{"paper_id":"2117d24a-0b26-4bad-8328-c68916e7d60f","body_text":"Exploring Optimal Cut-Offs of the MMPI-3 Substance Use Scale in Patients Seeking Metabolic and Bariatric Surgery | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Exploring Optimal Cut-Offs of the MMPI-3 Substance Use Scale in Patients Seeking Metabolic and Bariatric Surgery Lauren K. Allen, Haley E. Cook, Ashleigh A. Pona, Yossef S. Ben-Porath, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7609287/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 05 Dec, 2025 Read the published version in Obesity Surgery → Version 1 posted 7 You are reading this latest preprint version Abstract Introduction: Patients seeking metabolic and bariatric surgery (MBS) complete presurgical psychological assessments to identify potential factors that may impede surgical outcomes. Presurgical psychological assessments often screen for alcohol and substance use disorders and the Minnesota Multiphasic Personality Inventory – 3 (MMPI-3) is well suited to assess for problematic alcohol or substance use. Given the potential negative health outcomes associated with problematic alcohol/substance use in patients undergoing MBS, the recommended T-score cutoff of 65T or higher may not be optimal for identifying MBS candidates at a greater likelihood of clinically elevated symptomology – especially given its face validity. The purpose of the present study was to optimize the use and accuracy of the MMPI-3 Substance Use (SUB) scale for use with patients undergoing MBS. Method A sample of 1,257 participants from an academic medical center in the Midwest seeking MBS who produced a valid MMPI-3 protocol and had a retrospective chart review coded were included in the present study. Relative risk ratios (RRRs) were calculated to quantify the likelihood of various alcohol/substance use criteria being present at various MMPI-3 SUB scale score cut-offs. Results Optimal T-score cutoffs on the SUB scale ranged between 52T-58T, with 54 as the most commonly identified cutoff score that yielded the highest relative risk for problematic alcohol/substance use. Conclusions The recommended interpretation of the SUB scale at 54T would allow clinicians to more optimally capture those with current/past alcohol/substance problems and provide them with the appropriate pre/post-operative care if needed. Bariatric substance use MMPI Key Points • The MMPI-3 can effectively screen for substance use problems in MBS. • A lower T-score cut-off for interpretation is necessary for the SUB scale in MBS samples. • A T-score of 54T more appropriately captured problematic alcohol/substance use. Introduction Patients seeking metabolic and bariatric surgery (MBS) complete presurgical psychological assessments to identify potential factors that may impede surgical outcomes. 1 Presurgical psychological assessments assess environmental, familial, and behavioral factors including weight history, eating disorder history, cognitive functioning, available social support, and motivation for weight loss [ 2 – 4 ]. These factors have the potential to affect outcomes of MBS surgery, including emotional adjustment, adherence to the recommended postoperative lifestyle regimen, weight loss outcomes, and comorbidity treatment [ 3 , 4 ]. Rates of psychopathology are high in persons undergoing MBS, with major depression disorder, binge eating disorder, and alcohol use disorders being particularly common [ 5 , 6 ]. By identifying these psychosocial problems through presurgical psychological assessment, behavioral health professionals work to inform the treatment team of potential negative surgical outcomes to determine appropriate pre- and/or postoperative care [ 4 ]. Problematic alcohol/substance use could cause many negative health outcomes in patients undergoing MBS. Specifically, the prevalence of alcohol use disorder (AUD) has been found to rise in the second-year post MBS with one-fifth of participants reporting AUD symptoms within 5 years post-operation [ 7 , 8 ]. Studies related to alcohol following MBS imply that participants have experienced heightened subjective sensitivity to alcohol due to the change in rate of alcohol absorption through the body. Alcohol dehydrogenase, the stomach enzyme that breaks down alcohol, is reduced post-surgery. This enzyme reduction in combination with smaller stomach capacity results in alcohol content reaching the bloodstream faster and increased blood alcohol content overall. Increased blood alcohol content poses increased risks of alcohol related effects like impaired driving as well as increased likelihood of developing alcohol use disorder. [ 9 , 10 ] Additionally, prescription opioid use has been found to increase past baseline prevalence post-operation.[ 11 ] Finally, smoking is associated with multiple post-operative problems including 30-day morbidity/mortality, pulmonary complications, and marginal ulceration.[ 12 ] Smoking is an independent risk factor for short-term complications like post-operative pneumonia, failure to wean from ventilator, and reintubation.[ 13 , 14 ] Additionally, smoking is also associated with long-term complications such as persistent or recurrent marginal ulceration and bone fracture.[ 12 ] Presurgical psychological assessments often screen for alcohol and substance use disorders. The Minnesota Multiphasic Personality Inventory (MMPI-3; Ben-Porath & Tellegen, 2020) is a commonly used broadband measure that assesses not only alcohol/substance use, but also other behavioral factors associated with substance use (e.g., antisocial tendencies, disinhibition). Because the test is broadband, it also assesses various other domains associated with depression, anxiety, and eating disorder pathology among others. The MMPI-3 is a useful component of presurgical psychological assessment because it provides more objective, comprehensive data that may not be derived otherwise through the use of a clinical interview (Pona et al., 2022). The scale scores on the MMPI-3 produce good reliability and good convergent/discriminant validity in MBS settings (Marek et al., 2024; Pona et al., 2022). The MMPI-3 provides clinical utility through more objective, comprehensive data that may not otherwise be gleaned from a self-report clinical interview. Median Cronbach’s alpha estimates for each subscale have been found to range between 0.72 and 0.80 and mean inter-item correlations between 0.13 and 0.27. Additionally, validity analyses have exemplified significant associations between most MMPI-3 subscales and the Patient Health Questionnaire-9, General Anxiety Disorder-7, the Eating Disorder Examination-Questionnaire, the Alcohol Use Identification Test-C (AUDIT-C) and various external criteria such as diagnoses, abuse history, and suicide history, among others.[ 15 , 16 ] The MMPI-3 is validated for use in the assessment of patients seeking MBS and contains a specific Substance Abuse (SUB) scale that is capable of accurately assessing for past or current alcohol/substance use. The SUB scale utilizes cutoff scores to help identify those with substance use-related factors and inform treatment recommendations for those individuals. Identifying individuals at a greater likelihood of problematic alcohol/substance use helps predict their ability to adhere to post-surgery protocols and therefore improve their treatment outcomes. Past research using two samples of patients seeking MBS implied that the interpretation of the SUB scale on the MMPI-2-RF of 65T ought to be reconsided.[ 17 ] The data across these two samples suggested that SUB was better interpreted at a T-score of 55 instead of the traditional 65T. The update from the MMPI-2-RF to the MMPI-3 included updated (and new) item content and updated test norms.[ 18 , 19 ] Due to these changes, it is necessary to investigate whether the MMPI-3 version of the SUB Specific Problems Scale would also benefit from being interpreted at lower T-score cutoffs within the MBS population. The current recommended T-score cutoff for the MMPI-3 SUB scale is a score of 65 or higher (Ben-Porath & Tellegen, 2020). Given the potential negative health outcomes associated with problematic substance use in patients undergoing MBS, the recommended T-score cutoff of 65 or higher may not be optimal for identifying MBS candidates at a greater likelihood of problematic alcohol/substance use based off prior research with the MMPI-2-RF.