Pre-op/procedure psych evaluations

[Horners]

From my understanding, there are a handful of surgeries/procedures that require a psych evaluation prior to initiating the treatment.

While I am curious about all kinds of psych evaluations honestly (pre-transplant, bariatric, certain jobs like pilots and whatever else.)

Can someone explain to me why patients for bariatric surgery who are BMI >50 + Htn + DMII + you name it. Require a psych evaluation?

And another question, if bariatric patients require psych evals, how do cosmetic surgery candidates not also require psych evals?

Just imagine a case with a body dysmorphic patient (undiagnosed) who keeps going back to the cosmetic surgeon to fix issues only they see. Almost feels like giving a drug addict a prescription pad.


Your thoughts, experiences and corrections (if I’m wrong about my assumptions). Thank you.


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[WisNeuro]

https://asmbs.org/app/uploads/2016/06/2016-Psych-Guidelines-published.pdf

 

[Crayola227]

I don't think the issue is, is this person crazy for wanting this procedure, in the case of bariatric. As you point out, it's easy to see objective measures that it's indicated.

It's more that there actually isn't much point to the procedure if the patient isn't going to follow through on lifestyle interventions. People have eaten right through those staples until their lil bellies popped. So I think in this case the psych eval is to look at what issues the patient has regarding their weight, that doesn't relate to the size of their stomach, like emotional eating or other habits/psych issues. You want to assess the patient's motivation to eat right and exercise, because really bariatric is an adjunct (something that you add on that helps the main thing you're doing for a problem) for weight loss, particularly rapid weight loss. I'll explain why the rate matters. In any case, weight still has to be lost the "hard way" through diet and exercise. The restriction introduced by bariatric more assists in the speed of weight loss. For people that are that obese, time in losing the weight really is of the very essence, as with each day the risk of stroke, heart attack, diabetes, etc etc etc is so high, that to wait for lifestyle interventions alone, even done to their fullest potential, to lose the weight, is too slow. Sometimes losing the weight quickly enough can resolve someone's pre-diabetes, so that they don't go on to be diabetic, for example. By restricting the size of the stomach it really helps the patient bring about a calorie reduction that would otherwise be almost impossible on its own.

So this was to explain that such a surgery is not a magic bullet, and it has risks. Whether the procedure will have benefit or not, is mostly up to the post-surgical behavior of the patient. And medically, when we want to assess complex behavior and emotions, we typically turn to our psychiatrist friends.

As far as body dyspmorphia and cosmetic procedures, while it is somewhat related to the topic of weight/appearance, the indication and the purpose of a psych exam for issues related to purely elective cosmetic procedures, is different. For one, bariatrics (at least in the US when done according to proper guidelines) is done for health risks primarily, and is not considered cosmetic even though it is elective. It may have cosmetic effects certainly, and that can be a patient motivator, but it is not the primary purpose. Assessing the distress experienced by someone in relation to elective cosmetic surgery is not the same as assessing the root of someone's weight problem, and ability to change behavior.

 

[Horners]

I don't think the issue is, is this person crazy for wanting this procedure, in the case of bariatric. As you point out, it's easy to see objective measures that it's indicated.

It's more that there actually isn't much point to the procedure if the patient isn't going to follow through on lifestyle interventions. People have eaten right through those staples until their lil bellies popped. So I think in this case the psych eval is to look at what issues the patient has regarding their weight, that doesn't relate to the size of their stomach, like emotional eating or other habits/psych issues. You want to assess the patient's motivation to eat right and exercise, because really bariatric is an adjunct (something that you add on that helps the main thing you're doing for a problem) for weight loss, particularly rapid weight loss. I'll explain why the rate matters. In any case, weight still has to be lost the "hard way" through diet and exercise. The restriction introduced by bariatric more assists in the speed of weight loss. For people that are that obese, time in losing the weight really is of the very essence, as with each day the risk of stroke, heart attack, diabetes, etc etc etc is so high, that to wait for lifestyle interventions alone, even done to their fullest potential, to lose the weight, is too slow. Sometimes losing the weight quickly enough can resolve someone's pre-diabetes, so that they don't go on to be diabetic, for example. By restricting the size of the stomach it really helps the patient bring about a calorie reduction that would otherwise be almost impossible on its own.

So this was to explain that such a surgery is not a magic bullet, and it has risks. Whether the procedure will have benefit or not, is mostly up to the post-surgical behavior of the patient. And medically, when we want to assess complex behavior and emotions, we typically turn to our psychiatrist friends.

