Four referrals to a psychiatrist and not one questionnaire behind them
- The document. National clinical guidelines "Obesity" for adults, ID 28_3 in the Ministry of Health rubricator, year of approval 2024 with revision due no later than 2026, covering ICD-10 codes E66.0, E66.1, E66.2, E66.8 and E66.9. Developed by the Russian Association of Endocrinologists together with the Society of Bariatric Surgeons and approved by the Scientific and Practical Council of the Ministry of Health of the Russian Federation. The working group is led by Dedov, Mokrysheva, Melnichenko and Troshina, with the text written by Mazurina, Ershova and Komshilova. It is a guideline, not a study: it collected no data, has no comparison group and reports no outcome of its own.
- Where a psychiatrist stands in the route, in four places. Every patient with obesity, after secondary causes of weight gain have been excluded, is recommended an appointment with a psychiatrist or a psychotherapist specialising in somatic disease and psychosomatic disorders, references 85 and 86, graded C with evidence level 5. Patients with an indication for surgery are recommended an appointment with a psychiatrist to exclude contraindications, references 90 to 95, graded C with level 4. At the weight-maintenance stage after conservative treatment, regular appointments in person or remote with an endocrinologist, a dietitian and a psychotherapist or psychiatrist, references 179 to 182, C with level 5. After bariatric surgery, the same regular appointments with an endocrinologist, a surgeon and a psychotherapist or psychiatrist, references 88 to 95, C with level 5.
- What the document does not contain. The appendix reserved by the national template for assessment scales, questionnaires and other instruments for evaluating the patient's state, numbered G1 to GN, consists of two words: not provided. There is no screening tool, no cut-off score and no rescoring interval anywhere in the text. The thirteen quality-of-care criteria that close the document cover history taking, visual examination, anthropometry, daily energy calculation, blood pressure and heart rate, biochemistry, carbohydrate metabolism, endocrine screening, abdominal ultrasound, cardiac workup, structured patient education, body-weight measurement and drug prescribing. Not one of the thirteen is psychiatric.
- The grades are not distributed evenly. Surgical indications are given as age 18 to 60 with prior conservative treatment having failed, a BMI above 40 regardless of comorbidity or above 35 with a severe condition whose course weight loss can alter, at strength B and evidence level 2. Semaglutide titration is written to the milligram and the four-week step at the same B and 2. The four psychiatric points carry C with levels 5 and 4. On the document's own scales, C reads as a weak recommendation, level 5 as mechanistic rationale or expert opinion, and level 4 as non-comparative studies, case reports or case-control work.
The Russian obesity guideline names no instrument. The appendix its national template reserves for assessment scales, questionnaires and other tools for evaluating the patient's state carries a single line: not provided. Nothing is screened, nothing is scored, nothing is repeated at an interval. The document is the 2024 edition, ID 28_3, written by the Russian Association of Endocrinologists with the Society of Bariatric Surgeons, approved by the Scientific and Practical Council of the Ministry of Health, and it covers adults under the E66 codes.
What it does specify is who the patient sees. A psychiatrist or a psychotherapist stands in the route at four points. Every patient with obesity, once secondary causes of weight gain have been excluded, is to be seen by a psychiatrist or a psychotherapist specialising in somatic disease and psychosomatic disorders; that line sits among the other diagnostic investigations and is graded C with evidence level 5. Candidates for surgery are seen by a psychiatrist to exclude contraindications, graded C with level 4. At the weight-maintenance stage after conservative treatment the patient attends regular appointments, in person or remote, with an endocrinologist, a dietitian and a psychotherapist or psychiatrist. After bariatric surgery the same appointments continue, with the surgeon in place of the dietitian. Both are graded C with level 5.
Those grades are worth reading beside the ones the document hands out elsewhere. The surgical thresholds are precise: age 18 to 60, prior conservative treatment having failed, a BMI above 40 regardless of comorbidity or above 35 with a severe condition whose course weight loss can alter, at strength B and evidence level 2. Semaglutide is titrated to the milligram and the four-week step on the same B and 2. The psychiatric leg of the route carries C and expert opinion.
The contraindications name psychiatric states directly. Surgery is not recommended in severe depressions, psychoses including chronic ones, abuse of alcohol and other psychoactive substances, and certain personality disorders. Eating disorders are named among the states in which one of the recommended drugs is not to be used. Each of these is a category, and none arrives with a way of establishing that it applies: no threshold, no instrument, no window of observation. The thirteen quality-of-care criteria that close the document run from history taking to prescribing, and none of them is psychiatric.
For the clinician on the receiving end this settles one thing and leaves the other open. The referral is written into the route at four points, so the patient arrives, and arrives with a question that has an administrative shape: is there a contraindication, is the eating behaviour manageable, is the person holding the weight. What happens in the appointment, and what goes back in the letter, is not set anywhere in the document. Whatever gets used comes from the centre's own protocol or from the individual clinician. The route is national and the assessment inside it is local.
The appendix the national template reserves for assessment scales, questionnaires and other instruments for evaluating the patient's state, as printed in full: not provided.
This is a national clinical guideline, not a study. It collected and analysed no data of its own, has no comparison group and no outcome, and its grades come from its own two scales, on which strength C reads as a weak recommendation and evidence level 5 as mechanistic rationale or expert opinion. The silence of the appendix says that assessment is not standardised at the level of the document, not that assessment is nowhere performed: large endocrinology and bariatric centres may work to internal protocols, and nothing in the text stops a clinician from using an instrument of their own choosing. What the guideline withholds is the requirement, the threshold and the common form, not the practice. Russian clinical guidelines are not indexed in PubMed and carry no DOI, which makes this source unverified in that database rather than unreal; it was read from the Ministry of Health rubricator record for ID 28_3, version 3, published 25 December 2024, cross-checked against the full text reproduced at MedElement. The reference numbers in square brackets are the guideline's own numbering. Year of approval is 2024 with revision due no later than 2026, so the wording described here is the wording in force at the time of writing.