[ 17 ] Interpretating the SUB scale score on the MMPI-2-RF at 55T better identified patients who were engaging in problematic substance use. Thus, this study aims to examine whether lower T-score cutoffs for the MMPI-3 SUB scale improve clinicians’ ability to identify MBS patients at a greater likelihood of alcohol/substance use. The purpose of the present study was to optimize the use and accuracy of the MMPI-3 SUB scale for use with patients undergoing MBS. Alternative SUB cutoffs were examined in the present study using a large sample of MBS candidates. We hypothesized, based on previous findings with the MMPI-2-RF, that the generally recommended T-score cutoff of 65 on the MMPI-3 SUB scale would not optimally identify, or identify as accurately and effectively as possible, patients at a greater likelihood of problematic alcohol or substance use in the assessment of patients seeking MBS and that, instead, a lower T-score cutoff would provide better clinical utility. Method Participants Participants (N = 1,283) were recruited from a Midwestern Academic Medical Center. A total of 26 participants were excluded due to having an invalid MMPI-3 profile. The final sample included in analyses comprised of 1,257 participants. Participants’ ages ranged from 18 to 77, with a mean age of 42.2 years old ( SD = 11.1). Of the sample, 78.5% identified as women. Approximately 65.8% of the sample identified as White, 27.4% of the sample identified as Black or African American, and 6.8% identified as another race. The average presurgical Body Mass Index (BMI) was 50.58 kg/m 2 (SD = 10.70). Retrospective chart review to gather data for the study was approved by the third author’s Institutional Review Board. Measures Minnesota Multiphasic Personality Inventory – 3 (MMPI-3). [ 18 , 19 ] The MMPI-3 contains 335 true/false items that are scored across 10 validity scales and 42 substantive scales. As previously stated, scale scores on the MMPI-3 produce good reliability and convergent/discriminant validity in MBS settings.[ 15 , 16 ] Only the MMPI-3 SUB scale was examined in this study. The MMPI-3 SUB scale consists of item content related to history/current alcohol/substance use, frequency of alcohol/substance use, inappropriate use of prescription medication, and using alcohol/substances to cope and relax. T-scores on the MMPI-3 SUB scale can range from 39T to 86T with clinically elevated scores at 65T and higher. Raw scores are calculated into uniform T-Scores. Alcohol Use Disorders Identification Test-Consumption (AUDIT-C). [ 20 ] The AUDIT-C is a modified version of the Alcohol Use Disorders Identification Test (AUDIT). The AUDIT-C is a shorter validated instrument that measures alcohol consumption in the past 12 months using 3 items intended to screen for harmful alcohol use. AUDIT-C scores range from 0 to 12 with a score of ≥ 4 for men and of ≥ 3 for women indicating positive for hazardous alcohol use or an active alcohol use disorder. Cronbach’s alpha for the AUDIT-C in the current sample was .49, likely owing to limited variability and small item count for the scale. The mean inter-item correlation was .36 indicating good reliability. Clinical Criteria . A range of substance use criteria were coded from patients’ medical charts. These included whether or not alcohol/substance was currently (within the last month) being used (yes/no) or if there was a history (longer than a month ago) of alcohol/substance, whether or not the current/past alcohol/substance use was problematic (yes/no), or if they met criteria for a current/historic alcohol/substance use disorder based on Diagnostic and Statistical Manual for Mental Disorders – 5 – Text Revision (DSM-5-TR)[ 21 ] criteria. Only criteria that had positive endorsement were included. For example, no one in the sample reported currently abusing opioids and thus was not included in the analysis. Procedure The study design was cross-sectional in nature and a large, retrospective database was used. Data were collected between November, 2021 and January, 2023. Participants consented to have their data collected for research purposes at the time of their presurgical psychological evaluation for MBS. A clinical interview was then completed by doctoral level clinical psychologists that included covering criteria related to alcohol use and frequency, cannabis and medicinal cannabis use, stimulant use, hallucinogen use, opioid use, and nicotine use both in the form of tobacco and vape. All participants were also administered the MMPI-3 and a battery of other self-report measures (including the AUDIT-C). Chart review data from participants’ presurgical psychological evaluations were coded by a trained research assistant. Chart review data used in this study are listed in Table 1. Statistical Analyses Relative risk ratios (RRRs) were calculated to quantify the likelihood of those alcohol/substance use criteria being present at various MMPI-3 SUB scale score cut offs. They were computed by dividing the presence of the alcohol/substance use for patients who scored at various MMPI-3 SUB scale cutoffs by the presence of the alcohol/substance use for patients of those who did not achieve those MMPI-3 SUB scale cutoffs. To determine statistical significance, a RRR was considered statistically significant if 1.00 was not in the confidence interval. Risk if elevated is the percentage of the patients with elevated scores on the MMPI-3 and also have the presence of the alcohol/substance use criteria. Risk if not elevated is the percentage of patients with elevated scores on the MMPI-3 and did not endorse the alcohol/substance use criteria. The selection ratio (SR) is the percentage of patients who elevated the MMPI-3 SUB scale at those various T-scores regardless of whether they endorsed the alcohol/substance use criteria. Base rate (BR) is the percentage of patients who endorsed the alcohol/substance use criteria. RRRs were in place of traditional classification accuracies, such as positive predictive values (PPV) and negative predictive values (NPV) due to the very low base rate of substance use disorder (SUD) in our sample. PPV and NPV are highly sensitive to base rate prevalence. [ 22 , 23 ] In contexts where the base rates are low, the PPV tends to be deflated, regardless of the true discriminative ability of the predictor, and NPV tends to be artificially inflated. This could lead to misleading interpretations of a scale’s utility. Relative Risk Ratios offer a base-rate independent measure of how the likelihood of these substance use criteria differs between individuals above and below a given cut-off on the MMPI-3 SUB scale. Relative risk quantifies the increase in risk without being biased by the prevalence of the condition in the sample. All analyses were conducted in IBM’s SPSS Version 29. [ 24 ] Results The mean on the SUB scale in this sample was 42T (SD = 5). Additionally, 31.2% of the sample elevated the Uncommon Virtues (L) scale and 25.2% of the sample elevated the Adjustment Validity (K) scale. Both of the aforementioned scales are indicative of possible under-reporting that subsequently lowers substantive scale scores on the rest of the MMPI-3 – again, suggesting that interpreting a lower T-score cutoff on the SUB scale may be appropriate. All relative risk ratios are located in Table 1. The relative risk of current alcohol use [RRR = 1.32, 95% C.I: 1.14–1.54] among those with an MMPI-3 score above 54T was 1.32 times as high as the likelihood of current alcohol use among those with an MMPI-3 score below 54T. Current alcohol use disorder was associated with the highest relative risk at 58T [RRR = 21.72, 95% C.I: 8.79–53.69]. History of alcohol use disorder was also associated with the highest relative risk at 58T [RRR = 7.89, 95% C.I: 4.43–14.05]. The relative risk of current and past cannabis use being present was associated with the highest RRR at 52T [RRR = 13.45, 95% C.I: 7.35–24.59; RRR = 2.99, 95% C.I: 2.63–3.39] on the SUB scale; however, the risk for current cannabis use was better differentiated at 54T [RRR = 7.81, 95% C.I: 4.28–14.25]. Similarly, current nicotine use was associated with the highest relative risk at 52T [RRR = 2.55, 95% C.I: 1.63–3.98] but was better differentiated at 54T [RRR = 2.31, 95% C.I: 1.26–4.25] on the SUB scale. Problematic opioid use history was associated with the highest relative risk at 54T on the SUB scale [RRR = 13.43, 95% C.I: 6.78–26.58] as was past nicotine use [RRR = 1.80, 95% C.I: 1.55–2.10]The relative risk of current [RRR = 13.52, 95% C.I: 5.91–30.95] and past [RRR = 8.55, 95% C.I: 5.74–12.73] substance use disorder being present was associated with the highest RRR at 54T on the SUB scale. Finally, the relative risk of elevating the AUDIT-C scale was associated with the highest RRR at 65T [RRR = 7.37; 95% C.I: 2.69–20.16]. Discussion Previous research using the MMPI-2-RF suggested a cut-off of 55T or higher on the SUB scale better captured patients in MBS who were at a greater likelihood of using alcohol/substances.