Psychiatric Annals

CME Article 

Bariatric Surgery in Serious Mental Illness

Shaheed Merani, MD, PhD; Richdeep S. Gill, MD; Arya M. Sharma, MD, PhD, FRCPC; Daniel W. Birch, MD, FRCSC; Shahzeer Karmali, MD, FRCSC

Abstract

Obesity has been associated with many serious medical and psychiatric comorbidities, including type 2 diabetes mellitus, hypertension, coronary arterial disease, obstructive sleep apnea, gastroesophageal reflux, depression, anxiety, eating disorders, and sexual dysfunction.1

Abstract

Obesity has been associated with many serious medical and psychiatric comorbidities, including type 2 diabetes mellitus, hypertension, coronary arterial disease, obstructive sleep apnea, gastroesophageal reflux, depression, anxiety, eating disorders, and sexual dysfunction.1

Shaheed Merani, MD, PhD, is a Resident in General Surgery with Department of Surgery, University of Alberta, Edmonton, Canada. Richdeep S. Gill, MD, is a Resident in General Surgery with Department of Surgery, University of Alberta, Edmonton, Canada. Arya M. Sharma, MD, PhD, FRCPC, is Professor of Medicine and Chair in Obesity Research and Management at the University of Alberta, Edmonton, Canada; the Medical Director with Alberta Health Services Edmonton Region’s interdisciplinary Weight Wise Program; and Scientific Director with Canadian Obesity Network. Daniel W. Birch, MD, FRCSC, is Professor with Department of Surgery, University of Alberta; and Medical Director with Center for the Advancement of Minimally Invasive Surgery (CAMIS), Royal Alexandria Hospital, Edmonton, Alberta, Canada. Shahzeer Karmali, MD, FRCSC, is Assistant Professor of Surgery with Department of Surgery, University of Alberta; and with the Center for the Advancement of Minimally Invasive Surgery (CAMIS), Royal Alexandria Hospital, Edmonton, Alberta, Canada.

Drs. Merani, Gill, Sharma, Birch, and Karmali have disclosed no relevant financial relationships.

Address correspondence to: Shahzeer Karmali, MD, FRCSC, Royal Alexandra Hospital, Room 405, Community Services Center, 10240 Kingsway, Edmonton, Alberta, Canada, T5H 3V9; fax: 780-735-6652; email: shahzeer@ualberta.ca.

Obesity has been associated with many serious medical and psychiatric comorbidities, including type 2 diabetes mellitus, hypertension, coronary arterial disease, obstructive sleep apnea, gastroesophageal reflux, depression, anxiety, eating disorders, and sexual dysfunction.1

Defined by the World Health Organization as a body mass index (BMI) of more than 30 kg/m2, obesity has now exceeded a prevalence rate of 10% globally.2 This equates to an estimated 500 million obese individuals,3 a number that will likely reach 1.12 billion in the next 2 decades.2

Bariatric surgery outcomes include weight reduction, functional, quality of life, and mental health considerations. Because bariatric surgery has been shown effective,4 it is one of the fastest growing surgical interventions for obesity, with a sixfold increase between 1990 and 2000 in the annual rate of procedures performed in the US, from 2.4 to 14.1 per 100,000 adults.5

Surgery Criteria

Although there have been attempts at establishing guidelines for the indications and selection criteria for bariatric surgery,1,6–8 clinical application still varies. Commonly, bariatric surgery is reserved for those patients with BMI > 40 kg/m2 or BMI > 35 kg/m2, with obesity-related comorbidities, and for whom less-invasive methods of weight reduction have failed. The indication for surgery is linked to an understanding that the patients are well-informed, motivated, and can be provided with long-term medical surveillance after surgery.

Exclusion criteria have been summarized by many sources (see Sidebar 1).1,6–8 Although bariatric surgery techniques evolve, the absolute contraindications are shifting. For example, bariatric surgery has been offered to patients with a BMI > 30 kg/m2, a cohort once excluded from surgery.

Sidebar 1.

  • BMI < 35 kgm/m2.
  • Age < 18 years or > 65 years.
  • Medical condition that makes surgery too risky.
  • Clinically significant or unstable mental health concerns.
  • Unrealistic postsurgical target weight; and unrealistic expectations of a surgical treatment.
  • Not tried or optimized lifestyle or medical treatments.
  • History of poor compliance with lifestyle, medical, or mental health interventions.
  • Pregnancy, lactation, or a plan for pregnancy within 2 years of potential surgical treatment.
  • Lack of safe access for surgeon to abdominal cavity or gastrointestinal tract.
  • Smoking.

Although there are multiple techniques and approaches to bariatric surgery, all procedures can be classified as primarily restrictive or malabsorptive. Restrictive bariatric surgical procedures aim to induce early satiety and limit the volume of the gastric reservoir. Malabsorptive bariatric surgical procedures limit the total absorptive length of the gastrointestinal track.

Primarily restrictive bariatric surgical procedures include laparoscopic adjustable gastric banding (LAGB), vertically banded gastroplasty (VBG), and laparoscopic sleeve gastrectomy (LSG). Primarily malabsorptive bariatric surgical procedures include roux-en-Y gastric bypass (RYGB), and bileopancreatic diversion with duodenal switch (BPDDS).

