Mary Holcomb, Psy.D.

The number of bariatric procedures being performed in the U.S. is on the rise. A comprehensive assessment of bariatric candidates includes a medical/surgical evaluation, nutritional screening and psychological assessment. The medical evaluation is designed to identify and treat medical comorbities that may affect perioperative risks and long-term outcomes. The psychological assessment identifies risk factors that may affect the bariatric candidate's optimal post-surgical outcome.

Although there is no established criteria for screening out bariatric candidates based on psychological factors, a number of bariatric programs (Mayo Clinic, 2006), recommend that contraindications for surgery include: illicit drug abuse, active uncontrolled symptoms of schizophrenia, severe mental retardation (IQ<50), heavy alcohol use, and lack of knowledge about surgery. The majority of bariatric candidates do not fall into a discreet psychiatric category, instead they are likely to present with a mixed picture of psychiatric and psychosocial variables that could potentially impact surgical outcomes. It should be noted that a history of psychosocial difficulties or the presence of a psychiatric disorder that is well managed is not a contraindication for bariatric surgery.

Psychosocial factors affecting bariatric patients often include financial stressors due to comorbid health issues and an inability to work, limited mobility resulting in significantly restricted range of activities, and social isolation. The social stigma associated with obesity often serves to limit the typical bariatric patient's interaction with others and consequently their opportunity to receive adequate levels of social support. Social support has been well documented as a factor that serves to ameliorate the effects of stress. In numerous studies individuals who have adequate social support systems are shown to experience fewer psychological and physiological symptoms as a result of life stress. The individual who is socially isolated is not only at greater risk for becoming depressed, but also lacks the opportunity to develop a sense of identity as a member of a shared community. Isolation and loneliness further contribute to poor eating and lifestyle habits that fuel a downward negative cycle for the bariatric patient.

Lifestyle factors that contribute to obesity include lack of exercise, poor nutrition and unhealthy coping mechanisms for managing stress. Dietary education should be provided by a nutritionist prior to undergoing bypass. Individuals undergoing this procedure must not only be prepared to eat less, but be well informed of the nutritional and dietary changes necessary to achieve optimal post-surgical outcomes. In assessing the bariatric candidates motivation for surgery, the psychologist should inquire about the individual's readiness for change in addition to assessing their knowledge of dietary requirements. For example, bariatric candidates are often unaware of the need to restrict alcohol intake or of the number of nutritional supplements required post-surgery.

Many bariatric candidates have developed poor coping skills. Loneliness, boredom or other negative emotions have become triggers for overeating. If the bariatric candidate is not actively working toward developing healthier coping strategies, once food is removed as an outlet, they may experience an increase in negative affect that in turn increases their risk for additional mental health problems. The ability to modulate negative emotions as well as manage stress is critical for physical and psychological health. Healthy coping mechanisms for managing stress include the ability to think positively or use other cognitive strategies to appraise the self as well as significant life events. In addition, being physically active allows the individual to discharge excess tension, as does engaging in relaxation exercises such as yoga or meditation. Developing a hobby or interest that is rewarding can also serve as a healthy coping mechanism for stress management. Preparation for bariatric surgery should include a review of the individual's typical coping style as well as providing recommendations for areas of potential improvement.

In summary, many challenges face an individual with obesity. Proper assessment and preparation of the bariatric candidate prior to surgery is essential in order to achieve optimal post-surgical outcomes. Because the problems facing a bariatric patient are multi-faceted, the presurgical preparation should involve the combined efforts of a team of healthcare professionals including physicians, surgeons, nutritionists, and psychologists/psychiatrists. The psychologist's role consists of assessing psychological deficits as well as providing the bariatric candidate with recommendations for remediation. Counseling with the goal of enhancing mood, developing tools for stress management and expanding healthy coping mechanisms can be beneficial for many bariatric candidates depending on their psychological status. Essential for all bariatric candidates is the opportunity to receive social support in a nonjudgmental environment. Patients who utilize ongoing bariatric support services post-surgery gain the necessary education to sustain lifestyle and dietary changes, and the opportunity to establish relationships with other individuals who have a unique appreciation of their life issues. A sense of acceptance coupled with a feeling of belonging, can go a long way toward reintegrating patients into the community who have experienced extended periods of isolation due to their weight and/or comorbid health issues.


Mary Holcomb, Psy.D. is a Licensed Clinical Psychologist in independent practice with Associates in Psychology and Counseling. Dr. Holcomb has extensive experience in working with individuals experiencing health-related issues. She also works collaboratively with a number of central Florida bariatric programs to provide pre-surgical psychological assessment.