting adherence and the behavior of the participant which
causes achieving suboptimal weight loss. Furthermore, having surgical intervention is a stressful event, especially when it is affecting the lifestyle. The surgery
may worsen the psychiatric symptoms and the patient may need further assessment and tailored management. In this section we will discuss further the screening of depression, substance use disorder, and suicide risk assessment.
Major depressive disorder in itself is not a contraindication for the surgery.
However, if the depression is not treated, severe, or presented with active psychosis or suicidal ideation, then, postponing the surgery is considered. It is useful to
use self-assessment tools, for example the patient health questionnaire-9 (PHQ-9),
to screen and assess the severity of depression [55].
Suicide screening Active suicidal ideation is considered a contraindication to
the bariatric surgery. To screen for suicide, ask the participant a clear direct question of intending of self-harm and having suicidal thoughts. If the participant
had a positive answer, then continue with the suicide assessment. The American
Psychiatric Association (APA) has approved a brief suicidal risk assessment
named suicide assessment five-step evaluation and triage (SAFE-T) [56].
Substance use disorder is common among gastric sleeve candidates, especially
alcohol use disorder, and the presence of this untreated pathology is contraindicated with the surgery. Thus, screening for substance use should be part of the
psychiatric pre surgical evaluation. During this part of the assessment, the examiner should not rely solely on the self-report instruments. The screening instruments are complementary to the clinical assessment [57]. Accompanying the
clinical interview, the change in biomarkers may give a hint to the degree of the
substance use. As an example, in alcohol use, the liver enzymes are elevated such
as alanine aminotransferase (ALT), serum aspartate aminotransferase (AST), and
gamma glutamyl-transferase (GGT). However, these biomarkers are not sensitive, and they are affected by other medical issue, but they may support the clinical
assessment [58].
Since alcohol use disorder is the most common type of substance abuse among
the participants, there are brief methods to screen for the use of alcohol. The
CAGE questionnaire is a self-administered questionnaire with high sensitivity
around 91–93% for detecting heavy alcohol consumption [59] but is less sensitive
Psychiatric Evaluation: Pre and Post Sleeve
173
for less severe alcohol misuse. The Alcohol Use Disorders Identification Test
(AUDIT) is another widely used instrument to detect alcohol use disorders. It is
a 10 items questionnaire that has two versions, the clinical administered and selfreport. AUDIT is a validated and reliable instrument to detect different levels of
alcohol use disorder. Furthermore, AUDIT uses a standardized levels of alcohol
consumed regardless of the type of ingested drink [58].
Screening for substance use should also include screening of other addictive
behaviors such as smoking cigarette, shoplifting, or food or any form of addiction. This addictive behavior is common among bariatric surgery participants and
it might increase in frequency after the surgery. This can be explained by the concept of “addiction transfer”. Addiction transfer is defined as individuals replacing
one form of addiction with another one. In case of the bariatric population, it is the
transfer from addiction to food to another form of addiction, such as consumption
of alcohol, gambling, or other forms [57].
Educating the participants of the importance of this screening and the possible
effect of the surgery. Also, participants should be educated about addiction transfer
and how it affects the lifestyle. Individuals who suffer from untreated substance
use disorders or addiction, should seek help prior the operation, or postponing the
surgery is recommended till the issue is resolved.
The management plan may vary depending on the individual. Psychotherapy
is widely used to treat addiction problems and substance use disorders, especially
among the bariatric population undergoing bariatric surgery. Various methods are
used depending on the patient, including motivational interviewing (MI), CBT,
or 12- step programs [60, 61]. Pharmacological treatment is less evident among
patients undergoing bariatric surgery; however, it may be useful for some patients
more than others.
Adverse childhood experiences (ACE). In addition to the previous psychiatric
history taken, asking about Adverse childhood experiences (ACE) might be useful
to the evaluation. Childhood trauma, may be a factor in developing obesity or eating patterns that causes obesity. This could be explained that those individuals utilize the excess weight as a protective shield against stress or anxiety related issues
triggered by intimate relationships. Those individuals may become more vulnerable when they lose significant weight via surgery, and the surgery may provoke
new psychiatric issues [62].
13.5 Support System
Another aspect of the psychiatric preoperative assessment to explore, is the support system. Having a life changing surgery needs a good support system from
family members and close relationships. The lack of support system may affect
negatively the post surgical outcome. Some participants complain that their partners are feeling threatened after the significant weight loss after the surgery. It was
A. Al-Ozairi and H. Alshatti174
elaborated that this feeling was due to the improved positive transformation after
the weight loss, such as improved self-esteem and increased attractiveness of the
participants [63].
