Obesity is a global health concern with significant physical and mental health implications. While bariatric surgery is an effective intervention for weight reduction and improving obesity-related conditions, it's crucial to recognize the potential for mental health concerns, particularly depression, following surgery. Surgeons often focus on weight loss and improvement of obesity-related conditions as a primary outcome after bariatric surgery. However, the success of bariatric surgery also relies on the improvement of mental health status. This article aims to provide a comprehensive understanding of depression after weight loss surgery, its prevalence, associated factors, and management strategies.
The Growing Problem of Obesity and the Role of Bariatric Surgery
Obesity affects a significant portion of the global population, with approximately 1.9 billion adults considered overweight and 610 million obese. Obesity negatively impacts physical and mental well-being, leading to cardiovascular issues, metabolic syndrome, and decreased quality of life. Obese patients are nearly 55% more vulnerable to experience depressive symptoms than the non-obese population. They may experience anxiety, low self-esteem, depression, and impaired quality of life (QoL). These significant consequences limit the patients’ performance, decrease their chances of getting a job due to physical appearance, increase their absenteeism frequency, and enhance isolation and addiction risks.
Bariatric surgery is considered the safest and most effective procedure for weight reduction, reducing obesity-related comorbidities and improving survival. However, success after bariatric surgery depends not only on weight loss but also on the improvement of mental health status. Patients undergoing bariatric surgery are associated with a fourfold increase in the risk of attempted suicide as compared to the general community.
Prevalence of Depression After Bariatric Surgery
A meta-analysis encompassing 33 articles and 101,223 patients revealed that the prevalence of post-bariatric surgery depression is relatively high reaching up to 64.9%, with almost one in five patients affected by it. The prevalence of post-bariatric surgery depression was found to be 15.3% (95% confidence intervals {CI}: 15.0-15.5%, p<0.001) among which severe, moderate, and minimal depression accounted for 1.9% (95% CI: 1.5-2.4%, p<0.001), 5.1% (95% CI: 4.4-5.8%, p<0.001), and 64.9% (95% CI: 63.3-66.5%, p<0.001), respectively. This highlights the importance of addressing mental health concerns in patients undergoing bariatric surgery.
Factors Associated with Post-Bariatric Depression
Several factors contribute to the development of depression after bariatric surgery.
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Weight Regain: Depression is negatively correlated with weight loss. Depression is negatively correlated with weight loss (correlation -0.135; 95% CI: -0.176 to 0.093; p<0.001) and positively correlated with eating disorder (correlation 0.164; 95% CI: 0.079-0.248; p<0.001). Inadequate weight loss can lead to the re-emergence of obesity and its associated complications, impairing the patient's quality of life.
Eating Disorders: There has also been a correlation between post-bariatric depression arising due to eating disorders that can occur.. Depression can also increase your risk for medical complications such as heart disease, diabetes, cancer, and substance abuse. Post-bariatric depression was associated with eating disorders. Patients who previously relied on eating as a maladaptive coping mechanism for underlying mental illness and distress may face challenges when this option is limited post-surgery due to physical changes reducing stomach capacity. Consequently, they may replace their prior addictive eating habits with new or exacerbated substance use.
Quality of Life: Post-bariatric depression is associated with poor QoL. The impact of post-bariatric surgery depression on the mental component of the QoL was assessed among 704 patients from four studies. In the random-effects model (p<0.001, I2=98%), pooling the effect sizes revealed a statistically significant association between post-bariatric depressive manifestations and mental component of QoL (correlation 0.217; 95% CI: 0.145-0.286; p<0.001).
Body Image Dissatisfaction: The resultant loose skin and plateauing of body weight after rapid weight loss are associated with a high risk of body dissatisfaction. These situations are accompanied by unrealistic expectations regarding rapid weight loss and body contouring, which puts the patients under more stress.
Relationship Difficulties: Difficulties in relationships have been reported, including divorces, contributing to feelings of depression. Removing the emphasis on food, especially after many years, can be difficult. Irritability after surgery is common, and I hear from spouses that the first few months may be accompanied by certain temporary personality changes. The tendency to snap at the people closest to us during times of stress may play out with the bariatric patient as they navigate the initial stressful postoperative months.
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Life Stressors: The many changes a person experiences after surgery and stressful adaptations may lead to depression. Some people underestimate the amount of stress they will go through during the first few postoperative months. If a person is already under stress, the addition of surgery may be overwhelming. Depression is not uncommon under these circumstances. If a person meets criteria for clinical depression preoperatively, the added stress of the surgery may exacerbate the depression.
