Behavioral Health and Psychological Support
What this domain tests
This domain covers the psychological evaluation, which conditions require treatment before surgery, informed consent and expectation setting, and the behavioral risks that emerge afterward - especially alcohol and transfer addiction.
Evaluation elements
- Validated screens: PHQ-9, GAD-7, binge eating scale or EDE-Q, AUDIT-C, nicotine screen.
- Binge eating disorder is not an absolute contraindication; it is a treatment target requiring behavioral therapy before and after surgery.
- Active substance use disorder, untreated psychosis, and inability to consent are absolute barriers.
- Document realistic expectations: roughly 25–30% total weight loss, not attainment of "ideal" weight.
Postoperative behavioral risks
- Alcohol is absorbed faster and reaches a higher peak after RYGB; counsel on impaired driving and transfer addiction.
- Suicide risk rises after surgery; screen at follow-up, not only preoperatively.
- Tobacco, grazing, and liquid calories predict weight regain.
Worked example
A 38-year-old man requests sleeve gastrectomy. PHQ-9 is 18, AUDIT-C is 8, and he reports weekly binge episodes. Reasoning: surgery is deferred, not cancelled. Refer for depression treatment and alcohol counseling, treat binge eating with cognitive behavioral therapy, and reassess in 3 months. Documenting the plan protects both patient and program; clearing him because "he will feel better after surgery" invites relapse and loss to follow-up.
Traps
- Excluding every patient with a psychiatric diagnosis instead of treating the active condition.
- Missing alcohol use because the patient does not fit a stereotype.
- Accepting a stated goal of reaching BMI 22 without correcting it and documenting the conversation.