As far as body dyspmorphia and cosmetic procedures, while it is somewhat related to the topic of weight/appearance, the indication and the purpose of a psych exam for issues related to purely elective cosmetic procedures, is different. For one, bariatrics (at least in the US when done according to proper guidelines) is done for health risks primarily, and is not considered cosmetic even though it is elective. It may have cosmetic effects certainly, and that can be a patient motivator, but it is not the primary purpose. Assessing the distress experienced by someone in relation to elective cosmetic surgery is not the same as assessing the root of someone's weight problem, and ability to change behavior.

Thank you for really elaborating on the purpose of the pre-bariatric psych assessment. I was not exactly why sure why it was done. Essentially it’s to find a potential psychological cause of the patient’s obesity and to gauge motivation to change their life essentially.

I understand bariatric surgery is not primarily cosmetic, it is medical and can really save people’s lives.

However my question about cosmetic surgery still kind of remains unanswered. Why do we not have psychological screens for these patients?

I am not speaking from a moral high ground, I don’t view those who get cosmetic procedures as morally corrupt. I am saying, isn’t it really likely that these patients suffer from underlying psychological issues related to their motivation to get cosmetic surgery?



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[splik]

obesity is most commonly a psychiatric disorder. there are lots of reasons to have a pre-operative bariatric surgery evaluation including a diagnostic evaluation to make sure patients are receiving appropriate treatment for comorbid psychiatric issues. sexual trauma and attachment disorders are very common in morbidly obese and superobese patients. we want to know how they will cope with the requirements prior to and after surgery, whether their motivations and expectations are realistic, their understanding of the significant risks and complications (many people are worse off afterwards), that any adherence barriers are addressed, and any substance use disorders identified. missing a diagnosis of alcoholism in a bariatric patient can be disastrous.

cosmetic surgery is cash based. sometimes psych evaluations are put in place for things like bariatric surgery or transplantation because insurance companies dont want to pay for something if it's going to be a mess. for cash based services, there are no insurance diktats, and so it will be up to the cosmetic surgeon to decide. they may not think it good business sense to screen out people and limit their clientele. on the other hand, they may find pre-operative psychological evaluations a way of trying to reduce the risk of lawsuits and violence to them. also not everywhere requires a psychosocial eval of bariatric patients, but it is now considered standard of care. and there is nothing stopping patients going south of the border for an RYGB just like they can for cosmetic surgery

 

[Horners]

obesity is most commonly a psychiatric disorder. there are lots of reasons to have a pre-operative bariatric surgery evaluation including a diagnostic evaluation to make sure patients are receiving appropriate treatment for comorbid psychiatric issues. sexual trauma and attachment disorders are very common in morbidly obese and superobese patients. we want to know how they will cope with the requirements prior to and after surgery, whether their motivations and expectations are realistic, their understanding of the significant risks and complications (many people are worse off afterwards), that any adherence barriers are addressed, and any substance use disorders identified. missing a diagnosis of alcoholism in a bariatric patient can be disastrous.

cosmetic surgery is cash based. sometimes psych evaluations are put in place for things like bariatric surgery or transplantation because insurance companies dont want to pay for something if it's going to be a mess. for cash based services, there are no insurance diktats, and so it will be up to the cosmetic surgeon to decide. they may not think it good business sense to screen out people and limit their clientele. on the other hand, they may find pre-operative psychological evaluations a way of trying to reduce the risk of lawsuits and violence to them. also not everywhere requires a psychosocial eval of bariatric patients, but it is now considered standard of care. and there is nothing stopping patients going south of the border for an RYGB just like they can for cosmetic surgery

This was comprehensive, thank you.

I’d also like to ask about where else a psychiatric evaluation may be needed as I mentioned in my first post. I honestly have never been able to gather a comprehensive list.

Pre bariatric
Pre spinal stim implant
Pre transplant
Pre aviation (though I think you need a special cert for this? Idk)
Pre IVF

What else?
Still just a medical student, but where would a psych resident/attending learn to do these screens? Or are they primarily done by psychologists?



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[splik]

This was comprehensive, thank you.

I’d also like to ask about where else a psychiatric evaluation may be needed as I mentioned in my first post. I honestly have never been able to gather a comprehensive list.

Pre bariatric
Pre spinal stim implant
Pre transplant
Pre aviation (though I think you need a special cert for this? Idk)
Pre IVF

What else?
Still just a medical student, but where would a psych resident/attending learn to do these screens? Or are they primarily done by psychologists?



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They're not "screens" (or shouldn't be), nor are they "clearance" which is often how they are mis-used. I would not consider pre-procedural psychosocial evaluations the same as employment related FFD (fitness for duty) evaluations, as those have a different function and payment is different. It would not be considered normal to have a psychological evaluation before IVF, though prior to egg donation one might have a psychological evaluation.

Another big one not only your list is prior to gender affirming surgery, all patients need a "letter" which is basically a psychological evaluation, prior to this. At my institution, residents interested in LGBT mental health will learn to do these evaluations.