[ 17 ] The present study aimed to examine differential cutoffs of the MMPI-3 SUB scale for use with patients undergoing MBS. Thus, the aim of the present study was to examine whether lower T-score cutoffs for the MMPI-3 SUB scale improve the ability to identify MBS patients at a greater likelihood of problematic substance use. We hypothesized, based on prior research with the MMPI-2-RF, that the generally recommended T-score cutoff of 65 on the MMPI-3 SUB scale would not optimally identify patients at a greater likelihood of problematic alcohol or substance use in the assessment of patients seeking MBS and that, instead, a lower T-score cutoff would provide better clinical utility. That hypothesis was indeed supported and lower T-score cutoffs for the interpretation of SUB are warranted. As hypothesized, the present study found optimal T-score cutoffs on the SUB scale to range between 52T and 58T, with 54T as the most consistently identified optimal cutoff score across criteria. Indeed, only .3% of the sample scored 65T or higher on the MMPI-3 scale suggesting the possibility that a lower cutoff would be optimal because the base rates of the criteria of larger than this. Given the potential negative health outcomes associated with problematic alcohol/substance use in patients undergoing MBS, these results suggest that the currently recommended T-score cutoff of 65 or higher is not optimal for identifying MBS candidates at a greater likelihood of clinically elevated symptomology – further extending findings using the MMPI-2-RF. [ 17 ] Therefore, lowering the SUB scale T-score cutoff to 54 would allow clinicians to more optimally identify patients at a greater likelihood for substance use that may adversely affect surgical outcome and, if need be, provide them with the appropriate pre/post-operative care. Overall, the clinical utility of the MMPI-3 SUB scale provides clinicians with objective data in combination with verbal self-report data to make the conclusions necessary for patients undergoing MBS. Elevated scores indicate to clinicians the need to provide post-operative care instructions and monitoring related to the use of substances. It also implies that the practitioner needs to focus their clinical interview on a potential past/current alcohol/substance related use because they are at a greater likelihood of having problematic alcohol/substance problems. In instances where the SUB scale and verbal self-report contradict each other, under-reporting needs to be ruled out and that can be done by observing scores on the MMPI-3 under-reporting validity scales. Limitations & Future direction The present study is limited by its use of chart review data. Records obtained for chart review may have inconsistent documentation across providers and lack of standardization for deriving criteria. Additionally, the data in this study may be limited by participants’ likelihood to underreport their substance use behaviors. As described in this study, up to one-third of patients endorsed in some under-reporting responding. This would refer to a type of social desirability bias that highlights the tendency for people to underreport their drug and alcohol consumption in attempt [ 25 , 26 ]. In regard to the present study, individuals may have underreported substance use behavior to appear more fit for surgical candidacy given how face valid the SUB scale is. Similar to other samples where underreporting is problematic [ 27 , 28 ]. MMPI-3 SUB need to be interpreted with additional scrutiny at scale scores lower than 65T in patients seeking MBS – especially after a thorough chart review to address any discrepancies during the interview. Another limitation is that this study did not examine moderators. For instance, body composition, age, and gender affect metabolization of alcohol.[ 29 ] Future studies should consider other criteria, such as amount of alcohol beverages drank per day or impairments related to alcohol/substance use could be examined to take gender differences into account. Conclusion The generally recommended T-score cutoff of 65 on the MMPI-3 SUB scale was not found to optimally identify patients at a greater likelihood of problematic alcohol or substance use in the assessment of patients seeking MBS. Our data indicate that a cutoff T-score of 54 on the MMPI-3 SUB scale is optimal for identifying MBS candidates at a greater likelihood for problematic substance use. The recalibrated T-score cutoff should help improve clinicians’ ability to identify MBS patients at a greater likelihood of substance use and the varying negative outcomes associated with problematic use. Future studies should seek to replicate these findings with non-self-report based criteria such as through informant report or medical records. Declarations Ethical Approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed Consent: Informed consent was obtained from all individual participants included in the study. References Mechanick JI, Apovian C, Brethauer S, et al. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures–2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Surgery for Obesity and Related Diseases . 2020;16(2):175-247. Livhits M, Mercado C, Yermilov I, et al. 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Examination of the Reliability and Validity of the Minnesota Multiphasic Personality Inventory-3 (MMPI-3) in a Preoperative Bariatric Surgery Sample. J Clin Psychol Med Settings . Sep 2023;30(3):673-686. doi:10.1007/s10880-022-09908-2 Marek RJ, Ben-Porath YS, Panigrahi E, Pona AA. Further evidence regarding the convergent and discriminant validity of Minnesota Multiphasic Personality Inventory-3 (MMPI-3) scores in the preoperative psychological evaluation of patients seeking metabolic and bariatric surgery. Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery . Jun 2024;20(6):577-586. doi:10.1016/j.soard.2024.01.006 Tarescavage AM, Windover A, Ben-Porath YS, et al. Use of the MMPI-2-RF suicidal/death ideation and substance abuse scales in screening bariatric surgery candidates. Psychol Assess . Dec 2013;25(4):1384-9. doi:10.1037/a0034045 Ben-Porath YS, Tellegen A. 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Nov 2007;8(2):53-96. doi:10.1111/j.1539-6053.2008.00033.x IBM SPSS Statistics for Windows . IBM Corp; 2022. Latkin CA, Edwards C, Davey-Rothwell MA, Tobin KE. The relationship between social desirability bias and self-reports of health, substance use, and social network factors among urban substance users in Baltimore, Maryland. Addictive behaviors . 2017;73:133-136. Ambwani S, Boeka AG, Brown JD, et al. Socially desirable responding by bariatric surgery candidates during psychological assessment. Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery . Mar-Apr 2013;9(2):300-5. doi:10.1016/j.soard.2011.06.019 Talerico GM, McCallum JJ, Whitman MR, Tarescavage AM, Corey DM, Ben-Porath YS. Comparing the validity of MMPI-3 scores in prehire psychological screenings of male and female police officer candidates. Journal of personality assessment . 2024;106(1):27-36. Tarescavage AM, Corey DM, Gupton HM, Ben-Porath YS. Criterion validity and practical utility of the Minnesota multiphasic personality inventory–2–restructured form (MMPI–2–RF) in assessments of police officer candidates. Journal of personality assessment . 2015;97(4):382-394. Seyedsadjadi N, Ramchandani VA, Plawecki MH, et al. Fat-free mass accounts for most of the variance in alcohol elimination rate in women. Alcohol, Clinical and Experimental Research . 