"There is a real need for psychological interventions for these folks who are dramatically increasing in number and who undergo major life changes," says psychologist Marsha Marcus, PhD, chief of eating disorders and behavioral medicine at the University of Pittsburgh's Western Psychiatric Institute and Clinic. "There are different demands on people and different requirements in the presurgery period. How do you make the decision to proceed?"

Then there are the unique demands and requirements of the postsurgery period, notes Marcus, co-author of "Management of the bariatric surgery patient: Is there a role for the cognitive behavior therapist?" with colleague Melissa Kalarchian, PhD, in Cognitive & Behavioral Practice (Vol. 10, No. 2).

"You have to change your eating and your exercise, and you require medical monitoring forever," she explains. "People may need help in doing this."

As an indicator of their need for help, available literature suggests that about one-fifth of surgery patients do not meet their weight-loss goals and some even regain a significant amount of weight.

Luckily, some surgical patients have found help with Daniel Kirschenbaum, PhD, director of the Center for Behavioral Medicine and Sport Psychology in Chicago. Using a cognitive-behavioral approach that emphasizes self-monitoring (see main article), Kirschenbaum recommends surgery for some of his clients.

"Surgery is appropriate for anyone who is a couple hundred pounds overweight and who doesn't respond to the best available treatment," says Kirschenbaum. "It's a relatively urgent matter for someone that big."

Kirschenbaum emphasizes, however, that surgery alone is never enough. He estimates that those who continue self-monitoring after surgery "do way better than the average result that you can see in the literature from just the surgery alone."

One of Kirschenbaum's surgical clients dropped from 400 pounds to 270 pounds in less than a year. "The average results for someone like him," Kirschenbaum says, "is that he would have been expected to stall out in the 300s. But he's just zooming past that" by continuing to walk 12,000 steps a day and eat a low-fat diet.

More surgical procedures are being added to an already populated field that includes the Roux-en-Y gastric bypass, gastric banding, biliopancreatic diversion, gastroplasty and, recently, an implantable gastric stimulator, a kind of pacemaker for the stomach.

As part of that expansion, "Psychologists have been very active in screening, but there's been less systematic research," Marcus says. "Research in general is starting in this field." For example, the National Institutes of Health, he says, recently funded the first multisite trial to study the impact of surgery.

--L.E. RICH