Psychiatric intervention pre- and post-bariatric surgery.

INTRODUCTION

Obesity and related complications are endemic throughout the world, including in India. India accounts for 1.37 billions of obese individuals.[1] While nonpharmacological and non-surgical mode such as caloric restriction, exercise, and behavioral modification have been the mainstay of management of overweight to obesity with body mass index (BMI) <30 kg/m2, these strategies have not been found to be useful in sustained long-term weight loss in the severely obese individuals (BMI ≥40).[2] Asian populations, particularly, are at increased risk of developing centripetal obesity, which is a risk factor for the development of type 2 diabetic mellitus (T2DM) and other metabolic syndrome related-complications. Obesity and Metabolic Surgery Society of India guideline (2020) suggests that Bariatric/metabolic surgery should be considered a treatment strategy for acceptable Indian patients with a BMI ≥35 kg/m2 with or without the presence of any obesity-related comorbidity/ies and individuals with a BMI ≥30 kg/m2 having two or more obesity-related medical comorbidities.[3]

Given this, bariatric surgery has become a vital strategy to manage severe obesity. India has become a hub for such surgeries just following the United States and China. Research suggests that bariatric surgery not only results in weight loss but also improves the medical (T2DM, cardiovascular diseases, etc.) and psychological problems/comorbidities (depression and suicide attempt, quality of life [QoL], binge eating disorder [BED], etc.) among the recipient of surgery.[4] Commonly used Bariatric surgeries are categorized into restrictive type[5] (Sleeve gastrectomy), malabsorptive type (Roux-en-Y-gastric bypass [RYGB]), and combined (malabsorptive and restrictive) approach (one anastomosis gastric bypass/mini-gastric bypass).[2] It has been posited that the mental health problems seen in individuals seeking bariatric surgery (or are associated with obesity) are the outcomes of obesity rather than the cause of obesity. Therefore, the benefit of bariatric surgery is not only restricted to significant improvement in physical parameters but also significant improvement in affective symptoms, anxiety, BED s, QoL, etc.[6]

However, the success of surgery lies in a sound presurgical patient screening, including the psychological assessment (psychological problems/comorbidities, social support, motivation, and ability to cope-up with the postsurgical demands). Nevertheless, psycho-social assessment of individuals being planned for the bariatric surgery is a less-opted path in clinical practices; often is performed merely to fulfill the requirement of an insurance agency. The practice of nonperforming routine psychological assessment of these individuals is also due to lack of standard guidelines – both from surgery and mental health-on approach to pre-(or postsurgical) psychological assessment, fear on the part of patients of getting rejected for surgery, or undue delay in getting surgery, stigma (both patient and surgeon) and lack of orientation of the bariatric surgery team about the mental health needs of the individuals seeking bariatric surgery and postsurgical adjustments.[56]

THE RATIONALE OF THE GUIDELINE AND ITS SCOPE

In the absence of a clinical practice guideline (CPG) on the psychological assessment of the individuals seeking bariatric surgery or who have undergone surgery for their postsurgical surgical adjustment, a formal assessment protocol is not in place in the majority of the healthcare facilities involved in performing such surgeries in India. Moreover, as there is conflicting evidence regarding the effectiveness of such assessments and the impact of various psycho-behavioral interventions on postsurgical physical and psychological outcomes, such practices have not been promoted as well as adopted in the field of bariatric surgery. The current CPG is aimed at reviewing the current level of evidence on the psychological issues among the individuals seeking bariatric surgery, the impact of pre- and post-surgical psychological problems on the postsurgical outcomes, and, also, of the effectiveness of pre- and post-surgical psychological interventions on the postsurgical outcomes. However, this guideline does not claim to be the one-size-fits approach in all health settings, and its practice should be tailored according to the patient population, institutional practices, and available resources.

PSYCHOLOGICAL ISSUES AMONG INDIVIDUALS SEEKING BARIATRIC SURGERY

Literature suggests that individuals seeking bariatric surgery often suffer from depression (suicidality), BED, and had experienced childhood-sexual abuse (CSA), including personality issues.[7] In addition, they face significant stigma (including perceived stigma), suffer low self-esteem, sexual dysfunctions, relationship issues with the spouse/partner, insomnia, cognitive problems, poor coping skills (often eating is a maladaptive way of coping), and body image concerns. Consequently, have poor health-related QoL (HRQoL) [Table 1].[8]

Table 1

Prevalence of psychiatric disorders among the individuals seeking bariatric surgery

Psychiatric condition	Prevalence (pooled estimate†, 95% CI)
Any mood disorder	23 (15-31)
Depression	19 (14-25)
Binge eating disorder	17 (13-21)
Anxiety	12 (6-20)
Suicidal ideation or suicidality	9 (5-13)
Personality disorders	7 (1-16)
Substance abuse disorders§	3 (1-4)
Psychosis	1 (0-1)

Dawes AJ, Maggard-Gibbons M, Maher AR, Booth MJ, Miake-Lye I, Beroes JM, et al. Mental health conditions among patients seeking and undergoing bariatric surgery: A meta-analysis. JAMA 2016;315:150-63. †Pooled estimate is based on random-effect meta-analysis; §Does not include nicotine dependence syndrome. CI – Confidence interval

These psychological risk factors can worsen the pre- and post-surgical medical comorbidity/es. On the contrary, timely and effective addressal of these issues can result in a significant reduction in medical complications and frequent postsurgical hospitalization.[9] Therefore, the psychological issues of such individuals should be identified and resolved during the pre-surgical evaluation stage and to be monitored in postsurgical recovery stage as well and managed, if required.

