Today’s post comes from Sylvain Iceta. Sylvain is a postdoctoral fellow at the Quebec Heart and Lung Institute, Laval University. He is also the current Recruitment Coordinator of the OC-SNP National Executive.
Psychiatric disorders are common in obesity with an estimated prevalence of 30-70% (1). Bariatric surgery is recognized as the most effective treatment to achieve sustainable weight loss and reduce the risk of physical comorbidities (2). Is this also relevant for mental health? According to a recent study, 16% of bariatric surgery patients have consulted or will consult a psychiatrist, 39% of whom will do it for the first time after surgery (3). These findings bring us to reconsider the “dogma” according to which weight loss is “systematically” combined with an improvement in mental health.
The overall prevalence of mood disorders among bariatric surgery candidates is 23% (19% for depression (4); 3% to 6% for bipolar disorder (5)). The beneficial effect of bariatric surgery on the prevalence or the severity of depression, in both short and medium term, is now well established (6). The long-term results are less clear. Some studies indicate improvements of more than 15% in the prevalence of depression while others indicate returns to pre-operative levels as well as a higher prescription of antidepressants after bariatric surgery (6). The improvements observed with time after bariatric surgery are not exclusively related to weight loss and probably involve other factors such as: reduced inflammation and insulin resistance, improved function of the hypothalamic-pituitary axis, higher levels of daily activities, improved satisfaction with body image, improved cognitive functioning, better interpersonal relationships, and better sexual health (7).
Limited data are available on bipolar disorder (or schizophrenia) outcomes after bariatric surgery. The potential impact of surgery on the course of bipolar disorder is a major concern. Indeed, bipolar disorder is considered to be the primary psychiatric factor associated with early psychiatric readmission rate after surgery (8). A higher rate of relapse and drop-out associated with time after surgery has also been reported in patients with bipolar disorder (9). In addition, the management of treatment after surgery can be challenging, particularly because of the potential treatment absorption modifications. It is important to take particular consideration of patients suffering from severe mood disorders before validating eligibility for the bariatric surgery procedure and to ensure an effective postoperative psychiatric follow-up.
It has been established that candidates for bariatric surgery have a greater history of suicide attempts or self-harm than the general population (10). A meta-analysis published in 2019 reported a suicide mortality rate of 2.7 per 1000 and a hospitalization rate for suicide attempts or self-harm of 17 per 1000 (11). There was a significant increase in the risk of suicide after bariatric surgery (OR = 3.8) compared with “control” populations matched by age, gender and BMI (11). This risk was not found to be directly related to weight loss results. A history of suicide attempts, mood disorders, eating disorders or the onset of severe depression were identified as risk factors for suicide attempts after a bariatric surgery (7). Disappointment with unrealistic expectations, excess skin, body-image dissatisfaction, childhood abuse, perception of inadequate social support, and unresolved familial, professional and social conflicts are exacerbating factors in at-risk patients of suicide (7). It is imperative to conduct further studies in order to better understand and prevent suicide mortality in patients undergoing bariatric surgery.
Other psychiatric disorders
Anxiety disorders have an estimated prevalence of 12% among adults (4). Bariatric surgery appears to have a positive effect on anxiety disorders in the first year. Here again, the results regarding long-term outcomes are controversial, both in terms of prevalence and symptom severity (6).
Post-Traumatic Stress Disorder (PTSD), which is known to be significantly associated with obesity, is reported to have a prevalence of 1% among candidates for bariatric surgery (4). To my knowledge, there are no currently published studies exploring the weight loss trajectory of these patients after bariatric surgery. However, childhood trauma or sexual abuse is reported to be associated with a higher rate of food addiction or depression, but no major difference in weight loss after bariatric surgery (12,13).
Attention-Deficit Hyperactivity Disorder (ADHD) is estimated to have a prevalence of 20.9% of patients who are candidates for bariatric surgery (14). The presence of ADHD does not appear to influence weight loss (14). However, the fact that this disorder is characterized by increased impulsivity and attentional difficulties is likely to have an impact on the follow-up and long-term adherence. The studies are mostly based on self-reported data and more research is needed to better understand the impact of this disorder on weight trajectories and safety of bariatric surgery.