2023;47(5):848-855. doi:https://doi.org/10.1111/acer.15047 Table Table 1 is available in the supplementary files section Additional Declarations Competing interest reported. Ryan Marek and Ashleigh Pona received research grant funding from the University of Minnesota Press to support this data collection. Ryan Marek is a co-author of the MMPI-3 Spinal Procedure Candidate Reports (SPCIR), he receives royalties on sales of the report. Yossef Ben-Porath is a paid consultant to the MMPI-3 publisher, the University of Minnesota and Distributor, Pearson. As co-author of the MMPI-3, he receives royalties on sales of the test. Supplementary Files Table1.docx Cite Share Download PDF Status: Published Journal Publication published 05 Dec, 2025 Read the published version in Obesity Surgery → Version 1 posted Editorial decision: Revision requested 03 Nov, 2025 Reviews received at journal 25 Sep, 2025 Reviewers agreed at journal 24 Sep, 2025 Reviewers invited by journal 24 Sep, 2025 Editor assigned by journal 24 Sep, 2025 Submission checks completed at journal 23 Sep, 2025 First submitted to journal 13 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-7609287\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":524648602,\"identity\":\"39ccac37-8bcb-4423-bb05-2a4ec08a9a23\",\"order_by\":0,\"name\":\"Lauren K. Allen\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/ElEQVRIiWNgGAWjYDACduYGIGkBZjM2VABJZrAIHsDMCFIgAdVyBi5CrJbGNohOvDr4mxkbHxcwSMgb3D587OHMebXR/O1ALT8qtuHUInGYsdl4BoOE4YZzaemGG7cdz51xmLGBsefMbdzWHGZsk+ZhkGDccIbHTPLhtmO5DUAtzIxtuLXIH2Zs/w3UYr/hDP83yYdzjuXOJ6TFAGgLM1BLItAWNsmNDTW5GwhpMQT6RZrHQCJ55hk2M8kZxw7kbgRqOYjPL3LHmw9+5qmwse07w/xMsqemLnfe+cMHH/yowON9iPMQoQEmDxBQjwLqSFE8CkbBKBgFIwQAAOP7V8RnkMXkAAAAAElFTkSuQmCC\",\"orcid\":\"\",\"institution\":\"Sam Houston State University\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Lauren\",\"middleName\":\"K.\",\"lastName\":\"Allen\",\"suffix\":\"\"},{\"id\":524648605,\"identity\":\"2cde6ee2-6878-4b44-9928-bac3b29476e6\",\"order_by\":1,\"name\":\"Haley E. Cook\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Sam Houston State University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Haley\",\"middleName\":\"E.\",\"lastName\":\"Cook\",\"suffix\":\"\"},{\"id\":524648606,\"identity\":\"422899f8-ea67-4054-95b6-f08ef100b2da\",\"order_by\":2,\"name\":\"Ashleigh A. Pona\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"The Ohio State University Wexner Medical Center\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Ashleigh\",\"middleName\":\"A.\",\"lastName\":\"Pona\",\"suffix\":\"\"},{\"id\":524648607,\"identity\":\"df0fbc1d-fbe2-432d-82c5-55510871dca7\",\"order_by\":3,\"name\":\"Yossef S. Ben-Porath\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Kent State University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Yossef\",\"middleName\":\"S.\",\"lastName\":\"Ben-Porath\",\"suffix\":\"\"},{\"id\":524648611,\"identity\":\"c826c660-06d7-4ebf-8f4b-837d23c50e10\",\"order_by\":4,\"name\":\"Ryan J. Marek\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Sam Houston State University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Ryan\",\"middleName\":\"J.\",\"lastName\":\"Marek\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2025-09-13 19:53:15\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-7609287/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-7609287/v1\",\"draftVersion\":[],\"editorialEvents\":[{\"content\":\"https://doi.org/10.1007/s11695-025-08430-2\",\"type\":\"published\",\"date\":\"2025-12-05T15:57:59+00:00\"}],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":92948033,\"identity\":\"5e626eba-8d65-4376-aa58-969a8a9ef1a9\",\"added_by\":\"auto\",\"created_at\":\"2025-10-07 12:54:36\",\"extension\":\"docx\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"acdc-reference\",\"size\":91184,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"SUBRRRBlindedManuscript.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7609287/v1/a5f661a094ce977c50eaedee.docx\"},{\"id\":92947981,\"identity\":\"aaf01510-fbb2-4bf8-bb6f-4676c49dad31\",\"added_by\":\"auto\",\"created_at\":\"2025-10-07 12:54:34\",\"extension\":\"json\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"acdc-reference\",\"size\":7104,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"f1110f1f1a93451ba31298ede2cd2503.json\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7609287/v1/78bf7f9c0ec8f2e5a0a3fe9e.json\"},{\"id\":92948064,\"identity\":\"41a7c750-2a1a-4668-9a8a-cff5338541d8\",\"added_by\":\"auto\",\"created_at\":\"2025-10-07 12:54:38\",\"extension\":\"xml\",\"order_by\":2,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"acdc-reference\",\"size\":102362,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"f1110f1f1a93451ba31298ede2cd25031enriched.xml\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7609287/v1/65aea464a7e62f170721aafe.xml\"},{\"id\":92947984,\"identity\":\"45e42ee9-ec64-492f-9a1f-5bba4fe5cd7d\",\"added_by\":\"auto\",\"created_at\":\"2025-10-07 12:54:35\",\"extension\":\"xml\",\"order_by\":3,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"acdc-reference\",\"size\":101772,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"f1110f1f1a93451ba31298ede2cd25031structuring.xml\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7609287/v1/43bbbb33ab09b7be27882783.xml\"},{\"id\":92948170,\"identity\":\"a3984ceb-8280-4818-b692-f74232b50639\",\"added_by\":\"auto\",\"created_at\":\"2025-10-07 12:54:40\",\"extension\":\"html\",\"order_by\":4,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"acdc-reference\",\"size\":107714,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"earlyproof.html\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7609287/v1/ef3670b4fea381df1a75c03f.html\"},{\"id\":97723908,\"identity\":\"b280d150-ef6e-4573-988d-39a124c3297f\",\"added_by\":\"auto\",\"created_at\":\"2025-12-08 16:09:35\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":460460,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7609287/v1/efa294af-a0ef-4a56-a687-a73a049a0e8f.pdf\"},{\"id\":92947830,\"identity\":\"65327e3d-2220-422e-b92f-4a5bd621b818\",\"added_by\":\"auto\",\"created_at\":\"2025-10-07 12:54:24\",\"extension\":\"docx\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":25228,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"Table1.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7609287/v1/b7cdb72163509109db042db5.docx\"}],\"financialInterests\":\"Competing interest reported. Ryan Marek and Ashleigh Pona received research grant funding from the University of Minnesota Press to support this data collection. Ryan Marek is a co-author of the MMPI-3 Spinal Procedure Candidate Reports (SPCIR), he receives royalties on sales of the report. Yossef Ben-Porath is a paid consultant to the MMPI-3 publisher, the University of Minnesota and Distributor, Pearson. As co-author of the MMPI-3, he receives royalties on sales of the test.\",\"formattedTitle\":\"Exploring Optimal Cut-Offs of the MMPI-3 Substance Use Scale in Patients Seeking Metabolic and Bariatric Surgery\",\"fulltext\":[{\"header\":\"Key Points\",\"content\":\"\\u003cp\\u003e\\u0026bull; The MMPI-3 can effectively screen for substance use problems in MBS.\\u003c/p\\u003e\\u003cp\\u003e\\u0026bull; A lower T-score cut-off for interpretation is necessary for the SUB scale in MBS samples.\\u003c/p\\u003e\\u003cp\\u003e\\u0026bull; A T-score of 54T more appropriately captured problematic alcohol/substance use.\\u003c/p\\u003e\"},{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003ePatients seeking metabolic and bariatric surgery (MBS) complete presurgical psychological assessments to identify potential factors that may impede surgical outcomes.\\u003csup\\u003e1\\u003c/sup\\u003e Presurgical psychological assessments assess environmental, familial, and behavioral factors including weight history, eating disorder history, cognitive functioning, available social support, and motivation for weight loss [\\u003cspan additionalcitationids=\\\"CR3\\\" citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e]. These factors have the potential to affect outcomes of MBS surgery, including emotional adjustment, adherence to the recommended postoperative lifestyle regimen, weight loss outcomes, and comorbidity treatment [\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e]. Rates of psychopathology are high in persons undergoing MBS, with major depression disorder, binge eating disorder, and alcohol use disorders being particularly common [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e]. By identifying these psychosocial problems through presurgical psychological assessment, behavioral health professionals work to inform the treatment team of potential negative surgical outcomes to determine appropriate pre- and/or postoperative care [\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eProblematic alcohol/substance use could cause many negative health outcomes in patients undergoing MBS. Specifically, the prevalence of alcohol use disorder (AUD) has been found to rise in the second-year post MBS with one-fifth of participants reporting AUD symptoms within 5 years post-operation [\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e]. Studies related to alcohol following MBS imply that participants have experienced heightened subjective sensitivity to alcohol due to the change in rate of alcohol absorption through the body. Alcohol dehydrogenase, the stomach enzyme that breaks down alcohol, is reduced post-surgery. This enzyme reduction in combination with smaller stomach capacity results in alcohol content reaching the bloodstream faster and increased blood alcohol content overall. Increased blood alcohol content poses increased risks of alcohol related effects like impaired driving as well as increased likelihood of developing alcohol use disorder. [\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e] Additionally, prescription opioid use has been found to increase past baseline prevalence post-operation.