Meeting News Coverage

Increased awareness needed for psychopathologies before, after bariatric surgery

Physicians should be aware of depression, alcohol abuse and suicide rates and risk among their potential bariatric surgery candidates, a presenter said at Obesity Week 2013.

James E. Mitchell, MD, professor and chairman of the department of neuroscience at the University of North Dakota, reviewed the literature on psychopathologies and their interaction with bariatric surgery. In an interview with Endocrine Today, he said he focused on the studies that used diagnostic interviews for presurgical assessment.

“What they show is that people who are candidates for bariatric surgery have high rates of psychopathology,” he said. “In particular, the highest rates are found in the studies where the evaluations were done outside of the usual surgery evaluation process — in other words, the ones that were done independently, not to be shared with the surgical team. … The evaluations that are done many times as part of the normal evaluation process probably are underreporting because patients want to look as healthy as possible so they’ll get approved.”

The most common psychopathology is depression, but Mitchell said those rates also may be underreported because many patients are being treated for depression. As in the recent LABS study, patients often self-report and, if already taking antidepressants, may not report signs of depression.

After bariatric surgery, Mitchell said rates of depression tend to go down in the first year and rise slowly in the second and third years. One possible reason for this could be the body’s absorption of antidepressants after bariatric surgery.

“Because of the fact that the duodenum is excluded from the elementary flora, drugs like antidepressants are not going to be nearly as readily absorbed, so patients may become depressed after bariatric surgery because their blood level drops,” Mitchell said. “People who are following patients who are undergoing bariatric surgery need to realize that they may need to adjust dosage up. The natural tendency after bariatric surgery is to adjust the dosage down because they think people are smaller, but in reality, it’s probably the opposite direction.”

Alcohol abuse in bariatric surgery patients showed a statistically significant but “not dramatic” uptick across patients, he said.

“The alcohol thing is a problem and at this point no one knows how big of a problem it is, but it appears to develop, if it does, after the first year, probably after the second year thereafter,” he said.

Lastly, Mitchell covered the slowly increasing rates of suicide in bariatric surgery patients.

“The suicide rate seems to be going up, for reasons that are not clear. In general, rates of suicide are not markedly elevated in obese people. In fact, there is some work that shows they may be lower, but that’s debatable,” Mitchell said. “What little bit that’s been published suggests [suicide incidents] seem to be clustering 1 to 4 years after the procedure and that may relate to the fact that people have hit their weight nadir and are disappointed in that or experience weight regain after that.”

The three studies Mitchell reviewed have all been cross-sectional, and he said a prospective study is necessary. Suicide rates overall are still low and make that proposition difficult, he added.

For more information:

Mitchell JE. Select behavioral and psychosocial issues in extreme obesity. Presented at: Obesity Week; Nov. 11-15, 2013. Atlanta.

Disclosure: Mitchell’s financial relationships could not be confirmed.

Physicians should be aware of depression, alcohol abuse and suicide rates and risk among their potential bariatric surgery candidates, a presenter said at Obesity Week 2013.

James E. Mitchell, MD, professor and chairman of the department of neuroscience at the University of North Dakota, reviewed the literature on psychopathologies and their interaction with bariatric surgery. In an interview with Endocrine Today, he said he focused on the studies that used diagnostic interviews for presurgical assessment.

“What they show is that people who are candidates for bariatric surgery have high rates of psychopathology,” he said. “In particular, the highest rates are found in the studies where the evaluations were done outside of the usual surgery evaluation process — in other words, the ones that were done independently, not to be shared with the surgical team. … The evaluations that are done many times as part of the normal evaluation process probably are underreporting because patients want to look as healthy as possible so they’ll get approved.”

The most common psychopathology is depression, but Mitchell said those rates also may be underreported because many patients are being treated for depression. As in the recent LABS study, patients often self-report and, if already taking antidepressants, may not report signs of depression.

After bariatric surgery, Mitchell said rates of depression tend to go down in the first year and rise slowly in the second and third years. One possible reason for this could be the body’s absorption of antidepressants after bariatric surgery.

“Because of the fact that the duodenum is excluded from the elementary flora, drugs like antidepressants are not going to be nearly as readily absorbed, so patients may become depressed after bariatric surgery because their blood level drops,” Mitchell said. “People who are following patients who are undergoing bariatric surgery need to realize that they may need to adjust dosage up. The natural tendency after bariatric surgery is to adjust the dosage down because they think people are smaller, but in reality, it’s probably the opposite direction.”

Alcohol abuse in bariatric surgery patients showed a statistically significant but “not dramatic” uptick across patients, he said.

“The alcohol thing is a problem and at this point no one knows how big of a problem it is, but it appears to develop, if it does, after the first year, probably after the second year thereafter,” he said.

Lastly, Mitchell covered the slowly increasing rates of suicide in bariatric surgery patients.

“The suicide rate seems to be going up, for reasons that are not clear. In general, rates of suicide are not markedly elevated in obese people. In fact, there is some work that shows they may be lower, but that’s debatable,” Mitchell said. “What little bit that’s been published suggests [suicide incidents] seem to be clustering 1 to 4 years after the procedure and that may relate to the fact that people have hit their weight nadir and are disappointed in that or experience weight regain after that.”

The three studies Mitchell reviewed have all been cross-sectional, and he said a prospective study is necessary. Suicide rates overall are still low and make that proposition difficult, he added.

For more information:

Mitchell JE. Select behavioral and psychosocial issues in extreme obesity. Presented at: Obesity Week; Nov. 11-15, 2013. Atlanta.

Disclosure: Mitchell’s financial relationships could not be confirmed.

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