July 13, 2015/Digestive

Managing Psychosocial Risk Factors in Bariatric Surgery Patients

Mental health professionals are a key part of the team


By Leslie J. Heinberg, PhD


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Bariatric surgery is considered the most effective treatment for severe obesity (defined as body mass index ≥ 40 kg/m²), resulting in average weight loss of 35 percent of initial body weight as well as marked reductions in multiple medical comorbidities.1

However, unlike many other common surgeries, bariatric surgery is closely linked to behavior and psychosocial factors. Eating and exercise behaviors as well as psychological and social factors may have caused, exacerbated or maintained the severe obesity. Further, bariatric surgery candidates are a psychiatrically vulnerable population with a high level of psychiatric and psychosocial comorbidity.2-3

Mental Health a Key Component of Bariatric Surgery Assessment

Although surgery results in significant anatomical alterations, long-term success requires significant behavioral change and necessitates that individuals adhere to permanent lifestyle alterations in diet and exercise as well as reduce reliance on food to cope with life stressors. Because of these factors, mental health professionals are an essential component of the multidisciplinary assessment and treatment team at most bariatric surgery treatment centers.4

A behavioral health team of psychologists is fully integrated into the multidisciplinary care and research at Cleveland Clinic’s Bariatric and Metabolic Institute. We continue to focus our work on how to better identify, treat and manage psychosocial risk factors that may impede optimal success with surgery. The following reflects some of the research being conducted by our behavioral health team:

  • Binge eating disorder (BED) was recently included in the DSM-5.5 The lifetime prevalence rate for BED using the DSM-IV-TR6 research criteria tended to be higher in bariatric surgery candidates than in the normative population; however, studies had not examined how many more bariatric surgery candidates will meet the new, less conservative criteria of DSM-5, which lowered both frequency and duration of binge eating that qualifies as a disorder. We obtained data from 1,326 bariatric surgery candidates. Of those patients, 297 (22.4 percent) were diagnosed with current BED using DSM-IV-TR research criteria. Only a slightly greater percentage (an additional 3.43 percent) of bariatric surgery candidates met the diagnostic threshold for BED when using DSM-5 criteria. These individuals were demographically similar and produced similar psychological testing profiles when compared with patients who met DSM-IV-TR criteria.7
  • Recent research has demonstrated clinically significant cognitive impairment is present in as many as 23 percent of bariatric surgery patients and that preoperative impairments predict weight loss outcomes at one year. We examined whether such impairments could contribute to poorer adherence. Cognitive testing and a self-report measure of adherence to postoperative bariatric guidelines were completed during a four- to six-week postoperative appointment for 37 patients who had undergone laparoscopic Roux-en-Y gastric bypass surgery. Rates of nonadherence were high, ranging from 24.3 to 78.4 percent, depending on the recommendation. Strong correlations were observed between adherence to postoperative guidelines for physical activity, protein and vitamin intake, and cognitive measures of attention, executive function and memory.8
  • Psychological evaluation of bariatric surgery candidates often includes standardized psychological testing. Preoperative scores on the Minnesota Multiphasic Personality Inventory-2-Restructured Form were examined in the context of self-reported difficulties and behaviors at one month (N = 591) and three months (N = 329) postsurgery.9 Scores on subscales measuring somatization and somatic concerns were related to greater somatic problems at both one and three months following surgery (e.g., excessive pain and nausea). Scores on internalizing emotional disorders (e.g., anxiety, demoralization) predicted psychological distress (e.g., grieving the loss of food) and three-month maladaptive eating (e.g., graze eating). Subscales measuring externalizing behaviors (e.g., impulsivity and disinhibition) also were related to maladaptive eating at three months. This suggests the importance of early identification of patients who may have complications shortly after weight loss surgery.


Bariatric behavioral health is a relatively new specialty but is likely to continue to grow as the obesity epidemic continues. Our collaborative, multidisciplinary team affords us the opportunity to investigate and treat psychosocial factors in order to optimize outcomes for our patients.


Leslie J. Heinberg, PhD, is Director of Behavioral Services for Cleveland Clinic’s Bariatric and Metabolic Institute and Professor of Medicine at Cleveland Clinic Lerner College of Medicine.


1 Buchwald H, Oien DM. Metabolic/bariatric surgery Worldwide 2008. Obes Surg. 2009 Dec;19(12):1605-1611.

2 Kalarchian MA, Marcus MD, Levine MD, Courcoulas AP, Pilkonis PA, Ringham RM, et al. Psychiatric disorders among bariatric surgery candidates: relationship to obesity and functional health status. Am J Psychiatry. 2007 Feb;164(2):328-334.

3 Mitchell JE, Selzer F, Kalarchian MA, Devlin MJ, Strain GW, Elder KA, et al. Psychopathology before surgery in the longitudinal assessment of bariatric surgery-3 (LABS-3) psychosocial study. Surg Obes Relat Dis. 2012 Sep;8(5):533-534.

4 Walfish S, Vance D, Fabricatore AN. Psychological evaluation of bariatric surgery applicants: procedures and reasons for delay or denial of surgery. Obes Surg. 2007 Dec;17(12):1578-1583.

5 American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.


6 American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed., text rev. ed. Washington, D.C.: American Psychiatric Publishing; 2000.

7 Marek RJ, Ben-Porath YS, Ashton K, Heinberg LJ. Impact of using DSM-5 criteria for diagnosing binge eating disorder in bariatric surgery candidates: Change in prevalence rate, demographic characteristics, and scores on the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF). Int J Eat Dis. In press.

8 Spitznagel MB, Galioto R, Limbach K, Gunstad J, Heinberg LJ. Cognitive function is linked to adherence to bariatric postoperative guidelines. Surg Obes Relat Dis. 2013; 9:580-585.

9 Marek RJ, Ben-Porath YS, Merrell J, Ashton K, Heinberg LJ. Predicting one and three month postoperative somatic concerns, psychological distress, and maladaptive eating behaviors in bariatric surgery candidates with the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF). Obes Surg. In press.

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