[\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e] Finally, smoking is associated with multiple post-operative problems including 30-day morbidity/mortality, pulmonary complications, and marginal ulceration.[\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e] Smoking is an independent risk factor for short-term complications like post-operative pneumonia, failure to wean from ventilator, and reintubation.[\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e] Additionally, smoking is also associated with long-term complications such as persistent or recurrent marginal ulceration and bone fracture.[\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e]\\u003c/p\\u003e\\u003cp\\u003ePresurgical psychological assessments often screen for alcohol and substance use disorders. The Minnesota Multiphasic Personality Inventory (MMPI-3; Ben-Porath \\u0026amp; Tellegen, 2020) is a commonly used broadband measure that assesses not only alcohol/substance use, but also other behavioral factors associated with substance use (e.g., antisocial tendencies, disinhibition). Because the test is broadband, it also assesses various other domains associated with depression, anxiety, and eating disorder pathology among others. The MMPI-3 is a useful component of presurgical psychological assessment because it provides more objective, comprehensive data that may not be derived otherwise through the use of a clinical interview (Pona et al., 2022). The scale scores on the MMPI-3 produce good reliability and good convergent/discriminant validity in MBS settings (Marek et al., 2024; Pona et al., 2022). The MMPI-3 provides clinical utility through more objective, comprehensive data that may not otherwise be gleaned from a self-report clinical interview. Median Cronbach\\u0026rsquo;s alpha estimates for each subscale have been found to range between 0.72 and 0.80 and mean inter-item correlations between 0.13 and 0.27. Additionally, validity analyses have exemplified significant associations between most MMPI-3 subscales and the Patient Health Questionnaire-9, General Anxiety Disorder-7, the Eating Disorder Examination-Questionnaire, the Alcohol Use Identification Test-C (AUDIT-C) and various external criteria such as diagnoses, abuse history, and suicide history, among others.[\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e] The MMPI-3 is validated for use in the assessment of patients seeking MBS and contains a specific Substance Abuse (SUB) scale that is capable of accurately assessing for past or current alcohol/substance use. The SUB scale utilizes cutoff scores to help identify those with substance use-related factors and inform treatment recommendations for those individuals. Identifying individuals at a greater likelihood of problematic alcohol/substance use helps predict their ability to adhere to post-surgery protocols and therefore improve their treatment outcomes.\\u003c/p\\u003e\\u003cp\\u003ePast research using two samples of patients seeking MBS implied that the interpretation of the SUB scale on the MMPI-2-RF of 65T ought to be reconsided.[\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e] The data across these two samples suggested that SUB was better interpreted at a T-score of 55 instead of the traditional 65T. The update from the MMPI-2-RF to the MMPI-3 included updated (and new) item content and updated test norms.[\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e] Due to these changes, it is necessary to investigate whether the MMPI-3 version of the SUB Specific Problems Scale would also benefit from being interpreted at lower T-score cutoffs within the MBS population.\\u003c/p\\u003e\\u003cp\\u003eThe current recommended T-score cutoff for the MMPI-3 SUB scale is a score of 65 or higher (Ben-Porath \\u0026amp; Tellegen, 2020). Given the potential negative health outcomes associated with problematic substance use in patients undergoing MBS, the recommended T-score cutoff of 65 or higher may not be optimal for identifying MBS candidates at a greater likelihood of problematic alcohol/substance use based off prior research with the MMPI-2-RF.[\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e] Interpretating the SUB scale score on the MMPI-2-RF at 55T better identified patients who were engaging in problematic substance use. Thus, this study aims to examine whether lower T-score cutoffs for the MMPI-3 SUB scale improve clinicians\\u0026rsquo; ability to identify MBS patients at a greater likelihood of alcohol/substance use.\\u003c/p\\u003e\\u003cp\\u003eThe purpose of the present study was to optimize the use and accuracy of the MMPI-3 SUB scale for use with patients undergoing MBS. Alternative SUB cutoffs were examined in the present study using a large sample of MBS candidates. We hypothesized, based on previous findings with the MMPI-2-RF, that the generally recommended T-score cutoff of 65 on the MMPI-3 SUB scale would not optimally identify, or identify as accurately and effectively as possible, patients at a greater likelihood of problematic alcohol or substance use in the assessment of patients seeking MBS and that, instead, a lower T-score cutoff would provide better clinical utility.\\u003c/p\\u003e\"},{\"header\":\"Method\",\"content\":\"\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eParticipants\\u003c/h2\\u003e\\u003cp\\u003eParticipants (N\\u0026thinsp;=\\u0026thinsp;1,283) were recruited from a Midwestern Academic Medical Center. A total of 26 participants were excluded due to having an invalid MMPI-3 profile. The final sample included in analyses comprised of 1,257 participants. Participants\\u0026rsquo; ages ranged from 18 to 77, with a mean age of 42.2 years old (\\u003cem\\u003eSD\\u003c/em\\u003e\\u0026thinsp;=\\u0026thinsp;11.1). Of the sample, 78.5% identified as women. Approximately 65.8% of the sample identified as White, 27.4% of the sample identified as Black or African American, and 6.8% identified as another race. The average presurgical Body Mass Index (BMI) was 50.58 kg/m\\u003csup\\u003e2\\u003c/sup\\u003e (SD\\u0026thinsp;=\\u0026thinsp;10.70). Retrospective chart review to gather data for the study was approved by the third author\\u0026rsquo;s Institutional Review Board.\\u003c/p\\u003e\\u003c/div\\u003e\\n\\u003ch3\\u003eMeasures\\u003c/h3\\u003e\\n\\u003cp\\u003e\\u003cb\\u003eMinnesota Multiphasic Personality Inventory \\u0026ndash; 3 (MMPI-3).\\u003c/b\\u003e[\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e] The MMPI-3 contains 335 true/false items that are scored across 10 validity scales and 42 substantive scales. As previously stated, scale scores on the MMPI-3 produce good reliability and convergent/discriminant validity in MBS settings.[\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e] Only the MMPI-3 SUB scale was examined in this study. The MMPI-3 SUB scale consists of item content related to history/current alcohol/substance use, frequency of alcohol/substance use, inappropriate use of prescription medication, and using alcohol/substances to cope and relax. T-scores on the MMPI-3 SUB scale can range from 39T to 86T with clinically elevated scores at 65T and higher. Raw scores are calculated into uniform T-Scores.\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eAlcohol Use Disorders Identification Test-Consumption (AUDIT-C).\\u003c/b\\u003e[\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e] The AUDIT-C is a modified version of the Alcohol Use Disorders Identification Test (AUDIT). The AUDIT-C is a shorter validated instrument that measures alcohol consumption in the past 12 months using 3 items intended to screen for harmful alcohol use. AUDIT-C scores range from 0 to 12 with a score of \\u0026ge;\\u0026thinsp;4 for men and of \\u0026ge;\\u0026thinsp;3 for women indicating positive for hazardous alcohol use or an active alcohol use disorder. Cronbach\\u0026rsquo;s alpha for the AUDIT-C in the current sample was .49, likely owing to limited variability and small item count for the scale. The mean inter-item correlation was .36 indicating good reliability.