PRESURGICAL PSYCHOSOCIAL ASSESSMENT OF INDIVIDUALS SEEKING BARIATRIC SURGERY

The goal of presurgical psychological assessment is not limited to identifying any psychiatric illness but to evaluate the mental health stability of the patients to undergo surgery, to assess their level of motivation for the surgery, evaluating their level of the adherence to the presurgical lifestyle modifications (LSMs, exercise, dietary modifications, etc.) and factor influencing them, and comply with postsurgical recommendations, including the ability to cope-up with the postsurgical physical, psycho-social, and lifestyle stressors/demands [Table 2].[5]

Table 2

Components of presurgical psychological assessment

Succinctly describing the purpose of evaluation: Allayilng the misconception and prejudices related to psychological assessment (purpose to help the patient rather deeming them unfit)

Assessing knowledge and attitude: Their understanding about the surgical procedure and its outcomes, including their level of expectation

Assessing current and past mental health functioning: Assessing for all major psychiatric illnesses, particularly depression, BED, impulsivity, SUD, psychosis, personality ds. etc.

How symptoms were managed? (Types and setting of treatment) and their perception about the improvement with it

Stress and coping skills: Level of perceived stress and mood in the last 6 months–1 year and their coping techniques (problem – vs. emotion-focused) (particularly eating as a coping method)

Their perception about upcoming stress (relationship issues, physical changes, etc.) and prospective coping strategies

Social support: Level of social support they have and would need postsurgery towards treatment, including postsurgery follow-ups, and daily-life-related changes

Cognitive and social functioning: Level of cognitive functioning (memory, attention, and concentration, comprehension [MMSE], planning, impulse control, motivation) and social skills (interpersonal skills, including communication with the treatment team, etc.)

Motivation: Motivation towards surgery, reason to undergo surgery, locus of motivation (internal/external), comply with the recommendations, and behavioral changes required, etc.

Monitoring their compliance with the lifestyle modification: Monitoring their compliance with LSMs and factors (including psychosocial factors) influencing them

Objective psychosocial measures: Eating disorder (binge eating scale, TFEQ), depression and anxiety (PHQ-9), personality (MMPI), QoL (WHO-QoL-Bref/IWQOLLite/SF-36), coping skills (stress-coping behavior scale, proactive coping inventory)

Preparing a report to the surgical team: Fitness for surgery, factors (risk and protective factors) influencing patients pre- and post-surgical adjustments, flagging*, need for pre- or post-surgical nonpharmacological/pharmacological interventions

*Flagging refers to because of certain bio-psycho-social vulnerabilities patients should be observed more closely during the follow-up period); MMSE; Minnesota multi-phasic personality inventory; SCBC and PCI are validated in Indian population. QoL – Quality of life; MMSE – Mini-mental state examination; IWQOLLite – Impact of Weight on Quality-of-Life Questionnaire-Lite; SF-36 – Symptoms checklist-36; TFEQ – Three-Factor Eating Questionnaire; BED – Binge eating disorder; SUDs – Substance use disorders; LSMs – Lifestyle modifications; QoL – Quality of life; WHO-QoL-Bref – WHO-QoL-brief scale; MMPI – Minnesota multiphasic personality inventory; SCBC – Stress Coping Behavior Scale; PCI – Proactive Coping Inventory; PHQ-9 – The Patient Health Questionnaire-9

A psychologist (or mental health professionals [MHP]) should be trained in medical psychology as there is often a complex interplay of obesity, medical comorbidities, psychological problems, and postsurgical adjustments or complications.[6]

The psychological assessment should also include postsurgical relationship issues and potential source of stressors (job-related, treatment-related, change in the dynamics of the relationship, etc.). According to some international guidelines (Brazil, The United States), psychologists and/or psychiatrists of the multidisciplinary team should ensure the absence of substance use disorders (SUDs), psychotic disorders, and dementia.[610] Further, they are also responsible for guarantying that patients have the intellectual and cognitive capacities to assess the risks associated with the surgery and the special care needs that are warranted subsequently.[6]

Additionally, support group (psychoeducation about the surgery and potential outcomes, sharing of the psychological and physical concerns with other individuals seeking bariatric surgery, postsurgical changes, and needs, etc.) under the supervision of a nurse or counselor even before surgery, and motivational interviewing (exploring patients their level of motivation, expectation, unreasonable or unattainable goals and help them arrive at more moderate ideals.) have been found to improve postsurgical adjustment (both physical and psychological). However, these interventions have not been tested in a randomized-controlled design [Table 2].[11]

