The use and abuse of bariatric (weight loss) surgery has risen exponentially over the past decade. Initially proposed as an intervention for morbid obesity, this evolving technology is working its way down the obesity spectrum. Nowadays, it is not unheard of for moderately obese people, even children, to undergo this surgery.
If the occasional misapplication of this intervention is not problematic enough, many bariatric patients don’t even have a preoperative psychological evaluation. This should be an extensive assessment performed by a qualified psychologist. Perhaps worse still, even fewer patients receive adequate psychological support after surgery. I call this issue “the mind body problem” and I see it as a consequence of the artificial barriers we have put up between the physical and psychological aspects of health.
Evidence-based best practice in bariatric surgery dictates that psychological evaluations and support are integral aspects of the care pathway and patient journey. This inclusion of psychological evaluation and support helps ensure the best possible outcomes from the surgery, and can identify problems that might make immediate bariatric surgery a bad idea.
A report in Psychosomatic Medicine in 2005 noted that out of 188 bariatric programmes in the United States, 90 per cent required candidates for surgery to have a psychological assessment. Similar figures were reported for the UK in 2014. While 90 per cent is comparatively good, it still falls short of the target. In some countries surveyed, the inclusion of a psychological evaluation in bariatric care pathway was as low as 60 per cent.
It is recommended that this preoperative assessment be undertaken by a qualified psychologist. Some bariatric programmes take a simplistic view of the psychologist as a “gatekeeper” who helps determine who is and isn’t suitable for surgery. More forward-thinking programmes use psychologists to help prepare candidates for this life-changing surgery. The preoperative psychological input becomes more about identifying the best ways to support the individual both before and after surgery.
The psychological issues associated with bariatric surgery can be split into two broad categories: existing problems and those that arise after surgery. Existing problems might include major depression, binge eating disorder or addictions. The presence of such problems can have a huge bearing on weight-loss outcomes. For example, patients with binge eating disorders have been reported to lose less weight or experience greater weight gain after surgery. However, if this group of patients are identified in advance they can be given more appropriate support and enjoy improved outcomes.
The psychological problems arising after surgery can include anorexic or bulimic styles of eating. This can lead to greater than expected weight loss and disorders such as binging and purging. There is also growing evidence that some post-operative bariatric patients appear to be at higher risk of alcoholism and other addictive behaviours. In 2012, the Journal of the American Medical Association reported a study that showed an elevated risk of suicide in post-operative bariatric patients compared to the general population.
While most bariatric patients won’t experience the major psychological problems mentioned above, there are smaller, more common, issues that psychologists can address too. For example, unmet weight-loss expectations, body image issues and emotional eating are all relatively common psychological complaints frequently articulated by post-operative bariatric patients. Addressing these issues helps maintain good surgical outcomes over the longer term. If the “quick fix” is to be maintained, psychological support is crucial.
The UAE has a shortage of qualified psychologists. As long as this is the case the treatment of many physical health complaints – such as diabetes, cardiovascular disease, morbid obesity – will be suboptimal.
Mind, body and behaviour are closely intertwined, and world-class healthcare services pay equal attention to all three components. Psychologists specialise in mind and behaviour; we need more of them now.
Dr Justin Thomas is an associate professor of psychology at Zayed University and author of Psychological Well-Being in the Gulf States
On Twitter: @DrJustinThomas
