Decreasing readmission through psychological evaluation and treatment

Extreme obesity is accompanied by a substantial psychosocial burden. According to 6 of the highest quality studies completed to date, between 21–56% of individuals who present for bariatric surgery are suffering from psychiatric illness [1–6]. The most common diagnoses are the mood disorders, seen in up to 32% of patients. Up to 73% of candidates for surgery have a lifetime history of psychiatric illness; one third have been found to have a history of substance abuse [1–6]. Furthermore, between 16% and 39% report that they are engaged in mental health treatment at the time they present for bariatric surgery [7–9]. For these reasons, as well as others, the Guidelines for Clinical Practice for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient recommend that patients considered for bariatric surgery with a known or suspected psychiatric illness should undergo a formal mental health evaluation before surgery [10] .T hus, it is not surprising that most bariatric surgery programs and third-party payors in the United States require a psychological evaluation of patients before surgery. These evaluations provide an opportunity screen for the presence of psychopathology that may contraindicate surgery (i.e., severe, uncontrolled depression, active thought disorder or substance abuse) as well as identify psychosocial issues and behaviors that may threaten optimal postoperative outcomes [11]. There are a number of hypothesized behavioral predictors of poor postoperative outcomes [12]. The presence of any psychiatric diagnosis is perhaps the most relevant. The literature on the relationship between preoperative psychosocial status and postoperative weight loss is inconclusive, as many studies of this issue have used substandard methodologies [12]. However, 2 recent studies of high quality have found that patients with preexisting psychopathology experience smaller weight losses postoperatively [13,14]. Another potential predictor of poor postoperative outcomes is the presence of disordered eating before surgery. Approximately 5% of candidates for bariatric surgery suffer from binge eating disorder (BED) [15,16], which is defined as recurring episodes of eating significantly more food in a short period of time than most people would eat under similar circumstances, with episodes marked by feelings of lack of control. The binge episodes are associated with marked distress and occur, on average, at least once a week over 3 months [17]. Many more patients present with features of the disorder but do not meet the full diagnostic criteria; others present with disorganized, if not chaotic, eating behavior. The presence of BED before surgery has been associated with smaller postoperative weight losses within the first 2 years of surgery in some[18,19], but not all, studies [20]. After surgery, most patients report that they can no longer eat excessively large amounts of food necessary for the diagnosis of BED. However, a substantial percentage reports a loss of control over their eating behavior consistent with the diagnosis. An inability to control eating behavior after surgery, or difficulties adhering to the recommended postoperative diet, has been associated with smaller postoperative weight losses within the first 2 postoperative years [21,22] .T hey likely contribute to substantial weight regain and the desire for revision procedures years later in many patients. Anecdotally, these eating behaviors also have been associated with gastrointestinal events/complications, some of which may lead to readmission. A substantial minority of patients report continued issues with vomiting with the first 15 years after surgery