A thorough clinical interview should be conducted to evaluate persons’ personality issues, including level of impulsivity, binge-eating disorders, comorbid depressions, anxiety disorders, etc., as they can adversely affect their compliance with the recommendations of the treatment team. Moreover, certain personality factors result in a greater level of nonsatisfaction with the surgical outcomes and poor-therapeutic relationships with the treatment team. The clinical interview should be supported by the application of special psychological testing should be performed (Beck Depression Inventory, the Minnesota Multiphasic Personality Inventory, Binge Eating Scale). There are specific interview schedules, that could be modified as per the cultural and institutional requirements (Boston Interview and the PsyBari) [Table 2].[1213]

If the psychologist or MHP deems that the person lack capacity (to understand the risks, benefits, and results of the surgical procedure; a reluctance to adhere to the postoperative recommendations) or has certain psychiatric illnesses (active psychosis, mood disorder, multiple suicide attempts or a recent suicide attempt, addiction, dementia, severe mental retardation, severe life stressors) surgery should be postponed or rescinded.

POSTSURGICAL PSYCHOLOGICAL CONSEQUENCES

Assessment

Apart from improving the medical aspects of obesity and related comorbidities, bariatric surgery through a direct biological mechanism also brings about a positive psychological change among the recipients of surgery, an improvement that occurs irrespective of presurgical psychological interventions [Table 3]. For instance, a long-term assessment of bariatric surgery-2 (LABS-2) study involving 2036 patients who were followed for 5 years found that among the cohort who were initially not satisfied with their sexual lives, postsurgery, 56.0% of women and 49.2% of men experienced clinically meaningful improvements at year 1 which also persisted till the 5 years of follow-up.[7] Similarly, longitudinal studies have reported a significant improvement in depression (both prevalence and severity) following the bariatric surgery that persisted till 1–3 years after surgery, however, after which the effect wanned-off.[1415]

Table 3

Postsurgical psychological aspects of the individuals received bariatric surgery

Status of presurgical psychiatric problems/illnesses: Improvement in BED, depression, anxiety (though anticipatory anxiety## can emerge), self-harm, and suicidality, etc.

Substance use: Possible increase in substance use (including opioid analgesics) postsurgically, hence must be assessed routinely

Psychosocial function and HR-QoL: An increase in marriage and new relationship; paradoxically, also, an increased rate of divorce/separation# also seen)

Neurocognitive functioning: Improvement, including in memory and executive function

Sexual functioning: Usually postoperatively an improvement in sexual functioning of the patient is seen, however, it should be assessed for emergence of new symptoms

Re-emergence of psychiatric illness/symptoms: usually following 2–7 years after the surgery (BED, depression, suicidality, etc.), including disillusionment (loose skin, etc.)

Change in the pharmacology of the psychotropic medications: the transit time of drugs may be increased following sleeve-gastrectomy (leading to greater or lesser absorption of medications) or altered rate of absorption post-RYGB surgery (Li, SSRIs, SNRIs, etc.)

#Due to leaving old unsuccessful and maladaptive marriage upon gaining self-esteem postsurgery; ##After surgery secondary to dumping syndrome, etc., AUC, resulting in differential effectiveness and toxicity. AUC – Area under the curve; QoL – Quality of life; HR-QoL – Health-related quality of life; SSRIs – Selective serotonin reuptake inhibitor; SNRIs – Serotonin-non-epinephrine reuptake inhibitors; BED – Binge eating disorder; RYGB – Roux-en-Y-gastric bypass; Li - Lithium

Further, longitudinal studies suggest that individuals undergoing bariatric surgery have a higher risk of suicidality compared with patients who were provided treatment as usual or those treated with intensive LSMs.[16] The suggested reasons were unsatisfactory weight loss postsurgery, malabsorption of essential nutrients resulting in depression, impulsivity/intoxication due to altered pharmacokinetics (greater absorption of alcohol and other drugs) of substances, etc. Also, as postsurgery, the prevalence of indulgence in self-harm behaviors are higher than the general population, though this could be attributed to presurgical bio-psycho-social vulnerabilities of suicide and self-harm. Notably, the risk of suicide decreased postsurgery, at least in the initial 1 year, has been found to be lower than the presurgical period.[7]

Regarding SUDs, longitudinal studies have reported after RnYGB surgery among those with preexisting abnormal eating patterns (e.g., BED), there has been an increase in the prevalence of alcohol use disorders (addiction transfer-model), altered reward circuitry, and altered metabolism of alcohol.[17] Similarly, this altered reward model (though lacking empirical validation) could also result in an increased illicit substance use, and other SUDs with as high as 7.5% and 4.9% of participants reported incidents of SUDs within 5 years post-RYGB and postadjustable gastric banding, respectively.[7] This also holds for the overuse of opioid analgesics. Despite this, substance use and related problems postsurgery are often under-identified and undertreated. This warrants a more thorough assessment of substance use and related problems among the recipients of bariatric surgery.

