Experts Stress Value of Preoperative Psychological Testing in Patients Undergoing Weight-Loss Surgery

Although practice guidelines have long recommended a formal psychological evaluation for patients undergoing metabolic and bariatric surgery (MBS), controversy surrounding the predictive utility of such assessments has persisted.

A new literature review aims to address this ongoing debate by examining the value and limitations of preoperative behavioral health evaluations in the more than 280,000 patients who undergo MBS in the U.S. annually. Published in a recent issue of Surgery for Obesity and Related Diseases, the empirically based commentary builds a case for psychological evaluations by arguing why they should remain a core component of surgical weight-loss treatment.

“I think the evidence is quite clear: A psychological evaluation conducted by an appropriately trained clinician benefits all stakeholders and should continue to be the standard of care for patients undergoing weight-loss surgery,” says Cleveland Clinic psychologist and senior author Leslie Heinberg, PhD.

Pre-MBS psychological assessments, which have been recommended since 1991, are required by many third-party payors, she notes. Indeed, 2020 guidelines endorsed by the American Society for Metabolic and Bariatric Surgery, the Obesity Society, and the American Association of Clinical Endocrinologists state, “A formal psychosocial-behavioral evaluation performed by a qualified behavioral health to assess environmental, familial, and behavioral factors and risk for suicide should be required for all patients before a bariatric procedure....”

Understanding obesity

Despite this collaborative endorsement, Dr. Heinberg stresses that variabilities in postoperative outcomes highlight the need for an integrated approach that addresses both the physical and psychological aspects of weight loss. Although the potential benefits of MBS are well-established, she notes that many patients face unexpected emotional challenges when adjusting to their postsurgical routines.

“While MBS saves lives and remains our most efficacious weight-loss tool, outcomes vary and psychosocial complications remain a concern,” she says. “In light of the various risks of these procedures, the preoperative psychological evaluation should not be regarded as a mere formality but as a critical step in the surgical process.”

The efficacy of MBS as a treatment for class III obesity is widely recognized; most patients lose an average of 20–30% of their baseline weight in the year following surgery. Moreover, bariatric surgery has been shown to substantially improve and even resolve numerous obesity-related comorbidities, including diabetes and heart disease. However, Dr. Heinberg notes that there remains a significant number of patients for whom weight loss remains elusive or who have postoperative psychosocial difficulties.

“Suboptimal weight loss, significant weight recurrence and psychological complications can undermine the benefits of MBS and place patients at risk for further comorbidities, additional medical interventions, reduced quality of life, and increased morbidity and mortality,” she says. “This is why it’s so crucial to identify any risk factors that may jeopardize early postsurgical outcomes – and it’s where high-quality psychological assessments come into play. A well-executed mental health evaluation not only supports better outcomes following MBS but also highlights the multifaceted, emotionally complex nature of obesity.”

Looking ahead

Dr. Heinberg urges the medical community to look beyond traditional behavioral assessments when managing those who are considering weight-loss surgery. Importantly, she encourages providers to refine the methodologies commonly used in presurgical evaluations, asserting that formal clinical interviews may provide more insight than other less-structured screening tools, including chart reviews.

Of note, Dr. Heinberg endorses appropriate payor reimbursements for providers who perform preoperative psychological testing, most of whom rely on financial support – and the time it allows – to conduct robust evaluations. She also urges mental health professionals to approach pre-MBS evaluations with scientific rigor, incorporating multimethod data wherever feasible.

“When done well and with adequate time allowed, psychological testing has the ability to unearth information that can be used to prepare patients for success,” she says. “By integrating sensitive mental health assessments into pre-MBS protocols, clinicians can harness a holistic approach to care that can inform the journey toward improved health.”