\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eClinical Criteria\\u003c/b\\u003e. A range of substance use criteria were coded from patients\\u0026rsquo; medical charts. These included whether or not alcohol/substance was currently (within the last month) being used (yes/no) or if there was a history (longer than a month ago) of alcohol/substance, whether or not the current/past alcohol/substance use was problematic (yes/no), or if they met criteria for a current/historic alcohol/substance use disorder based on Diagnostic and Statistical Manual for Mental Disorders \\u0026ndash; 5 \\u0026ndash; Text Revision (DSM-5-TR)[\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e] criteria. Only criteria that had positive endorsement were included. For example, no one in the sample reported currently abusing opioids and thus was not included in the analysis.\\u003c/p\\u003e\\n\\u003ch3\\u003eProcedure\\u003c/h3\\u003e\\n\\u003cp\\u003eThe study design was cross-sectional in nature and a large, retrospective database was used. Data were collected between November, 2021 and January, 2023. Participants consented to have their data collected for research purposes at the time of their presurgical psychological evaluation for MBS. A clinical interview was then completed by doctoral level clinical psychologists that included covering criteria related to alcohol use and frequency, cannabis and medicinal cannabis use, stimulant use, hallucinogen use, opioid use, and nicotine use both in the form of tobacco and vape. All participants were also administered the MMPI-3 and a battery of other self-report measures (including the AUDIT-C). Chart review data from participants\\u0026rsquo; presurgical psychological evaluations were coded by a trained research assistant. Chart review data used in this study are listed in Table\\u0026nbsp;1.\\u003c/p\\u003e\\n\\u003ch3\\u003eStatistical Analyses\\u003c/h3\\u003e\\n\\u003cp\\u003eRelative risk ratios (RRRs) were calculated to quantify the likelihood of those alcohol/substance use criteria being present at various MMPI-3 SUB scale score cut offs. They were computed by dividing the presence of the alcohol/substance use for patients who scored at various MMPI-3 SUB scale cutoffs by the presence of the alcohol/substance use for patients of those who did not achieve those MMPI-3 SUB scale cutoffs. To determine statistical significance, a RRR was considered statistically significant if 1.00 was not in the confidence interval. Risk if elevated is the percentage of the patients with elevated scores on the MMPI-3 and also have the presence of the alcohol/substance use criteria. Risk if not elevated is the percentage of patients with elevated scores on the MMPI-3 and did not endorse the alcohol/substance use criteria. The selection ratio (SR) is the percentage of patients who elevated the MMPI-3 SUB scale at those various T-scores regardless of whether they endorsed the alcohol/substance use criteria. Base rate (BR) is the percentage of patients who endorsed the alcohol/substance use criteria.\\u003c/p\\u003e\\u003cp\\u003eRRRs were in place of traditional classification accuracies, such as positive predictive values (PPV) and negative predictive values (NPV) due to the very low base rate of substance use disorder (SUD) in our sample. PPV and NPV are highly sensitive to base rate prevalence. [\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e] In contexts where the base rates are low, the PPV tends to be deflated, regardless of the true discriminative ability of the predictor, and NPV tends to be artificially inflated. This could lead to misleading interpretations of a scale\\u0026rsquo;s utility. Relative Risk Ratios offer a base-rate independent measure of how the likelihood of these substance use criteria differs between individuals above and below a given cut-off on the MMPI-3 SUB scale. Relative risk quantifies the increase in risk without being biased by the prevalence of the condition in the sample. All analyses were conducted in IBM\\u0026rsquo;s SPSS Version 29. [\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e]\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003eThe mean on the SUB scale in this sample was 42T (SD\\u0026thinsp;=\\u0026thinsp;5). Additionally, 31.2% of the sample elevated the Uncommon Virtues (L) scale and 25.2% of the sample elevated the Adjustment Validity (K) scale. Both of the aforementioned scales are indicative of possible under-reporting that subsequently lowers substantive scale scores on the rest of the MMPI-3 \\u0026ndash; again, suggesting that interpreting a lower T-score cutoff on the SUB scale may be appropriate.\\u003c/p\\u003e\\u003cp\\u003eAll relative risk ratios are located in Table\\u0026nbsp;1. The relative risk of current alcohol use [RRR\\u0026thinsp;=\\u0026thinsp;1.32, 95% C.I: 1.14\\u0026ndash;1.54] among those with an MMPI-3 score above 54T was 1.32 times as high as the likelihood of current alcohol use among those with an MMPI-3 score below 54T. Current alcohol use disorder was associated with the highest relative risk at 58T [RRR\\u0026thinsp;=\\u0026thinsp;21.72, 95% C.I: 8.79\\u0026ndash;53.69]. History of alcohol use disorder was also associated with the highest relative risk at 58T [RRR\\u0026thinsp;=\\u0026thinsp;7.89, 95% C.I: 4.43\\u0026ndash;14.05]. The relative risk of current and past cannabis use being present was associated with the highest RRR at 52T [RRR\\u0026thinsp;=\\u0026thinsp;13.45, 95% C.I: 7.35\\u0026ndash;24.59; RRR\\u0026thinsp;=\\u0026thinsp;2.99, 95% C.I: 2.63\\u0026ndash;3.39] on the SUB scale; however, the risk for current cannabis use was better differentiated at 54T [RRR\\u0026thinsp;=\\u0026thinsp;7.81, 95% C.I: 4.28\\u0026ndash;14.25]. Similarly, current nicotine use was associated with the highest relative risk at 52T [RRR\\u0026thinsp;=\\u0026thinsp;2.55, 95% C.I: 1.63\\u0026ndash;3.98] but was better differentiated at 54T [RRR\\u0026thinsp;=\\u0026thinsp;2.31, 95% C.I: 1.26\\u0026ndash;4.25] on the SUB scale. Problematic opioid use history was associated with the highest relative risk at 54T on the SUB scale [RRR\\u0026thinsp;=\\u0026thinsp;13.43, 95% C.I: 6.78\\u0026ndash;26.58] as was past nicotine use [RRR\\u0026thinsp;=\\u0026thinsp;1.80, 95% C.I: 1.55\\u0026ndash;2.10]The relative risk of current [RRR\\u0026thinsp;=\\u0026thinsp;13.52, 95% C.I: 5.91\\u0026ndash;30.95] and past [RRR\\u0026thinsp;=\\u0026thinsp;8.55, 95% C.I: 5.74\\u0026ndash;12.73] substance use disorder being present was associated with the highest RRR at 54T on the SUB scale. Finally, the relative risk of elevating the AUDIT-C scale was associated with the highest RRR at 65T [RRR\\u0026thinsp;=\\u0026thinsp;7.37; 95% C.I: 2.69\\u0026ndash;20.16].\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003ePrevious research using the MMPI-2-RF suggested a cut-off of 55T or higher on the SUB scale better captured patients in MBS who were at a greater likelihood of using alcohol/substances.[\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e] The present study aimed to examine differential cutoffs of the MMPI-3 SUB scale for use with patients undergoing MBS. Thus, the aim of the present study was to examine whether lower T-score cutoffs for the MMPI-3 SUB scale improve the ability to identify MBS patients at a greater likelihood of problematic substance use. We hypothesized, based on prior research with the MMPI-2-RF, that the generally recommended T-score cutoff of 65 on the MMPI-3 SUB scale would not optimally identify patients at a greater likelihood of problematic alcohol or substance use in the assessment of patients seeking MBS and that, instead, a lower T-score cutoff would provide better clinical utility. That hypothesis was indeed supported and lower T-score cutoffs for the interpretation of SUB are warranted.