Vitamin Deficiencies: Vitamin deficiencies are another factor that can reflect as symptoms of fatigue and mental health concerns. To support nutrition and overall health, it is important to follow supplement guidelines after surgery. Various micronutrient deficiencies following bariatric surgery have been reported due to food absorption changes. Although all types of procedures were associated with deficiencies, malabsorptive or combined types increased the risk of vitamin B12 deficiency by over 3-fold compared to restrictive procedures, owing to reduced parietal cells and decreased production of intrinsic factors. In addition, mineral deficiencies such as iron and calcium are more prevalent with combined-type procedures, as the main sites of absorption for these minerals occur in the duodenum and proximal jejunum, which are bypassed with this procedure. As a result, a study revealed that anemia occurred in nearly half of all patients undergoing RYGB, affecting approximately 17% of those undergoing restrictive-type procedures.The effect of vitamin D absorption varies depending on the type of surgery undergone. According to a recent review, sleeve gastrectomy showed no deficiencies in vitamin D absorption at multiple postoperative time points (3, 6, and 12 months). Additionally, compared to preoperative states, the risk of vitamin D deficiency decreased following sleeve gastrectomy.
Alterations in the Gut Microbiome: Alterations in the gut microbiome can impact mood and behavior by influencing gut peptides such as ghrelin, glucagon-like peptide 1, peptide YY, and cholecystokinin.
Postoperative Addiction Transfer: Patients who previously relied on eating as a maladaptive coping mechanism for underlying mental illness and distress may face challenges when this option is limited post-surgery due to physical changes reducing stomach capacity. Consequently, they may replace their prior addictive eating habits with new or exacerbated substance use. Substance use in the postoperative period is prevalent, with alcohol being the most commonly reported substance used. There have been numerous reports of bariatric surgery patients ultimately dying from cirrhosis during the postoperative period.
Weight Stigma: This reduction in weight stigma was linked to notable improvements in both mental and physical health. Previous research had established that the chronic stress of weight stigma directly contributes to many of the health risks associated with obesity, and sure enough, people who experienced less stigma in the years following surgery had lower levels of anxiety and depression. They were also less at risk for disordered eating, such as binge eating.
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Types of Bariatric Surgery and Their Psychiatric Implications
Bariatric surgery encompasses a variety of procedures, each with its unique mechanisms and potential psychiatric implications. These procedures can be broadly categorized into restrictive-type and combined restrictive and malabsorptive type.
Restrictive-type procedures: These procedures primarily limit food intake, inducing early satiety.
Laparoscopic adjustable gastric banding: This involves fitting an adjustable band to create a small proximal gastric pouch, restricting food consumption.
Laparoscopic sleeve gastrectomy: This entails removing a portion of the stomach to form a "sleeve," reducing its capacity.
Combined restrictive and malabsorptive type procedures: These procedures combine restriction with malabsorption, altering nutrient absorption.
Roux-en-Y-gastric bypass (RYGB): This involves creating a small gastric pouch and connecting it to a segment of the jejunum, bypassing a portion of the stomach and small intestine.
Biliopancreatic diversion (BPD): This procedure removes a section of the stomach and creates alternative routes to the small intestine. A BPD with a duodenal switch incorporates a vertical sleeve gastrectomy and a duodenoenterostomy.
Psychiatric sequelae may vary depending on the type of procedure undergone. For instance, a cohort study conducted in Taiwan tracking patients over 12 years discovered a 1.5-fold heightened risk for major depressive disorders (MDDs) after malabsorptive procedures compared to restrictive procedures.
Identifying and Managing Post-Bariatric Depression
Assessment of post-bariatric psychological outcomes is critical to identify morbidly obese patients who require further supportive treatment. Patients at a higher risk of post-bariatric depression should be subjected to close monitoring. This includes exhaustive pre-operative assessment of depression and psychological disorders, along with employing timely and effective anti-depressive interventions. This could enhance the effectiveness of the surgery, amplify weight reduction after surgery, and improve the long-term QoL.