Furthermore, LABS-2 study involving 1159 patients with 4–5 years of follow-up found that post gastric bypass, patients reported modest degrees of being bothered by excessive skin, primarily in their waist/abdomen, thighs, and chest/breasts body areas. Being female, young, and having severe obesity is associated with a higher level of dissatisfaction, perceived disfigurement, and depression postsurgery, which required out-of-pocket expenditure. Furthermore, hence, postsurgical psychological assessment, thus, intervention should aim to address this.

Post-surgery, peak improvements in HR-QoL outcomes were noted during the initial 1st year up, which is followed by a gradual decline till 5 years, at which it got stabilized, these findings have also been supported by a systematic review (involving 19 prospective cohort studies).[18] Nevertheless, HR-QoL remained improved relative to the preoperative QoL but remained below that of the general population. Similarly, longitudinal studies revealed that neurocognitive functions (memory, executive function) improved postsurgery.[1920]

Longitudinal studies, Swedish Obese Subjects, and the Scandinavian Obesity Surgery Registry revealed that bariatric surgery-induced weight loss is associated with a greater likelihood of change in relationship status. While a single individual opting for a marriage or a new relationship, married individuals experience an increased incidence of divorce and separation. Thus, patients may be counseled preoperatively and made aware of the potential relationships changes postsurgery and their impact on patient’s life.[21]

Similarly, pharmacokinetics of the psychotropic medications can significantly change postsurgery. For instance, the transit time of certain drugs may be increased following sleeve-gastrectomy (leading to greater or lesser absorption of medications) or altered rate of absorption of lLithium (increased dissolution of extended-release preparations of lithium and subsequent rapid absorption of the drug, resulting in Lithium toxicity), selective serotonin reuptake inhibitor (SSRIs), and serotonin-nonepinephrine reuptake inhibitors (SNRIs) post-RYGB surgery Altered Area Under the Curve for SSRIs and SNRIs.

To summarise, although current level of evidence does support the short-to-medium (up to 2 years) benefit in psychiatric outcomes postsurgery, there is no long-term benefits (2–7 years).

POSTSURGICAL PSYCHOLOGICAL EVALUATION OF RECIPIENTS OF BARIATRIC SURGERY

The goal is to assist recipients of bariatric surgery in their unique needs throughout the course (short as well as long-term) of recovery. However, there is no clear-cut guideline pertaining to postsurgical psychological assessment of recipients of bariatric surgery. Kinzel (2020) suggests that regular psychological sessions (such as change of self-esteem because of weight loss, problems in adopting new eating behaviors and the risk for developing a new eating disordered behavior, and problems involving adequate problem-solving) result in good postsurgical psychological and physical adjustments. However, this needs to be investigated in controlled trials.[22]

Similarly, there is randomized controlled trial (RCT) involving individuals undergoing LABG that suggest postsurgical assessment such as accurate case history, clinical examination, precise analysis of eating behaviors, and a psychological evaluation to assess the patient’s compliance after the operation including correcting compulsive eating habits, coping with the anxiety following surgery, etc., results in a good postsurgical outcome such increased weight loss, early and late complications, and lesser band calibrations and LABG inflation in weight.[23] Thus, the psychological assessment must be in place postsurgery to evaluate the recipients’ level of motivation and capability to adhere to the recommendations of the surgical team (avoiding compulsive eating, adhering to dietary and exercise regimen, etc). Furthermore, to cope up with the psychological (anxiety, relationship issues, dissatisfaction, less than desirable response to surgery, etc.) and physical challenges postsurgery (disfigurement) [Table 4].

Table 4

Postsurgical psychological assessment of recipients of bariatric surgery

Perception of the patients about outcome of the surgery: Patients’ perception about improvement in both physical (weight loss, eating pattern, etc.) and psychosocial (low mood, self-esteem, HRQoL, etc.) parameters following surgery, including level of satisfaction/dissatisfaction, and expected long-term outcome of surgery should be assessed

Status of presurgical psychiatric illness: The status of pre-surgical psychiatric issues (depression, BED, anxiety, personality issues, body-shape concerns, self-esteem, stigma, etc.) should be assessed

Attitude and motivation towards post-surgical treatment: Their attitude and motivation for the demands of postsurgical treatment and LSMs needs to be assessed

Dynamics of their relationship: The change in their relationship with spouse/partner and significant others and its influence on treatment adherence should be evaluated

Upcoming stressors: Job-related changes and possible future stressors should be assessed

Social support: Availability of current level of social support to meet the demands of treatment and daily life affairs should be assessed

Coping methods: Their coping methods for any upcoming stressors should be evaluated

Attitude and willingness to follow-up with the treating team: Their attitude and level of motivation to regularly meet the surgery team (including dietician, MHPs [particularly among those with pre-existing mental health concerns], etc.)

