Bariatric surgery can results in improvements in patients’ psychiatric behaviours such as eating behaviours, mood disorders and body image, although the mechanism as to why is not clear, according to a study by Portuguese researchers. Published in the Archives of Clinical Psychiatry (São Paulo), the paper ‘A psychiatric perspective view of bariatric surgery patients’, states that despite these improvements clinicians should be aware that a risk of suicide and substance abuse (especially alcohol) after gastric bypass surgery remain in some patients.
“In order to create clinical guidelines to ameliorate bariatric surgery follow-up and facilitate the early diagnosis of eating disorders after surgery.”
The authors note that psychiatric problems are common among morbidly obese patients with several studies reporting a higher prevalence of psychiatric disorders in patients seeking bariatric surgery compared with the general population. Additional studies have again noted a higher prevalence of bariatric patients presenting with mood disorders, anxiety disorders, somatiation, hypochondria, obsessive compulsive disorders, binge eating behaviours and binge eating disorder (BED). Nevertheless, a considerable number of studies have demonstrated that weight loss and metabolic improvement as a result of bariatric surgery has also resulted in an overall improvement in mental health and psychosocial factors, the authors write.
In addition, the evidence that surgery can result in the alleviation of psychological, psychosocial and psychiatric status is demonstrated through greater patient optimism, higher self-esteem and patients taking a more active role in life, they note.
However, they report that is not seen in all studies and some of these benefits seem to be limited to the first years following weight loss surgery. Moreover, the presence of a postoperative psychiatric disorder can predict a lower probability of achieving a good outcome.
Therefore, the aim of their review was to evaluate specific areas of psychopathology – eating behaviours, mood disorders, body image, suicide and substances of abuse – in morbidly obese patients undergoing to bariatric surgery
The authors reviewed all relevant literature via the PubMed database from January of 2002 to June of 2015. In total 75 articles were included from the research with additional articles included from the references list from relevant articles.
They report that a majority of the studies noted an improvement in eating behaviour after bariatric surgery (smaller amount of food eaten, a decrease in hunger, an earlier satiety, less inadequate eating behaviours and more control over patient food intake). But when patients have binge eating behaviours postoperatively, it is associated with reduced mental health and poor weight outcome.
Overall, they write that the postoperative results are inconsistent and therefore recommend long-term research and standardising the evaluation and diagnosis of eating behaviour “in order to create clinical guidelines to ameliorate bariatric surgery follow-up and facilitate the early diagnosis of eating disorders after surgery.”
They report that most studies reported a decrease in depression and depressive symptoms after bariatric surgery, with females demonstrating a more marked decline than men. Again, there were no consistent results from the studies under review with some reporting significantly reduced levels of depression symptoms one, two and ten years after bariatric surgery, but others indicating an initial improvement in the first years postoperatively followed by the reappearance or worsening of depressive symptoms (associated with weight regain or weight stabilization)
Furthermore, a significant long-term relationship has been reported between depression and greater weight loss but not for anxiety symptomology. Again, some studies reported that bariatric patients may achieve normal scores of depression and anxiety following bariatric surgery.
“These inconsistent results may imply the presence of confounding factors. A prior trauma has been suggested as a possible candidate. Bariatric patients with traumatic background may present psychiatric complaints that are not fundamentally weight-related. Thus, traumatic histories might mediate the relationship between poorer postoperative weight loss and the maintenance of psychiatric symptoms,” they write.
They add patients’ expectations after surgery that may have a negative impact if the expected results are not obtained. Moreover, psychiatric medication may be a confounding influence on patient’s mood/anxiety post-surgery and they suggest that clinicians should attempt to place patients on weight-neutral medications, avoiding medication such a tricyclic antidepressants or mirtazapine (which are known to cause weight gain).
“For these reasons, postoperative monitoring of patients taking psychopharmacological medication is recommended. More knowledge needs to be acquired in the area of psychotropic medication pharmacokinetics in order to create clinical practice directives for the best care of bariatric patients.”
More females report body image dissatisfaction and is associated with higher incidence of depression and low self-esteem. Several studies showed that body image impairment, attractiveness and lack of familiarity with the body improved after surgery, although most studies have only investigated changes in the first and second year after surgery.
Residual body image dissatisfaction due to increasing and/or sagging skin has been reported following surgery and one study noted a correlation between the amount of excess skin and the degree of body image discomfort of bariatric patients.
The authors recommend that bariatric surgeons should counsel patients prior to surgery in order to prevent the psychological distress caused.
The authors report that several studies have found that severely obese people may have an increased mortality by suicide and an increase of suicides in the surgical patients. However, they acknowledge that there is a significant variation in the characteristics of the studies and length of follow-up. Therefore, it is difficult to establish corrective comparisons between patients after bariatric surgery and the general population.
Interestingly, some studies have reported that post-operative patients noticed that they become more intoxicated after consuming less alcohol and that there is a more rapid onset of intoxication effects comparing to the preoperative period. It is thought that RYGB limits the first step of metabolism and, consequently, higher serum levels of ethanol are obtained.
With regards to opioid use following bariatric surgery, some studies have suggested that the amount of opioid substance was greater postoperatively than preoperatively. One possible explanation is that obese individuals demonstrate more pain sensitivity and lower pain detection thresholds than those who are not obese and altered pain processing persists after bariatric surgery. Opioid consumption after surgery is greater among patients who are younger, men, and have been previously hospitalised because of psychiatric disorders.
“More studies evaluating substance abuse postoperatively are necessary to assist in the understanding of this area,” they note.
“Psychiatric disorders such as depressive, anxiety and binge eating disorders are prevalent among bariatric surgery candidates and an overall improvement in this psychopathology is observed after bariatric surgery,” they conclude. “Further research is warranted for a more complete understanding of psychopatological areas in bariatric surgery patients. Furthermore, long-term studies are needed to elucidate the decline in improvements with time that is reported in some studies. This knowledge will allow a better preoperative selection, but above all, a more efficient follow-up.”