Depending on the settings different evaluations may be done by psychologists, psychiatrists, or even social workers. At my institution all transplant and MCS patients have a psychosocial eval from a social worker, but only a small proportion see a psychiatrist or psychologist. I have my residents and med students do these evaluations under my supervision. We also do evaluations for living donors, but again only certain living donors have a psychiatric evaluation (history of mental illness or substance use disorder, non-directed donor, under 21, someone on the team wants them to see a psychiatrist etc).

Residents and students are unlikely to get to do FFD evaluations because of the nature of this. If you want to learn how to do this you need to attend the relevant trainings and/or complete a forensic psychiatry fellowship that includes training on this (many do not).

There are certain cases where a psychiatrist rather than a psychologist (or as well as) should do an evaluation - particularly where there is a history of serious mental illness (e.g. schizophrenia), and/or when psychotropic medications are a big part of the picture and recommendations about this are needed.

Psychologists often approach these evaluations somewhat differently to psychiatrists (and in general do a more comprehensive job of it). They are more likely to use psychological testing. Personally, I think it is overkill to do psychological testing for every pre-operative evaluation, and I only recommend psychological testing in certain cases.

 

[futuredo32]

I've had a cosmetic procedure and my dermatologist regularly does botox and fillers for me, no psych clearance needed. Unless one has body dysmorphic disorder, I don't see it as being all that different than wearing make up , getting a manicure or coloring your hair. You are doing something you want to do to improve your appearance. My insurance company picked up the cost of my blepharosasty (sp?) and I paid for the forehead lift. I got botox at the beginning of the first wrinkle. I am currently undergoing the first of 5 treatments of facial resurfacing to look younger, I and my friends all do this, we were proactive. In our society men get distinguished women get older. Look at Hollywood, most men can be older and wrinkled- no problem, but older actresses? They don't get the same roles as older actors. Some of my patients in high prestige positions feel like they have to get cosmetic surgery to stay younger looking to keep their jobs and they are probably right.
I will be undergoing IVF , no psych clearance needed.
I have seen so many people fail after bariatric surgery. If they can't lose weight or stop overeating on their own, is something that makes them ill if they overeat going to help? I have several patients who failed their gastric bypass/gastric sleeve surgery and are left with the side effects of the surgery.

 

[LadyHalcyon]

This was comprehensive, thank you.

I’d also like to ask about where else a psychiatric evaluation may be needed as I mentioned in my first post. I honestly have never been able to gather a comprehensive list.

Pre bariatric
Pre spinal stim implant
Pre transplant
Pre aviation (though I think you need a special cert for this? Idk)
Pre IVF

What else?
Still just a medical student, but where would a psych resident/attending learn to do these screens? Or are they primarily done by psychologists?



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We do evals for people getting pain pumps. I should put the term evaluation in quotation marks because really the only thing insurance wants us to do is a conduct a clinical interview and administer the mmpi. My supervisor told me that some people with severe PTSD were triggered by the pump and tore it out of their skin; not sure how true this is. I agree that, depending on the severity of the plastic surgery, there should be a psych eval or at the very least a screener. I also think there should be a very comprehensive psych eval prior to gender reassignment surgery. I know that sentiment may not be the most PC at the moment, but research supports the overlap between bpd and gender identity disorder. Gender reassignment surgery is a very important decision and if the person doesn't in fact have true gender identity disorder the surgery could be very harmful.

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[Mass Effect]

As far as body dyspmorphia and cosmetic procedures, while it is somewhat related to the topic of weight/appearance, the indication and the purpose of a psych exam for issues related to purely elective cosmetic procedures, is different. For one, bariatrics (at least in the US when done according to proper guidelines) is done for health risks primarily, and is not considered cosmetic even though it is elective. It may have cosmetic effects certainly, and that can be a patient motivator, but it is not the primary purpose. Assessing the distress experienced by someone in relation to elective cosmetic surgery is not the same as assessing the root of someone's weight problem, and ability to change behavior.

Actually, that's not why they would do a psych eval in cases of body dysmorphia, and some cosmetic surgeons DO require one before they will operate. They look for a psych eval because a psychiatric opinion about whether this is someone who is just bugged by some body part or deformity or if it's body dysmorphia, which potentially carries the risk of the patient never actually being satisfied with any result and seeking surgery over and over and over again. I'd argue that's a health issue as well and has everything to do with mental health and well-being. You could, in fact, be harming a patient with body dysmorphia by doing a cosmetic procedure on them when their motivation is mental illness.