BED – Binge eating disorders; QoL – Quality of life; HR-QoL – Health-related quality of life; LSMs – Lifestyle modifications, MHPs – Mental health professionals

ASSOCIATION OF PRESURGICAL PSYCHO-SOCIAL CHARACTERISTICS OF THE INDIVIDUALS SEEKING BARIATRIC SURGERY AND POSTSURGICAL OUTCOMES

There is insufficient evidence to determine the relationship between preoperative mental health conditions and postoperative weight loss outcomes.[78] Systematic review and meta-analysis have shown that presurgical psychiatric illness/problems (depression, BED, suicide, CSA) have not been found to have any significant impact on postsurgical weight loss.[78]

INTERVENTIONS

Management of psychological problems among the individuals undergoing or undergone bariatric surgery involve lifestyle and behavioral modifications, nonpharmacological interventions, and pharmacological interventions in select group of patients.

Pharmacological interventions

It’s not uncommon for the obese patients to be considered for the bariatric surgery (and post-surgically as well) to suffer from clinical depression, anxiety, BED, impulsivity, or other psychiatric disorders. These illnesses could be an outcome of the obesity or comorbid with the obesity. Since psychotropic medications used to treat these conditions may worsen the obesity and associated medical comorbidities, they should be used only when required that too agents which are less likely to cause weight gain or metabolic syndrome. A detail about the choice of the drugs for various psychiatric disorders based on their propensity to cause metabolic or cardiovascular adverse effects have been tabulated in Table 5.[2425]

Table 5

Psychotropic medications and their propensity for weight gain, dyslipidaemia, diabetes mellitus, and hypertension

Drug category	Obesity	Dyslipidaemia	Diabetes	Hypertension
Antidepressants
Bupropion	-	- (if lead to weight loss)	?	+
SSRIs, SNRIs	?	?	-/0	0 (SSRIs)/+ (SNRI)
TCA, mirtazapine, paroxetine	+	0 to + (if lead to weight gain)	++ (TCAs)	+ (TCAs)
Anxiolytics
Paroxetine, TCA, mirtazapine	+	0 to + (if Lead to weight gain)	++ (TCAs)	++ (TCAs)
SSRIs, SNRIs	?	0	-/0	-/0
Buspirone, anti-adr., Benzodiazepines	0	0	0	0/- (anti-adr.) 0
Pregabalin	?	?	?	?
Mood stabilizer†
Lamotrigine/topiramate	-/0	?	0/-	0
Lithium, valproate	++	0 (valproate) to + (lithium)	0/- (lithium) to + (valproate)	0
Antipsychotics
SGA*	++ (quetiapine)	0 (aripiprazole) to + (quetiapine, risperidone, olanzapine)	0 (Aripiprazole)/+(quetiapine, risperidone)/+++ olanzapine, clz.)	0 to + (if weight gain)

References: Sadock BJ, Sadock VA, editors. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 10th ed. Philadelphia: Lippincott Williams & Wilkins; 2017. Mazereel V, Detraux J, Vancampfort D, van Winkel R, De Hert M. Impact of psychotropic medication effects on obesity and the metabolic syndrome in people with serious mental illness. Front Endocrinol 2020;11:573479. *Though SGAs are often used in varying dose as an augmenting agent for depression, as mood stabilizers, or as sedative; †Used in impulsivity. - – Reduction; 0 – No effect; + – Some effect; ++ – Moderate; +++ – Marked; ? – Uncertain/variable; Anti-adr. – Anti-adrenergic agent (e.g., propronalol); SGAs – Second generation anti-psychotics, cloz. – Clozapine; SSRIs – Selective serotonin reuptake inhibitors; SNRIs – Selective norepinephrine reuptake inhibitors; TCAs – Tricyclic antidepressants

Management of depression

It is recommended that individuals with mild-to-moderate depression to be primarily managed with the nonpharmacological interventions such as interpersonal therapy, CBT, supportive therapy, etc., particularly, when there are significant psycho-social stressors, intrapsychic conflicts, or interpersonal difficulties.[26] However, antidepressants may be used as an initial treatment strategy in mild, moderate, and often, severe depression, especially when there is the history of prior positive response to antidepressant medication, presence of severe symptoms, significant sleep and appetite disturbances, agitation, or anticipation of the need for maintenance therapy. Patients with severe depression with psychotic features will require the use of combination of antidepressant and antipsychotic medication and/or ECT. The choice of the medications is determined by the severity of the depression, safety profile of the medications and tolerability [Table 5].

Management of anxiety disorders

Likewise of depression, obese patients with mild-to-moderate level of anxiety disorders (generalized anxiety disorders, panic disorders, phobia, obsessive–compulsive disorders, etc.) should be managed with the nonpharmacological interventions such as relaxation exercises (Jacobson’s progressive muscle relaxation, behavioral therapy, biofeedback, etc.), CBT, systematic desensitization methods, etc. Anti-anxiety medications, however, are indicated when the anxiety disorders are severe, previous history of response to medication, presence of significant vegetative or autonomic symptoms, incomplete remission with the nonpharmacological interventions. The choice of anxiolytics should be based on relative propensity of these agents to alter the metabolic profile and weight of the individuals [Table 5].