Given the elevated suicide risk among postoperative bariatric surgery patients, it is prudent to implement a systematic screening program for depression and suicidal ideation. Such a program can be effectively integrated into routine follow-up consultations. The Patient Health Questionnaire (PHQ-9) is a recommended tool for this purpose. This brief self-administered survey comprises 9 items, each scored from 0 to 3, resulting in a potential total score ranging from 0 to 27. The PHQ-9 effectively targets vital symptoms of depression, such as anhedonia, dysphoria, fatigue, appetite irregularities, feelings of guilt, lack of motivation, difficulty concentrating, changes in motor activity (such as agitation and retardation), and thoughts of suicide, by assigning scores based on the frequency of these symptoms over the assessment period. A score greater than 10 on the assessment indicates at least moderate depression, warranting consideration for counseling and pharmacotherapy. A score exceeding 15 indicates the necessity for active pharmacotherapy and psychotherapy treatment. Finally, a score surpassing 20 indicates an immediate need for pharmacotherapy and an expedited referral to a psychiatrist, psychologist, or therapist for collaborative treatment. Furthermore, any positive response to question 9, which specifically inquires about suicidal thoughts, should prompt an immediate risk assessment for the threat of imminent danger to the patient.
Other psychometric tools, including the Columbia Suicide Scale, can be used to assess suicide risks further. If necessary, immediate consultation with a psychiatrist should be obtained and acute hospitalization pursued. Alongside screening for depression, it is imperative to thoroughly investigate the patient's eating habits, with particular attention to potential eating disordered behaviors, and closely monitor their weight trends.
The patient should also be screened for potential substance use after surgery. One useful psychometric tool for assessing substance use is the Screening, Brief Intervention, and Referral for Treatment (SBIRT) tool.
In patients presenting with anxiety symptoms, a thorough history and physical examination are necessary to exclude organic diseases, including dumping syndrome. Cardiac causes of palpitations should also be explored, considering the likelihood of electrolyte imbalances in the postoperative period.
Several strategies can be employed to manage depression after bariatric surgery:
Individual therapy: The many changes a person experiences after surgery and stressful adaptations may lead to depression. Therapy is the best way for a person to sort through these changes and alleviate depression. There are many psychologists, but identifying one with bariatric background may be a challenge. A referral from a center of excellence is a good place to start. This may be helpful, as a professional with bariatric experience can be requested.
Medication: Add an antidepressant.
Support groups: Every center of excellence provides support groups for patients. Another thing that would be helpful is joining a support group of people who have been through the surgery themselves.
Emergency assistance: If a patient is seriously considering suicide, he or she should call 911 immediately or go directly to an emergency department. Depression skews the thinking so that suicide appears on the surface to be a solution. Thoughts cannot be trusted when in a depressed state.
Prevention Strategies
Develop healthy ways to deal with stress: Since the most stressful time is the few months directly following surgery, it is important to develop these strategies prior to surgery. Try a new hobby, develop friendships with other bariatric patients, use positive affirmations, take a yoga class, or listen to music.
Make the switch from food as the main event to an activity: Making this transition before the surgery may decrease stress postoperatively. Learn to view food as the fuel for your activities. It may be challenging to see friends for putt-putt golf or to attend a play rather than going out to dinner, but the emphasis should now be on the activity.
Employ and practice healthy and positive self-talk.
Exercise often: Staying active during this time is also very important. This can mean exercise, or even just getting out of the house for a fun adventure. Endorphins from exercise can help balance any lack of serotonin.
Find a therapist: Even if not depressed, it is always a good idea to have a therapist in place for the first few months postoperatively. This professional will get to know the patient, be able to identify a trend toward depression early, and be the liaison with the physician if the patient wishes to try an antidepressant.
Prepare the family for changes and ask them to become involved in the decision-making process: Changes will affect everyone in the household. Relationships within the home may be strained during the initial postoperative period.
Difficulty taking medication: If a patient is already on an antidepressant prior to surgery, make him or her aware that taking pills postoperatively will be difficult for some time.
Prevention based on a history: If there is a history of depression, suicide attempts, suicidal ideation, or inpatient psychiatric hospitalization, the patient should be prepared by having both a psychiatrist and a psychologist.
Timing of surgery: If already severely depressed, surgery should be postponed until depression decreases whenever possible.
The Role of the Interprofessional Team
The activity also highlights the crucial role of an interprofessional healthcare team, comprising psychiatrists, psychologists, therapists, and case managers, in treating patients undergoing bariatric surgery, thereby enhancing patient outcomes through comprehensive mental healthcare.
Limitations and Future Directions
The majority of the included articles were of observational design, revealing a potential risk of selection bias. There was significant heterogeneity between the included studies. This heterogeneity might stem from different demographic characteristics, assessment methods, and surgical techniques. However, further studies need to be conducted to tackle the limitations of the current meta-analysis.
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