\\u003c/p\\u003e\\u003cp\\u003eAs hypothesized, the present study found optimal T-score cutoffs on the SUB scale to range between 52T and 58T, with 54T as the most consistently identified optimal cutoff score across criteria. Indeed, only .3% of the sample scored 65T or higher on the MMPI-3 scale suggesting the possibility that a lower cutoff would be optimal because the base rates of the criteria of larger than this. Given the potential negative health outcomes associated with problematic alcohol/substance use in patients undergoing MBS, these results suggest that the currently recommended T-score cutoff of 65 or higher is not optimal for identifying MBS candidates at a greater likelihood of clinically elevated symptomology \\u0026ndash; further extending findings using the MMPI-2-RF. [\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e] Therefore, lowering the SUB scale T-score cutoff to 54 would allow clinicians to more optimally identify patients at a greater likelihood for substance use that may adversely affect surgical outcome and, if need be, provide them with the appropriate pre/post-operative care. Overall, the clinical utility of the MMPI-3 SUB scale provides clinicians with objective data in combination with verbal self-report data to make the conclusions necessary for patients undergoing MBS. Elevated scores indicate to clinicians the need to provide post-operative care instructions and monitoring related to the use of substances. It also implies that the practitioner needs to focus their clinical interview on a potential past/current alcohol/substance related use because they are at a greater likelihood of having problematic alcohol/substance problems. In instances where the SUB scale and verbal self-report contradict each other, under-reporting needs to be ruled out and that can be done by observing scores on the MMPI-3 under-reporting validity scales.\\u003c/p\\u003e\\n\\u003ch3\\u003eLimitations \\u0026 Future direction\\u003c/h3\\u003e\\n\\u003cp\\u003eThe present study is limited by its use of chart review data. Records obtained for chart review may have inconsistent documentation across providers and lack of standardization for deriving criteria. Additionally, the data in this study may be limited by participants\\u0026rsquo; likelihood to underreport their substance use behaviors. As described in this study, up to one-third of patients endorsed in some under-reporting responding. This would refer to a type of social desirability bias that highlights the tendency for people to underreport their drug and alcohol consumption in attempt [\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e]. In regard to the present study, individuals may have underreported substance use behavior to appear more fit for surgical candidacy given how face valid the SUB scale is. Similar to other samples where underreporting is problematic [\\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e]. MMPI-3 SUB need to be interpreted with additional scrutiny at scale scores lower than 65T in patients seeking MBS \\u0026ndash; especially after a thorough chart review to address any discrepancies during the interview. Another limitation is that this study did not examine moderators. For instance, body composition, age, and gender affect metabolization of alcohol.[\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e] Future studies should consider other criteria, such as amount of alcohol beverages drank per day or impairments related to alcohol/substance use could be examined to take gender differences into account.\\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eThe generally recommended T-score cutoff of 65 on the MMPI-3 SUB scale was not found to optimally identify patients at a greater likelihood of problematic alcohol or substance use in the assessment of patients seeking MBS. Our data indicate that a cutoff T-score of 54 on the MMPI-3 SUB scale is optimal for identifying MBS candidates at a greater likelihood for problematic substance use. The recalibrated T-score cutoff should help improve clinicians\\u0026rsquo; ability to identify MBS patients at a greater likelihood of substance use and the varying negative outcomes associated with problematic use. Future studies should seek to replicate these findings with non-self-report based criteria such as through informant report or medical records.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eEthical Approval:\\u003c/strong\\u003e All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eInformed Consent:\\u003c/strong\\u003e Informed consent was obtained from all individual participants included in the study.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eMechanick JI, Apovian C, Brethauer S, et al. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures\\u0026ndash;2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic \\u0026amp; Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. \\u003cem\\u003eSurgery for Obesity and Related Diseases\\u003c/em\\u003e. 2020;16(2):175-247.\\u003c/li\\u003e\\n\\u003cli\\u003eLivhits M, Mercado C, Yermilov I, et al. Is social support associated with greater weight loss after bariatric surgery?: a systematic review. \\u003cem\\u003eObesity reviews : an official journal of the International Association for the Study of Obesity\\u003c/em\\u003e. Feb 2011;12(2):142-8. doi:10.1111/j.1467-789X.2010.00720.x\\u003c/li\\u003e\\n\\u003cli\\u003eSchlottmann F, Nayyar A, Herbella FA, Patti MG. Preoperative evaluation in bariatric surgery. \\u003cem\\u003eJournal of Laparoendoscopic \\u0026amp; Advanced Surgical Techniques\\u003c/em\\u003e. 2018;28(8):925-929.\\u003c/li\\u003e\\n\\u003cli\\u003eSogg S, Lauretti J, West-Smith L. Recommendations for the presurgical psychosocial evaluation of bariatric surgery patients. \\u003cem\\u003eSurgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery\\u003c/em\\u003e. May 2016;12(4):731-749. doi:10.1016/j.soard.2016.02.008\\u003c/li\\u003e\\n\\u003cli\\u003eDawes AJ, Maggard-Gibbons M, Maher AR, et al. Mental health conditions among patients seeking and undergoing bariatric surgery: a meta-analysis. \\u003cem\\u003eJAMA : the journal of the American Medical Association\\u003c/em\\u003e. 2016;315(2):150-163.\\u003c/li\\u003e\\n\\u003cli\\u003eMitchell JE, Selzer F, Kalarchian MA, et al. Psychopathology before surgery in the longitudinal assessment of bariatric surgery-3 (LABS-3) psychosocial study. \\u003cem\\u003eSurgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery\\u003c/em\\u003e. Sep-Oct 2012;8(5):533-41. doi:10.1016/j.soard.2012.07.001\\u003c/li\\u003e\\n\\u003cli\\u003eKing WC, Chen J-Y, Courcoulas AP, et al. Alcohol and other substance use after bariatric surgery: prospective evidence from a US multicenter cohort study. \\u003cem\\u003eSurgery for Obesity and Related Diseases\\u003c/em\\u003e. 2017;13(8):1392-1402.\\u003c/li\\u003e\\n\\u003cli\\u003eKing WC, Chen JY, Mitchell JE, et al. Prevalence of alcohol use disorders before and after bariatric surgery. \\u003cem\\u003eJAMA : the journal of the American Medical Association\\u003c/em\\u003e. Jun 20 2012;307(23):2516-25. doi:10.1001/jama.2012.6147\\u003c/li\\u003e\\n\\u003cli\\u003eBuffington CK. Alcohol use and health risks: survey results. \\u003cem\\u003eBariatric Times\\u003c/em\\u003e. 2007;4(2):1-21.\\u003c/li\\u003e\\n\\u003cli\\u003eErtelt TW, Mitchell JE, Lancaster K, Crosby RD, Steffen KJ, Marino JM. Alcohol abuse and dependence before and after bariatric surgery: a review of the literature and report of a new data set. \\u003cem\\u003eSurgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery\\u003c/em\\u003e. Sep-Oct 2008;4(5):647-50. doi:10.1016/j.soard.2008.01.004\\u003c/li\\u003e\\n\\u003cli\\u003eKing WC, Chen J-Y, Belle SH, et al. Use of prescribed opioids before and after bariatric surgery: prospective evidence from a US multicenter cohort study. \\u003cem\\u003eSurgery for Obesity and Related Diseases\\u003c/em\\u003e. 2017;13(8):1337-1346.\\u003c/li\\u003e\\n\\u003cli\\u003eChow A, Neville A, Kolozsvari N. Smoking in bariatric surgery: a systematic review. \\u003cem\\u003eSurg Endosc\\u003c/em\\u003e. Jun 2021;35(6):3047-3066. doi:10.1007/s00464-020-07669-3\\u003c/li\\u003e\\n\\u003cli\\u003eGupta PK, Gupta H, Kaushik M, et al. Predictors of pulmonary complications after bariatric surgery. \\u003cem\\u003eSurgery for Obesity and Related Diseases\\u003c/em\\u003e. 2012;8(5):574-581.\\u003c/li\\u003e\\n\\u003cli\\u003eHaskins IN, Amdur R, Vaziri K. The effect of smoking on bariatric surgical outcomes. \\u003cem\\u003eSurgical endoscopy\\u003c/em\\u003e. 2014;28:3074-3080.