13.6 Psychiatric Medication
The use of psychiatric medications is also common among the bariatric patients.
Also, patients with mental illness are at higher risk of obesity and metabolic disturbances. The psychiatric medications may contribute to that risk. Screening for
psychotropics should take place prior the surgery to look for any medication that
might influence the weight the gain or affect the metabolism of the participant.
Some antidepressants such as Amitriptyline and Mirtazapine may induce weight
gain among the participants. Multips antipsychotics such as Olanzapine and
Clozapine can cause metabolic disturbances that result in weight gain. Also, few
of the mood-stabilizers such as Valproate and Lithium may increase appetite and
induce weight gain [64].
14 Psychiatric Assessment Conclusion
Taking care of bariatric patients is done by a multidisciplinary team, and they must
be informed about the readiness of the patient for the surgery from psychiatric
point of view [43].
The majority of the candidates (96%) are cleared to have the surgery. The remaining 3–4% were absolutely contraindicated and were denied to have the surgery due
to serious psychiatric issues, such as psychosis, thought disorder, suicidal ideation,
active substance use, untreated eating disorder, and lack of decision making capacity.
That small percentage was constant throughout several studies [29, 30, 65, 66].
A group of candidates are in a grey area. Those individuals have few psychiatric concerns, but they are cleared to have the surgery under certain conditions.
The surgery is delayed for a short period of time till they start with the psychiatric
treatment. Studies revealed that this issue could happen among 15–31% of participants [30, 67]. While delaying the surgery is beneficial to the participant, there is
an undeniable rate who do not return for the surgery. Some studies found that up to
12% of the candidates never return for the surgery. Only 16% of participants return
for the surgery after it was postponed due to an underlying eating disorder [17].
15 Special Populations
We will discuss the following three special populations due to the different nature
of the problems they face. For example, adolescents and bariatric surgery is
becoming more and more common, however, the preoperative assessment of pediatrics and adolescents requires a different approach with certain considerations,
Psychiatric Evaluation: Pre and Post Sleeve
175
such as bullying and self-image issues. Another population are those with intellectual disability who, because of their deficit in their cognitive function, may find
it difficult to adhere to the management plan or fathom the importance of having a
strict diet for the first couple of weeks after the surgery, which affect the surgical
outcome. Another population that may suffer from cognitive function limitation is
the ageing adults.
In this section we will discuss populations (the adolescent and the intellectually
disabled) and the difficulties we face and the solutions when assessing them.
15.1 The Adolescent Patient
The preoperative assessment of adolescents has a similar approach to adults. The
evaluation should be comprehensive with a multidisciplinary team to assess if the
participant is fit to have surgery. However, there are certain aspects should be considered when evaluating the adolescent candidate. Exploring those aspects will
help a better surgical outcome.
The main issue of obesity troubling the adolescents is the social stigma. It is
widely spread among individuals with obesity regardless of age, gender, and geographical distribution. However, the development of peer-focused social skills
begins at adolescence when teens interact with their peers and develop sense of
identity and being included in a social group as part of their social functioning.
During this time, they are most vulnerable to the negative comments and social
stigma about their weight or body shape. Bullying or weight related teasing has a
great impact on adolescents and affect how they define themselves and their identity. This effect is noticeable among teenagers, the rate of depression has increased
among teens with obesity and in particular among females [18].
Family environment is another major factor affecting the course of obesity in
adolescences. During childhood, children are hugely affected by the behaviors and
ideals of close family members. Some of those behaviors become tradition and
some of those ideals become consolidated ideas shaping the individual’s perception toward self and the community. Family support is a double sided weapon, the
family may be a motivating factor for the adolescent to seek the sleeve gastrectomy
procedure due to certain health concerns of the general well being of their child.
One the other hand, within the same family environment there might be elements
that contribute to weight gain. Those elements may be the family eating habits,
unhealthy dietary choices, or the availability of unhealthy food. Since the family
environment has a huge influence on the adolescents, they have difficulties change
that environment without the help and support of their family members [68].
Another challenge is the adolescent client’s adherence to management plans.
During adolescence, a strong sense of independence and identity is developing.
Lack of adherence to management plan among adolescent candidates is a well
recognized issue [69] and that could be because of peer pressure and trying to fit
in, as well as difficulty following dietary recommendations such as avoiding fast
foods.