 

[Crayola227]

Actually, that's not why they would do a psych eval in cases of body dysmorphia, and some cosmetic surgeons DO require one before they will operate. They look for a psych eval because a psychiatric opinion about whether this is someone who is just bugged by some body part or deformity or if it's body dysmorphia, which potentially carries the risk of the patient never actually being satisfied with any result and seeking surgery over and over and over again. I'd argue that's a health issue as well and has everything to do with mental health and well-being. You could, in fact, be harming a patient with body dysmorphia by doing a cosmetic procedure on them when their motivation is mental illness.

lol before I saw this I was rereading my post and thinking on that point I wasn't being very clear...

I stand by the idea that the issues *typically* involved in deciding if someone is a good candidate for bariatric is a bit different than what is at play with eval'ing someone who wants plastic surgery, of course I could be wrong.

I agree wholeheartedly that body dysmorphia is absolutely a health issue, and one that is not "just" a question of mental health either. I think this is true of every mental illness, actually, including personality disorders. It's pretty rare that someone's mental illness is not having detrimental effects on their physical well-being or self-care or what have you.

I'd go a step further. It's come up that obesity is one of the most serious physical health issues facing our country, on a level that could be called an epidemic, and an extremely costly one.

Splik points out a lot of mental health issues are associated with that. I don't know how relevant it is nowadays, but some of my favorite studies came out of the ACE study. I have made some required reading for all my students. I think it's extremely relevant regardless of specialty. I personally believe it provides an excellent and rational explanation for a lot of patients' "irrational" behaviors and so many of the ways that they are killing themselves. That and the fact that I think a lot of socioeconomic and cultural values contribute to unhealthy living.

That said, I firmly believe the most significant step that we can take to address all that ails this country on a health level, would be prioritizing mental health. I think that is where the rest of health flows. I was once told by a urologist, that if people just drank enough water, it would essentially put them out of business. I think this is true for mental health. If we could wave a wand and make everything to do with mental health the #1 priority in this country, I think the impact would be huge. I'm being a bit hyperbolic, but I do think there are a huge number of diagnoses that would be addressed if what was the primary problem on a patient's problem list was their mental health issues.

 

[Horners]

I've had a cosmetic procedure and my dermatologist regularly does botox and fillers for me, no psych clearance needed. Unless one has body dysmorphic disorder, I don't see it as being all that different than wearing make up , getting a manicure or coloring your hair. You are doing something you want to do to improve your appearance. My insurance company picked up the cost of my blepharosasty (sp?) and I paid for the forehead lift. I got botox at the beginning of the first wrinkle. I am currently undergoing the first of 5 treatments of facial resurfacing to look younger, I and my friends all do this, we were proactive. In our society men get distinguished women get older. Look at Hollywood, most men can be older and wrinkled- no problem, but older actresses? They don't get the same roles as older actors. Some of my patients in high prestige positions feel like they have to get cosmetic surgery to stay younger looking to keep their jobs and they are probably right.
I will be undergoing IVF , no psych clearance needed.
I have seen so many people fail after bariatric surgery. If they can't lose weight or stop overeating on their own, is something that makes them ill if they overeat going to help? I have several patients who failed their gastric bypass/gastric sleeve surgery and are left with the side effects of the surgery.

Thank you for sharing your perspective getting some cosmetic work done. Also the IVF psych evaluations, from what I read online and what I saw in my rotations was that there is a psych evaluation prior to getting donors (sperm or egg). Idk if this standard of care or just something that certain clinics do.

Question to you and to others though, where is the line between mental illness and simply wanting to improve your appearance (make up, Botox, nice clothes?)

Certainly someone with poor hygiene (no showers, haircuts etc) is a possible sign of mental illness (prodrome for schizo?) but what about the other end of the spectrum?


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[NITRAS]

I just wanted to point out that the single most crazy patient I have so far encountered who accumulated, literally, years of hospitalization after a gastric bypass before dying a terrible death from recurrent fungemia and abdominal abscesses.

 

[futuredo32]

Thank you for sharing your perspective getting some cosmetic work done. Also the IVF psych evaluations, from what I read online and what I saw in my rotations was that there is a psych evaluation prior to getting donors (sperm or egg). Idk if this standard of care or just something that certain clinics do.

Question to you and to others though, where is the line between mental illness and simply wanting to improve your appearance (make up, Botox, nice clothes?)

Certainly someone with poor hygiene (no showers, haircuts etc) is a possible sign of mental illness (prodrome for schizo?) but what about the other end of the spectrum?


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Good question. I just had collagen injected in my lips. I was hoping for fuller lips than I got. I'm seeing my derm for a skin check in the next coming weeks and will voice my opinion. He won't do anything that looks unnatural. I don't obsess about it it's far from the biggest problem I have. I think the DSM 5 criteria is pretty good overall.

 

[futuredo32]

Ps skin check for melanoma not cosmetic

 

[Horners]

Ps skin check for melanoma not cosmetic

LOL thank you for that clarification


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