Many patients ask why they have to see a mental health professional before getting bariatric surgery.
The value of the preoperative psychosocial evaluation for surgical candidates is well documented. A National Institutes of Health Consensus Panel concluded a few years ago that a psychiatric evaluation was not needed in every case but should be available if indicated (Ann. Intern. Med. 1991;115:956-61). More than 80% of bariatric programs require such evaluations. In addition, major insurance companies in the United States require a "comprehensive/presurgical psychological/psychiatric evaluation as part of a mandatory work-up before approving surgery" (Am. J. Psychiatry 2009;166:285-91).
Undoubtedly, before surgery, we can make recommendations to the patients and the bariatric surgery team by identifying the patients’ strengths and potential barriers or challenges, and using this information to develop interventions to assist the patients in being successful. For example, if the patients are participating in any eating disorder behaviors, (for example, skipping meals, emotional eating, binge eating, or night eating), we can raise the their awareness and help them get control of these behaviors before surgery.
We also can assist patients in anticipating difficulties that might arise as their lifestyles change, including ways in which their body image changes will affect work and social relationships. This is different from the pragmatic approach of the surgeon and nutritionist, whose roles are more circumscribed.
Because of the uniqueness of each individual, patients’ different lifestyles and backgrounds, and continued stressors, the mental health provider specializing in bariatric care also is uniquely positioned to assist patients in coming up with a plan that will work for them.
But what happens after the patients have the surgery? Theoretically, our work with the patients before surgery prepared them for the psychological and physical transformation they are likely to undergo. Just as the surgery is a procedure, the postsurgical period is a process. In light of this, I would submit that bariatric patients should be under the care of mental health professionals after surgery.
One of the main psychological issues that often arise with patients is distress around the excess or loose skin that is left behind after excess weight loss. But this is certainly not the main psychological issue faced by these patients. Several other postsurgical psychological issues also can arise around navigating in daily routines and around relationships, for example. For patients with morbid obesity and psychiatric disorders, particularly those with personality disorders, greater difficulties can be seen in "adapting to the new demands, including the need to cope with stress and other problems in a new way, to relearn how to eat, distress over weight loss plateaus, failure to achieve a normal-looking body, etc." (Eat. Weight Disord. 2010;15:e275-80). We can prepare patients for these changes and challenges before surgery and help them process the implications after their procedures.
Postsurgical work with patients also might help them adapt their lifestyles so that a large portion of the weight stays off. Investigators in the Swedish obese subjects intervention study found that a significant proportion of bariatric surgery patients experienced "considerable weight regain at the 10-year follow-up" (Int. J. Obes. [Lond.] 2007:31:1248-61).
Despite our best efforts to educate patients about body image issues before surgery, some patients would benefit from psychosocial interventions in this area after surgery.
Surgery is only the beginning for these bariatric surgery patients. Patients might not necessarily be prepared for the way in which these changes will affect their lives and relationships. Mental health professionals can help integrate these issues for the patient by providing psychoeducation and preparing them for what to expect during both the preoperative and postoperative periods. In short, the work we do on behalf of bariatric surgery patients is essential to their long-term success and quality of life.
Dr. Goldman is a bariatric psychologist in the Bellevue Center for Obesity and Weight Management program and a clinical assistant professor in the department of psychiatry at the NYU School of Medicine, New York.