Psychiatric disorders are particularly common in bariatric surgery candidates but should not lead to systematically counter-indicating such surgery. Although, it has long been expected that patients undergoing bariatric surgery will improve psychologically alongside their weight-loss, the current literature shows that although these disorders do not affect the weight prognosis, they can sometimes persist or even worsen after such surgery. One of the main challenges in the coming years will be to better understand the mechanisms leading to the emergence of new psychiatric disorders (i.e. anorexia nervosa) or to an increase in suicide mortality. A proper preoperative psychiatric assessment, by a trained psychiatrist, is essential to limit psychiatric iatrogeny as well as to better support weight management and reinforce psychological well-being following bariatric surgery.
- Avila C, Holloway AC, Hahn MK, Morrison KM, Restivo M, Anglin R, et al. An Overview of Links Between Obesity and Mental Health. Current Obesity Reports. 2015;4(3):303-10.
- Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric Surgery. JAMA. 2004;292(14):1724.
- Morgan DJR, Ho KM, Platell C. Incidence and Determinants of Mental Health Service Use After Bariatric Surgery. JAMA Psychiatry. 2019.
- Dawes AJ, Maggard-Gibbons M, Maher AR, Booth MJ, Miake-Lye I, Beroes JM, et al. Mental Health Conditions Among Patients Seeking and Undergoing Bariatric Surgery. JAMA. 2016;315(2):150.
- Grothe KB, Mundi MS, Himes SM, Sarr MG, Clark MM, Geske JR, et al. Bipolar Disorder Symptoms in Patients Seeking Bariatric Surgery. Obesity Surgery. 2014;24(11):1909-14.
- Gill H, Kang S, Lee Y, Rosenblat JD, Brietzke E, Zuckerman H, et al. The long-term effect of bariatric surgery on depression and anxiety. Journal of Affective Disorders. 2019;246:886-94.
- Müller A, Hase C, Pommnitz M, De Zwaan M. Depression and Suicide After Bariatric Surgery. Current Psychiatry Reports. 2019;21(9).
- Litz M, Rigby A, Rogers AM, Leslie DL, Hollenbeak CS. The impact of mental health disorders on 30-day readmission after bariatric surgery. Surg Obes Relat Dis. 2018;14(3):325-31.
- Jalilvand A, Dewire J, Detty A, Needleman B, Noria S. Baseline psychiatric diagnoses are associated with early readmissions and long hospital length of stay after bariatric surgery. Surgical Endoscopy. 2019;33(5):1661-6.
- Windover AK, Merrell J, Ashton K, Heinberg LJ. Prevalence and psychosocial correlates of self-reported past suicide attempts among bariatric surgery candidates. Surgery for Obesity and Related Diseases. 2010;6(6):702-6.
- Castaneda D, Popov VB, Wander P, Thompson CC. Risk of Suicide and Self-harm Is Increased After Bariatric Surgery—a Systematic Review and Meta-analysis. Obesity Surgery. 2019;29(1):322-33.
- Steinig J, Wagner B, Shang E, Dölemeyer R, Kersting A. Sexual abuse in bariatric surgery candidates – impact on weight loss after surgery: a systematic review. Obesity Reviews. 2012;13(10):892-901.
- Holgerson AA, Clark MM, Ames GE, Collazo-Clavell ML, Kellogg TA, Graszer KM, et al. Association of Adverse Childhood Experiences and Food Addiction to Bariatric Surgery Completion and Weight Loss Outcome. Obesity Surgery. 2018;28(11):3386-92.
- Mocanu V, Tavakoli I, MacDonald A, Dang JT, Switzer N, Birch DW, et al. The Impact of ADHD on Outcomes Following Bariatric Surgery: a Systematic Review and Meta-analysis. Obesity Surgery. 2019;29(4):1403-9.