Management of the binge-eating disorders

The BEDs often are comorbid with the depression, OCD, impulse control disorders, etc. The management of the BED involves a multi-pronged approach that includes nutritional rehabilitation and counseling, psychosocial interventions (motivational interviewing, CBT, IPT. etc.), and medications. The drugs that have been found to be effective are (1) antidepressants like SSRIs (higher than those used for depression, e.g., fluoxetine 60 mg/day; Sertraline has also found to be effective) however TCAs and MAOIs should be avoided, (2) anti-convulsant (topiramate; lamotrigine, and Zonisamide for impulsivity; etc.), when other drugs are ineffective. On contrast, mood-stabilizers such as lithium and valproate to be avoided for it can cause significant weight gain [Table 5].[27]

Pre-operative Lifestyle Modification Programmes and Behavioural Interventions

It seems prudent that multi-disciplinary team involved in care of person with obesity being considered for bariatric surgery to emphasize or work on with the patients on behavioural and LSMs. Such structured lifestyle programme can sensitise the patients about the need of benefit of maintaining a regular dietary and exercise regime apart from positive impact of a general wellbeing that such practices bring about both pre-and post-operatively.[28] It must be also highlighted here that mandatory putting a patient on LSMs program before surgery or deeming it as an eligible criterion for surgery does not result in better pre-or post-surgical outcomes rather can lead to poorer outcome secondary to delay in getting the surgery, perceived stigma or feeling of being prejudiced, greater medical complications, etc.[29] Thus, the purpose of the LSMs should be to empower them so that a favorable lifestyle changes so developed could ensure maintenance of a good physical (diet, activity, etc.) and psychological wellbeing (motivation, self-efficacy, etc.) postsurgery.

Psychological interventions

Psychological interventions are often indicated to address the psychosocial issues of patients being considered or have received surgery. Various evidence-based psychological interventions that improve postsurgical psychological and physical outcomes have been described below:

Presurgical psychological interventions

Pre-surgical psychological interventions have been found to improve patients’ surgical outcomes, including postsurgical physical and psychological adjustments. Presurgical nonpharmacological (and pharmacological interventions, when required) have been shown to improve both the physical (weight loss, physical activity) and psychosocial outcomes of the bariatric surgery, especially in the initial period, however, this improvement does not differ significantly after 1–2 years (vs. no psychological intervention presurgically).[30]

Brief supportive psychotherapy (BSP) has been shown to improve postsurgical physical and psychological outcome of the individuals undergoing BS. For instance, Caniato and Skorjanec conducted an RCT involving at risk-individuals (with binge eating pattern, depression) undergoing laparoscopic adjustable gastric. Here, the intervention arm (n = 152) received 10 sessions of BST aiming to address cyclical reaction pattern responsible for maintenance of a problem (binge eating pattern, depression, etc.) and focuses on changing the patient’s perception of his or her experience rather than on altering the experience. While the control arm received usual care (n = 385). Participants were assessed on their weight loss and health status (objective parameters) and QoL and self-perception (Moorehead-Ardelt Quality of Life Questionnaire) both on short-(at 1 year) and long-term basis (>2 year). They found that those who received BST preoperatively had significantly higher weight loss (46% excess weight loss [EWL]) at 1 year compared to those received usual care (40% EWL). A trend that followed on long-term basis as well, though this difference was not statistically significant. Furthermore, their QOL improved over time (both objectively and subjectively). The authors posited that preoperative BST gives a satisfactory result. They concluded that good compliance preoperatively corrected their eating habits that was maintained over years and was a good predictor of better long-term success.[30] Though better long-term data is still required.

A graphical depiction of presurgical psychological assessment and targeted intervention has been provided in Figure 1.

Figure 1

Flowchart depicting the presurgical assessment psychological assessment of the individuals undergoing bariatric surgery and potential intervention

Postsurgical interventions

Likewise of the presurgical lifestyle and dietary modifications, postsurgical lifestyle and dietary modifications pay a huge dividend in long run, particularly those with history of BED or poor affective regulation.[29] The interventions should aim at promoting healthy eating pattern (chewing well, taking small bites, stop eating when first sense of the abdominal fullness appears, avoid in-between foods, not using food as a coping method for negative affective state, etc.) and regular physical activity (regular and scheduled exercise, etc.). These LSMs or behavioural interventions should also target various psycho-social aspects individuals who underwent bariatric surgery.[2931]

The postsurgical phases have been categorized postsurgical physical Adjustment (up to 6 months postsurgery), postsurgical psychological adjustments (>6 months through 18 months), and long-term maintenance.[11] A graphical representation for the same postsurgical assessment and interventions have been shown in Figure 2.

