What pre‑operative psychiatric assessment and management are recommended for adult bariatric surgery candidates with severe obesity (BMI ≥ 40 kg/m² or ≥ 35 kg/m² with obesity‑related comorbidities)?

Pre-Operative Psychiatric Assessment for Bariatric Surgery Candidates

All bariatric surgery candidates require mandatory presurgical mental health evaluation to identify psychological factors that may influence long-term surgical success and to prepare patients for required lifestyle changes. 1, 2

Rationale for Psychiatric Evaluation

The psychiatric and psychological assessment serves two critical functions:

• Identifies factors that may influence long-term success in maintaining weight loss after surgery 2
• Prepares patients for lifestyle changes needed both before and after the surgical procedure 2
• Ensures psychological stability and understanding of required behavioral modifications 3

Required Pre-Operative Assessments

Mental Health Evaluation Components

A comprehensive mental health evaluation must be completed before proceeding with bariatric surgery 1, 3. This evaluation should specifically assess:

• Active psychiatric disorders that could impair surgical recovery or adherence to post-operative protocols 2
• History of substance abuse, as this represents a contraindication to surgery 2
• Patient motivation and compliance with long-term treatment requirements 2
• Cognitive capacity to provide informed consent and understand lifestyle modifications 1
• Emotional maturity to handle the psychological demands of major surgery and sustained behavioral change 1

Nutritional Assessment

Presurgical nutrition evaluation is mandatory alongside the mental health assessment 1. This comprehensive evaluation addresses:

• Current dietary patterns and nutritional deficiencies 1
• Understanding of post-operative dietary restrictions 1
• Ability to comply with lifelong nutritional supplementation requirements 1

Patient Selection Criteria

Eligibility Requirements

Candidates must meet these criteria before psychiatric clearance:

• BMI ≥40 kg/m² or BMI ≥35 kg/m² with obesity-related comorbidities (diabetes, hypertension, sleep apnea, etc.) 1, 4, 3
• Documented failure of adequate diet and exercise programs 4, 3
• Assurance that patient is well-informed, motivated, and compliant 2
• Acceptable operative risk based on medical evaluation 3

Psychological Contraindications

Active untreated psychiatric conditions or substance abuse represent contraindications to proceeding with surgery 2. Specifically exclude patients with:

• Current substance abuse disorders (alcohol, drugs) 2
• Severe untreated depression or psychosis that impairs decision-making capacity 2
• Inability to understand or commit to required lifestyle changes 3

Post-Operative Psychiatric Considerations

Increased Risk of Depression

Bariatric surgery patients face significantly increased risk of new-onset depression compared to medically managed patients 5. Specifically:

• 8.9% of surgical patients developed new depression versus 6.5% of medical patients (RD 2.4%, RR 1.5) 5
• Increased opioid treatment rates (19.4% surgical vs 15.8% medical, RR 1.3) 5

Long-Term Mental Health Support

Ongoing psychological support is essential for surgical success:

• Long-term multidisciplinary follow-up for at least 2 years, sometimes lifelong 3
• Regular psychological support as part of comprehensive post-operative care 3
• Monitoring for depression and substance use given increased post-operative risks 5

Common Pitfalls to Avoid

Do Not Delay Appropriate Referrals

Avoid delaying bariatric referral due to misconceptions that patients must exhaust all conservative options when they meet surgical criteria with multiple severe comorbidities 6. Obesity is a chronic disease requiring specialized medical management 6.

Recognize Surgery Is Not Standalone Treatment

Bariatric surgery requires comprehensive lifestyle changes and is not a cure 3. Key considerations:

• 20-30% of patients experience suboptimal response or weight regain despite surgery 3
• Long-term success depends on continued participation in comprehensive lifestyle programs 1, 4
• Surgery is an adjunct to lifestyle treatment, not a replacement for behavioral modification 6

Ensure Adequate Support Systems

Patients must have home support and stable social circumstances 1. The psychiatric evaluation should assess:

• Availability of family or social support for post-operative recovery 1
• Ability to attend regular follow-up appointments for years after surgery 3
• Financial and logistical capacity to maintain long-term care 3

Recommended Action Plan

1. Refer all eligible candidates (BMI ≥40 or ≥35 with comorbidities) to experienced bariatric centers with multidisciplinary teams 1, 6

2. Ensure completion of mandatory mental health evaluation before surgical clearance 1, 3, 2

3. Optimize any identified psychiatric conditions before proceeding with surgery 2

4. Establish long-term mental health monitoring plan given increased depression and opioid use risks 5

5. Confirm patient understanding that surgery requires lifelong behavioral changes and medical follow-up 1, 3