New Recommendations for the Presurgical Psychosocial Evaluation of Bariatric Surgery Patients

Published in May Issue             

The ASMBS Integrated Health Clinical Issues and Guidelines Committee has issued recommendations for the presurgical psychosocial evaluation of patients undergoing bariatric surgery. Co-authors include: Stephanie Sogg, PhD, Assistant Professor of Psychology, Harvard Medical School and Clinical Psychologist, Massachusetts General Hospital Weight Center, Boston; Lisa West-Smith, PhD, LISW-S, Assistant Professor, University of Cincinnati, College of Medicine, Department of Psychiatry & Behavioral Neuroscience, Department of Surgery and Director, Behavioral Health Services, UC Health Weight Loss Center; and Jennifer Lauretti, PhD, ABPP, FACHP, Clinical Health Psychologist, UMass Memorial Weight Center and Assistant Professor, Department of Psychiatry, University of Massachusetts Medical School.

Here are five questions we asked them about the new recommendations, which will be published in SOARD.

What are the implications of the updated set of recommendations for
bariatric surgery?

Although the majority of programs require patients to obtain a behavioral health assessment prior to weight loss surgery, a standardized protocol does not yet exist. Reasons for this likely include variability in clinic settings, geographical differences that may impact access to behavioral health providers and also program specific needs. For example, it is important to consider the patient demographics, payor specific requirements and program constraints when developing protocols.

Our intent is to put forward a formal set of recommendations to help guide behavioral health professionals who are evaluating patients for bariatric surgery. Ideally, the recommendations will help to promote standardization of evaluation methods in the field, and establish some standards for best practice. We also want to increase the knowledge of the people conducting these evaluations, to help them understand better why it is important to evaluate certain domains, and what is known (and not yet known) in the psychosocial literature regarding
bariatric surgery.

One of the implications of the guidelines is the focus on the expanded role of the bariatric behavioral healthcare provider in the care of bariatric surgery patients to assist in optimizing surgical outcomes. That is not necessarily narrowly restricting behavioral health input to pre-surgical evaluation, but (where resources permit) expanding the role to pre-op preparation and post-op monitoring, support, and intervention when needed. An evaluation visit with a bariatric behavioral health provider is conceptualized as a valuable opportunity to establish a trusted connection to a behavioral health provider as a resource and integral member of their care team – someone who can potentially contribute to the patient’s care throughout the bariatric process.

Why the need for the update?

It is ASMBS policy to update formal recommendation and guidelines documents periodically, as new knowledge emerges. Additionally, both the prevalence of bariatric surgery and the integration of behavioral health care within bariatric practices have increased dramatically since the 2004 document was written. There has also been an enormous explosion of bariatric behavioral health research published since that time. This updated document was created to ensure that the recommendations for pre-op evaluations are based on a synthesis of the most recent empirical findings and expert opinion.

What are the biggest changes to the recommendations and why are
they important?

The 2004 document was produced by an ad-hoc Behavioral Health Committee, as at that time, there was no Integrated Health Clinical Issues and Guidelines Committee (and far less involvement of behavioral health within the ASMBS membership or leadership). This new document, which comes out of the Integrated Health Clinical Issues and Guidelines Committee, was produced according to formal ASMBS protocol for developing such documents (which did not exist in 2004), and has been approved by the ASMBS leadership.

The 2004 document was really excellent and rather comprehensive, but less systematic in scope and included less discussion of empirical evidence (partly because there was so much less of the relevant empirical evidence at that time).

Many of the topics covered in the two documents are the same, as is the overall message/philosophy, but the updated document has more incorporation of the empirical research, and much more research has been published since 2004; thus, most of the domains are discussed in more detail in the updated document. In addition, the current document includes a new section, which discusses the importance of ongoing behavioral health monitoring and support after surgery, which reflects a shift in bariatric practice and philosophy between 2004 and today.

Do most practices follow these recommendations already? Do you anticipate changes in practice as a result of the recommendations?

We cannot know exactly how all programs across the US, or globally, conduct their practices. Our impression is that there is great diversity across programs in terms of what practice models they use, their access to resources, their treatment philosophies, etc.

What’s the big “take away” message you hope those reading them get from
the recommendations?

The bariatric behavioral health care provider is an integral member of the multidisciplinary team of providers working with bariatric surgery patients (both before and after surgery). A trained bariatric behavioral health professional is ideally suited to support the complex and dynamic process of behavior change required when a patient undergoes bariatric surgery. Sustained adherence to the post-surgical regimen is dependent on adequate psychosocial functioning, and is linked to improved surgical outcomes. These outcomes can be optimized with the support of a team of providers.

We also feel it is important to stress that there is no one behavioral health discipline (e.g., psychiatrist, psychologist, clinical social worker, etc.) that is more qualified than any other to evaluate and work with bariatric patients; what is important is the breadth and depth of the specialized knowledge, experience, and skill sets required to perform this care competently and serve our patients well.

One major hope we have is that becoming familiar with these recommendations will prompt behavioral health and other bariatric providers to focus more on basing practice on
empirical knowledge.

We would also hope to see both surgeons and behavioral health clinicians moving away from the “clearance” model, and toward a model focused on the collaborative enhancement of patient outcomes, with behavioral health care being available throughout the bariatric surgery process, not solely at the evaluation stage.