A. Al-Ozairi and H. Alshatti176
Adolescents seeking sleeve gastrectomy are motivated by many factors, such
as health concerns, seeking better body image, the pressure of family members, or
due to social concerns. This may lead to developing unrealistic expectations about
the surgery, the post-surgical body shape, scars, optimal weight loss, the amount
of excess skin, or life restrictive activities. The candidates may be unsatisfied with
surgical results because they were not prepared from the beginning, and this may
cause further discomfort in body image or even a new onset of psychiatric disorders like depression or body dysmorphic disorder. Experimentation with substance
or sexuality is common during adolescence. The presented challenges after the
surgery and the lack of preparation for the surgical outcome may raise an issue of
substance use disorder.
It is crucial to explore the social and family environment domains of the adolescents with the addition to the other domains which are similarly evaluated in
adults. Participants should be educated about the social stigma and its effect on
understanding the consequences of the surgery. The participants should be asked
about their expectations from the surgery, and any unrealistic ideas must be rectified to prepare them for the post surgical outcome. The psychological aspects of
the rapid weight loss after the surgery should be addressed.
To avoid resisting the post surgical recommendations, clinicians and adolescents should be connecting. This can occur by understanding the values, goals,
and cultural backgrounds of the adolescents. The young participants should be
included in the management plan and their opinions should be considered. They
must sense that their values are taken in consideration rather than ordering them
around. These ways of communications with the adolescent candidates is helpful
to improve the adherence to the management plan and better outcome. Motivating
the participant to socially interact with other adolescents who share same goals to
implement a strong social peers support.
15.2 Limited Cognitive Function
Cognitive function is one of the major factors affecting outcomes post sleeve gastrectomy. Thus, managing participants suffering from cognitive vulnerabilities
is challenging. This group may include various populations, such as individuals with low IQ, learning disabilities, history of low educational achievement, or
dementias. As previously mentioned, cognitive limitation affects the post-surgical
weight loss through various aspects. Individuals who has difficulties in information consolidation may find it difficult to obtain and analyze vital information in
respect to the procedure itself, possible complications, and lifestyle changes.
Limited educational level could be an obstacle to the participants concerning the
utility of self-monitoring methods and related educational materials. Participants
with memory difficulties may not be able to recall crucial information or recommendations to optimize the weight loss, minimize complications, improve healing,
Psychiatric Evaluation: Pre and Post Sleeve
177
taking medications, or diet plans after the surgery which may increase the risk of
unpleasant events afterwards. A deficit in executive functions will have a great
negative impact on the participant’s capability of behavioral control, problem solving skills, analyzing current events and predicting the consequences. A dysfunction in such system is a predictor of reaching suboptimal weight loss or weight
regain after the surgery [70].
Individuals suffering from limited cognitive function and seeking a sleeve gastrectomy should, at minimum, have the cognitive capacity to decision making in
regards to the surgical procedure, understanding the possible consequences, and
the importance of life changing behaviors. Further, it is important to assess their
social supports and if they can cope with the changes post-sleeve gastrectomy.
16 The Impact of Bariatric Surgery on Mental Health
Individuals seek sleeve gastrectomy for multiples reasons. Some participants seek
the surgery due to their unsatisfied body shape and image, to reduce their weight,
or due to medical comorbidities. The surgery may improve general mental health,
but also may trigger new onset of psychiatric disorders, like body dysmorphic
disorder.
The literature is filled with studies indicating the significant improvement in
health after sleeve gastrectomy [71, 72]. Major studies have explored this impact
on the candidates for the short and long term. The main example of such studies
is the Swedish obese subjects (SOS) study, which is a prospective study that followed participants for a long period of time for around two years. In this section
we will discuss the impact of the sleeve gastrectomy on the mental health status,
and the quality of life.
16.1 Quality of Life
It is evident in the literature that there is an improvement in health related quality
of life after the surgery. This improvement might reach a peak and then slightly
decline over time. This pattern is seen in the SOS study, it was found that patients
reported significant improvements in health-related quality of life after a period
of 6–12 months. However, these major improvements reached their peak at that
period and a slight decline in such improvement is noticed after a period of two
years after the surgery. Despite the slight decline two years after the surgery, the
improvements in health-related quality of life were positively linked to the amount
of weight lost [37].
The majority of the patients reported improvements in martial satisfaction and
sexual activity [73]. Also, participants reported improvements in body image after
the surgery [19].