Figure 2

Post Surgical evaluation for psychological adjustments, motivation to comply with the treatment regime, including lifestyle changes required, and evaluation of presurgical psychological issues

Postsurgical psychological interventions

Stigma and a strong sense of failure often prevent patients from seeking a MHP consultation promptly. Thus, depriving them of the necessary psychological support. It’s interesting to know that as compared presurgical period, significantly greater proportion of the recipients of surgery expressed willingness to undergo postsurgical psychological sessions.[22] Literature also suggests that a regular visit to a psychologist for behavioral interventions and CBT techniques (vs. not following up in the such programs) results in greater improvement in various domains of MMPI. It needs to be highlighted here that although postsurgical psychological interventions do improve the physical health and mental health outcomes postsurgery, including coping skills for self-nurturance, on a short-term basis (1–2 years), these improvements often do not persist beyond 2–3 years.[1032]

Psychological intervention in the postsurgery physical adjustment stage

This phase is also referred to as the honeymoon phase and is characterized by a rapid weight loss and elated mood. However, some individuals still face difficulties in making alterations in their patterns of eating and may experience food cravings, or anticipatory anxiety (regarding vomiting or plugging), among a variety of other issues. Interventions directed at correcting these problems can aid to adjust to the physical manifestations of surgery.[3334] Similarly, desensitization and exposure and response prevention should be used as well as supportive therapy to allay their anxiety concerning the postmeal adverse physical problems and anxiety.

For instance, an RCT involving 17 participants (intervention arm vs. 15 participants receiving minimal intervention [control arm]) who received behavioural intervention (monthly behavioral consultations and biweekly weight management materials for 6 months) reported a significant improvement in postoperative physical and psychosocial functioning (family and marital life, activity) and eating behaviour (consuming less fat and protein) vis-à-vis’ minimal intervention group. However, the difference was not significant in terms of postsurgical weight loss (both groups reported a significant weight loss at 1 year). Authors concluded that such behavioural interventions enhance postsurgical behavioural and lifestyle adjustments; though the findings were limited by the small sample size of the study.[35]

The Compulsive Eater’s Program for Gastric Bypass Patients is another CBT-based program (where participants were provided with the reading materials, eating diary maintenance, forum to discuss their feelings, identifying and managing urges, self-esteem, change in body-image).[32] A pre-post study design involving patients with full or subthreshold BED 2-6 mth after surgery who were deliver CBT in group setting (participants met every week for 12 weeks and subsequently, on monthly basis (in groups or individually) and assessed on Beck’s depression inventory, BED scale, Questionnaire on Eating and Weight Patterns, reported the intervention had a positive impact on the patients’ understanding and awareness of problems. It also helped them develop alternative coping strategies and means of self-nurturance. However, in the absence of the control arm, the study findings need further exploration.

Although psychological interventions are promising strategies to address the psychosocial adjustments of the recipients of the surgery, including their adherence to the exercise regime and behvaioral modifications, it may not be logistically feasible to provide psychological assistance to all the patients, thus, at-risk individuals or those flagged in the preoperative period should be regularly assessed (educating them about early signs/symptoms, this would facilitate early detection of psychological problems and prompt intervention) and, if required, provided with the regular sessions (CBT and inter-personal therapy style). Similarly, new role or relationship adjustments can also bring about significant stress for the patients as well as their family members; likewise, increased self-esteem and functioning may affect their family/marital dynamics. Thus, joint counseling would be helpful to address this issue.

Psychological intervention during the maintenance stage

The role of psychological interventions cannot be overemphasized at this stage. As the effect of the surgery wanes off after about 1–2 years, the previous psychological problems (falling into the old pattern of eating, depression, low self-esteem, etc.) and new issues (loose-skins, cope up with the regain in weight, relationship issues, etc.) emerges. Therefore, psychological interventions aiming at correcting distorted cognitive patterns, poor coping methods, disillusionment, etc., would be useful.[3637]

For instance, Kalarchian and Marcus highlighted that a “comprehensive” approach to treatment during this phase should focus on healthy eating habits, disordered eating patterns, and increased physical activity. Relapse prevention therapy targeting at high-risk situations (for maladaptive eating pattern, low-mood, stress, etc.) and a list of warning signs (missing follow-up visits, not complying with the dietary or exercise regime, reappearance of inter-personal issues, etc.) that serve to forewarn the individual that difficulties may lay ahead are also useful strategy.[31]

To summarize, psychological interventions are useful approach to manage the psychosocial problems among the recipients of surgery. Although the improvement is greatest initially postadjustments periods (6 m-2 years postsurgery).

RECOMMENDATIONS

Based on the available literature and level of evidence, we recommend that individuals being assessed for bariatric surgery or prospective recipient of the surgery should undergo a formal psychological assessment by a psychiatrist. The assessment should have a decisive role on the surgery. It may include more detailed evaluation, need for regular monitoring, pharmacological or nonpharmacological intervention. Similarly, all patients who have undergone surgery should be evaluated postsurgery for their psychological adjustments, motivation to comply with the treatment regime, including lifestyle changes required, and evaluation presurgical psychological issues, if any [Figure 2].