\\u003c/li\\u003e\\n\\u003cli\\u003ePona AA, Marek RJ, Panigrahi E, Ben-Porath YS. Examination of the Reliability and Validity of the Minnesota Multiphasic Personality Inventory-3 (MMPI-3) in a Preoperative Bariatric Surgery Sample. \\u003cem\\u003eJ Clin Psychol Med Settings\\u003c/em\\u003e. Sep 2023;30(3):673-686. doi:10.1007/s10880-022-09908-2\\u003c/li\\u003e\\n\\u003cli\\u003eMarek RJ, Ben-Porath YS, Panigrahi E, Pona AA. Further evidence regarding the convergent and discriminant validity of Minnesota Multiphasic Personality Inventory-3 (MMPI-3) scores in the preoperative psychological evaluation of patients seeking metabolic and bariatric surgery. \\u003cem\\u003eSurgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery\\u003c/em\\u003e. Jun 2024;20(6):577-586. doi:10.1016/j.soard.2024.01.006\\u003c/li\\u003e\\n\\u003cli\\u003eTarescavage AM, Windover A, Ben-Porath YS, et al. Use of the MMPI-2-RF suicidal/death ideation and substance abuse scales in screening bariatric surgery candidates. \\u003cem\\u003ePsychol Assess\\u003c/em\\u003e. Dec 2013;25(4):1384-9. doi:10.1037/a0034045\\u003c/li\\u003e\\n\\u003cli\\u003eBen-Porath YS, Tellegen A. \\u003cem\\u003eThe Minnesota Multiphasic Personality Inventory-3: Manual for administration, scoring, and interpretation.\\u003c/em\\u003e University of Minnesota Press; 2020.\\u003c/li\\u003e\\n\\u003cli\\u003eBen-Porath YS, Tellegen A. \\u003cem\\u003eThe Minnesota Multiphasic Personality Inventory-3: Technical Manual.\\u003c/em\\u003e University of Minnesota Press; 2020.\\u003c/li\\u003e\\n\\u003cli\\u003eBush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. \\u003cem\\u003eArchives of internal medicine\\u003c/em\\u003e. Sep 14 1998;158(16):1789-95.\\u003c/li\\u003e\\n\\u003cli\\u003eAssociation AP. \\u003cem\\u003eDiagnostic and Statistical Manual of Mental Disorders\\u003c/em\\u003e. 2022.\\u003c/li\\u003e\\n\\u003cli\\u003eKraemer HC. \\u003cem\\u003eEvaluating medical tests: Objective and quantitative guidelines\\u003c/em\\u003e. 1st ed. Sage Publications, Inc; 1992.\\u003c/li\\u003e\\n\\u003cli\\u003eGigerenzer G, Gaissmaier W, Kurz-Milcke E, Schwartz LM, Woloshin S. Helping Doctors and Patients Make Sense of Health Statistics. \\u003cem\\u003ePsychol Sci Public Interest\\u003c/em\\u003e. Nov 2007;8(2):53-96. doi:10.1111/j.1539-6053.2008.00033.x\\u003c/li\\u003e\\n\\u003cli\\u003e\\u003cem\\u003eIBM SPSS Statistics for Windows\\u003c/em\\u003e. IBM Corp; 2022.\\u003c/li\\u003e\\n\\u003cli\\u003eLatkin CA, Edwards C, Davey-Rothwell MA, Tobin KE. The relationship between social desirability bias and self-reports of health, substance use, and social network factors among urban substance users in Baltimore, Maryland. \\u003cem\\u003eAddictive behaviors\\u003c/em\\u003e. 2017;73:133-136.\\u003c/li\\u003e\\n\\u003cli\\u003eAmbwani S, Boeka AG, Brown JD, et al. Socially desirable responding by bariatric surgery candidates during psychological assessment. \\u003cem\\u003eSurgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery\\u003c/em\\u003e. Mar-Apr 2013;9(2):300-5. doi:10.1016/j.soard.2011.06.019\\u003c/li\\u003e\\n\\u003cli\\u003eTalerico GM, McCallum JJ, Whitman MR, Tarescavage AM, Corey DM, Ben-Porath YS. Comparing the validity of MMPI-3 scores in prehire psychological screenings of male and female police officer candidates. \\u003cem\\u003eJournal of personality assessment\\u003c/em\\u003e. 2024;106(1):27-36.\\u003c/li\\u003e\\n\\u003cli\\u003eTarescavage AM, Corey DM, Gupton HM, Ben-Porath YS. Criterion validity and practical utility of the Minnesota multiphasic personality inventory\\u0026ndash;2\\u0026ndash;restructured form (MMPI\\u0026ndash;2\\u0026ndash;RF) in assessments of police officer candidates. \\u003cem\\u003eJournal of personality assessment\\u003c/em\\u003e. 2015;97(4):382-394.\\u003c/li\\u003e\\n\\u003cli\\u003eSeyedsadjadi N, Ramchandani VA, Plawecki MH, et al. Fat-free mass accounts for most of the variance in alcohol elimination rate in women. \\u003cem\\u003eAlcohol, Clinical and Experimental Research\\u003c/em\\u003e. 2023;47(5):848-855. doi:https://doi.org/10.1111/acer.15047\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"},{\"header\":\"Table\",\"content\":\"\\u003cp\\u003eTable 1 is available in the supplementary files section\\u003c/p\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"obesity-surgery\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"obsu\",\"sideBox\":\"Learn more about [Obesity Surgery](https://link.springer.com/journal/11695)\",\"snPcode\":\"11695\",\"submissionUrl\":\"https://submission.springernature.com/new-submission/11695/3\",\"title\":\"Obesity Surgery\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"stoa\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false},\"keywords\":\"Bariatric, substance use, MMPI\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-7609287/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-7609287/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eIntroduction:\\u003c/h2\\u003e\\u003cp\\u003ePatients seeking metabolic and bariatric surgery (MBS) complete presurgical psychological assessments to identify potential factors that may impede surgical outcomes. Presurgical psychological assessments often screen for alcohol and substance use disorders and the Minnesota Multiphasic Personality Inventory \\u0026ndash; 3 (MMPI-3) is well suited to assess for problematic alcohol or substance use. Given the potential negative health outcomes associated with problematic alcohol/substance use in patients undergoing MBS, the recommended T-score cutoff of 65T or higher may not be optimal for identifying MBS candidates at a greater likelihood of clinically elevated symptomology \\u0026ndash; especially given its face validity. The purpose of the present study was to optimize the use and accuracy of the MMPI-3 Substance Use (SUB) scale for use with patients undergoing MBS.\\u003c/p\\u003e\\u003ch2\\u003eMethod\\u003c/h2\\u003e\\u003cp\\u003e A sample of 1,257 participants from an academic medical center in the Midwest seeking MBS who produced a valid MMPI-3 protocol and had a retrospective chart review coded were included in the present study. Relative risk ratios (RRRs) were calculated to quantify the likelihood of various alcohol/substance use criteria being present at various MMPI-3 SUB scale score cut-offs.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e\\u003cp\\u003eOptimal T-score cutoffs on the SUB scale ranged between 52T-58T, with 54 as the most commonly identified cutoff score that yielded the highest relative risk for problematic alcohol/substance use.\\u003c/p\\u003e\\u003ch2\\u003eConclusions\\u003c/h2\\u003e\\u003cp\\u003eThe recommended interpretation of the SUB scale at 54T would allow clinicians to more optimally capture those with current/past alcohol/substance problems and provide them with the appropriate pre/post-operative care if needed.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Exploring Optimal Cut-Offs of the MMPI-3 Substance Use Scale in Patients Seeking Metabolic and Bariatric Surgery\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-10-07 12:31:11\",\"doi\":\"10.21203/rs.3.rs-7609287/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2025-11-03T17:58:55+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2025-09-25T12:57:28+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"276131275812267555735118612049284839834\",\"date\":\"2025-09-24T12:18:51+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2025-09-24T12:11:07+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2025-09-24T10:10:03+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2025-09-23T06:53:58+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"Obesity Surgery\",\"date\":\"2025-09-13T19:49:18+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"obesity-surgery\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"obsu\",\"sideBox\":\"Learn more about [Obesity Surgery](https://link.springer.com/journal/11695)\",\"snPcode\":\"11695\",\"submissionUrl\":\"https://submission.springernature.com/new-submission/11695/3\",\"title\":\"Obesity Surgery\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"stoa\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false}}],\"origin\":\"\",\"ownerIdentity\":\"754cfa9d-a89f-4b4e-b1ca-7b9eb14e27a0\",\"owner\":[],\"postedDate\":\"October 7th, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"published-in-journal\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2025-12-08T16:02:48+00:00\",\"versionOfRecord\":{\"articleIdentity\":\"rs-7609287\",\"link\":\"https://doi.org/10.1007/s11695-025-08430-2\",\"journal\":{\"identity\":\"obesity-surgery\",\"isVorOnly\":false,\"title\":\"Obesity Surgery\"},\"publishedOn\":\"2025-12-05 15:57:59\",\"publishedOnDateReadable\":\"December 5th, 2025\"},\"versionCreatedAt\":\"2025-10-07 12:31:11\",\"video\":\"\",\"vorDoi\":\"10.1007/s11695-025-08430-2\",\"vorDoiUrl\":\"https://doi.org/10.1007/s11695-025-08430-2\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-7609287\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-7609287\",\"identity\":\"rs-7609287\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}