This CPG can help surgical team in a comprehensive assessment of the individuals being planned for the bariatric surgery. A proper psychological assessment can help in better postsurgical outcomes, both physical and psychological. However, this guideline can be tailored according to the needs of the Indian patients and the health infrastructure of the country. The detail recommendations have been elaborated in Table 6.

Table 6

Recommendation and clinical practice guideline pertaining to psychological assessment and interventions for individuals seeking bariatric surgery or recipients of bariatric surgery

Domains of psychological evaluation and management	Recommendations
Structure of the multi-disciplinary team involved in bariatric surgery	Apart from surgeons, nutritionist, physical medicine expert, endocrinologist, nursing staff/counsellor, a MHP (a psychiatrist or psychologist) should be the part of the team. This would ensure a comprehensive assessment and care
Participant’s selection	Basic psychological assessment in all the individuals seeking bariatric surgery in a nonjudgemental and nonstigmatized manner with the goal to identify at-risk individuals (flagging)
	More detailed structured interviews for individuals who are at risk of developing psychological problems after the surgery
	To delay or refuse surgery for individuals who are actively suicidal, severely depressed, actively psychotic, ongoing substance use disorders, mental retardation, or dementia, etc.
Presurgical psychological assessment	A detailed semi-structured interview lasting for 30–45 min
	Use of interview schedule (like Boston or PsyBari schedule)
	Use of instruments validated in Indian population for assessment (Binge eating evaluation scale, PHQ-9, GAD-7, MMSE, MMPI, stress coping behavior scale or proactive coping inventory proactive coping, WHO-QOL-BREF, etc.)
	Assessing the level of motivation for the surgery and post-surgical recommendations (exercise, eating pattern, follow-ups)
	MHP should have decisive role in fitness for surgery based on the psychological status of the individual’s seeking surgery
Postsurgical psychological assessment	To assess the changed relationship, upcoming stressors, disillusionment, anticipatory anxiety, maladaptive coping skills, re-appearance of abnormal binge eating pattern, worsening of depression, sexual functioning, physical activity, etc.
Psychological interventions	Presurgical: Motivational interviewing to improve the motivation of the prospective recipients of surgery for taking nonsurgical measures (adaptive eating pattern, exercise, stress management, etc.) Also, moderating the level of expectation from the surgery and potential roadblocks
	Group therapy: Psychoeducation about the surgery, mutual sharing of emotions, their attitude towards obesity and bariatric surgery, and learning from the experiences of others.
	Brief-strategy CBT
	Postsurgical: CBT, behavioral interventions (for more adaptive eating patterns, regular exercises, stress management), relapse prevention strategies (cue-induced abnormal eating pattern), inter-personal therapy (to deal with the relationship issues), and family counseling
	A multi-disciplinary comprehensive program when there are interrelated problems (psychological maladjustment, indulgence in old eating habits, nonadherence to exercise, and follow-ups)
Training	Psychiatry-trainees (including psychiatric nurses, psychologists, etc.) to be trained in MH aspects of obesity and bariatric surgery
	Curriculum on bariatric surgery under the consultation-liaison programme
	Development and validation of psychological assessment and management protocol for Indian population seeking bariatric surgery
	Research on the epidemiology and determinants of MH problems in those suffering from obesity and seeking BS
	Further, culture-specific psychological interventions are feasible in the Indian health system

BS – Bariatric surgery; MH – Mental health; MHP – Mental health professional; MMSE – Mini-mental state examination; MMPI – Minnesota multiphasic personality inventory; QoL – Quality of life; WHO-QoL-Bref – WHO-QoL-brief scale; PHQ-9: The Patient Health Questionnaire-9; GAD-7: Generalized Anxiety Disorder-7; CBT- Cognitive Behavioral Therapy

CONCLUSION

Psychological problems are common among the obese individuals and those seeking bariatric surgery. Psychological problems are the result of the obesity rather than a cause for it. Bariatric surgery apart from bringing about an improvement in obesity and medical complications, results in improvement in psychological outcomes of the patients (such as depression, BEDs, low-self-esteem, HRQoL, etc.). In contrast, presurgical mental illness does not predict postsurgical weight loss, though they worsen most-surgical functioning. Therefore, pre-, and post-surgical psychological interventions form an important part of medical care for individuals undergoing bariatric surgery. Psychological interventions (CBT, behavioral interventions, multi-model comprehensive program, etc.) improve in binge eating pattern, HRQoL, weight loss, however, these effects persist on short-to-medium term basis only. MHPs have a major role to play in the decision-making for the surgery and medical care of individuals seeking bariatric surgery or recipients of surgery. This CPG adds to limited to the bariatric surgery and mental health from India. The guideline can help in developing protocol in psychological assessment and management of individuals seeking bariatric surgery. More research is required from India, particularly those pertain to the culture-specific interventions and tailored to health infrastructure.

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Conflicts of interest

There are no conflicts of interest