Because each procedure has a specific risk-benefit ratio, understanding the effect of the psychiatric disease in obese patients undergoing bariatric surgery, and the possible effect of the surgery to the patient’s mental health, will allow appropriate surgical consultation.

Surgical Outcomes

Typically, outcomes of interest in bariatric surgery include both weight loss and improvement in the patient’s comorbidities. Recent data suggest that maximum excess weight loss at 1 to 2-years post-bariatric surgery ranges from 20% to 32%.9 Long-term average total weight loss at 10 years ranges from 32% to 42%. Similar to the weight reduction outcomes after bariatric surgery, RYGB and LSG have been reported to produce type 2 diabetes mellitus remission rates of 84% and 66%, repectively.9,10

Data exist that failure of sustained weight loss is seen in a substantial proportion of patients.11 This occurs with all three of the most commonly performed bariatric surgeries: RYGB, LAGB, and LSG.11,12 There is also a potential for people with food addictions to turn their addictive behavior to other substances postsurgery. Wendling and Wudyka concluded that physicians caring for patients postbariatric surgery need to be alert for signs of postoperative addictions.13 These addictions can range from substance abuse to gambling addictions.

Preoperative Mental Health

The new relationship between bariatric surgery and mental health is more complex. Pre-existing psychiatric disease has been used by many as exclusion criteria for bariatric surgery research, and also in clinical practice as a contraindication to surgery.

The coexistence of obesity and psychiatric disease has been documented by Sarwer and colleagues, who reported 62% of 90 patients referred for bariatric surgery received at least one psychiatric diagnosis at the time of evaluation.14 The most common psychiatric diagnosis was major depressive disorder (n = 28), followed by binge eating disorder (n = 24), and substance abuse or dependence (n = 15). Bipolar disorder, panic disorder, and bulimia nervosa were documented, although less frequently. These findings corroborate with previous data that showed a higher prevalence of psychiatric disease among the morbidly obese cohort than in controls.15

The high prevalence of mental health issues among patients considered for bariatric surgery has been investigated as a preoperative risk factor for surgical outcomes. The belief that psychiatric comorbidity may negatively contribute to weight loss after bariatric surgery has led to uniform psychiatric screening by bariatric surgery centers. However, studies conducted in the 1990s showed no correlation between psychiatric factors measured and bariatric surgical outcomes at any of the endpoints 6 to 36 months postsurgery.16 Recent studies have confirmed earlier findings. Although there was a trend toward a difference, Donald and colleagues concluded in their 2003 study that at 6 months follow-up, Axis I and II diagnoses had no predictive value in weight loss in patients who underwent vertically banded gastroplasty.17 A systematic review of data by Herpetz and colleagues with data from 1980 to 200218 further supported the hypothesis that personality disorders have no predictive value for the postoperative course of weight or mental state.

Wadden and colleagues demonstrated that preoperative binge-eating disorder does not attenuate the benefit of bariatric surgery,19 although previous data show that binge eating was not cured by obesity surgery.20 Overall, there are multiple independent efforts demonstrating that binge eating is not a negative prognosticator of weight loss after bariatric surgery.21,22

As a surrogate marker of preoperative depression, antidepressant use before surgery has been shown to have no negative effect on outcome after gastric bypass surgery.23 In addition, posttraumatic stress disorder has been identified by one group to not be a contraindication to bariatric surgery.24

However, van Hout concluded in 2005 that clinicians should identify psychiatric disease in candidates for surgery.25 Subsequently, Greenberg and colleagues wrote evidence-based recommendations on psychiatric screening before bariatric surgery.26 The recommendations are controversial, however, and these tools at present are not associated with predictive value of surgical outcome.27,28

Postoperative Mental Health

In a 2003 review, Herpertz and colleagues29 identified 40 publications that focused on psychiatric outcomes after bariatric surgery. The investigators concluded that mental health and psychosocial status, including social relations and employment opportunities, improve for most people after bariatric surgery, thus leading to an improved quality of life. They identified that psychiatric co-morbidities, especially mood disorders, decrease postsurgically; however, they also cautioned that the effect of bariatric surgery on preoperative comorbid binge-eating symptoms was found to depend on the type of operation.

Depression

As the most frequent psychiatric comorbidity, depressive mood disorders have been investigated with interest in the bariatric postoperative period. A recent prospective study of 151 consecutive bariatric surgery patients reported a decline in the prevalence of depressive disorder from 33% at baseline (preoperative) to 14.3% 24 to 36 months after surgery.30 A similar finding was also noted by Zeller and colleagues31 in a smaller investigation of adolescents undergoing RYGB, showing that Beck Depression Inventory decreased from 20.5 postoperatively to 8.6 at 6-month follow-up.

Earlier, Assimkapoulous and colleagues reported a similar finding in women undergoing either RYGB or sleeve gastrectomy, as measured in the Greek population using the Hospital Anxiety and Depression Scale.32 Some authors have cited that postbariatric surgery improvements in quality of life are more related to attenuated depressive symptoms postsurgery rather than weight loss itself.33

Anxiety

Anxiety has been addressed as a subset analysis by both DeZwaan and colleagues and by Assimkapoulous and colleagues.30,32 Both investigations noted a statistically significant trend in the postsurgical reduction of anxiety symptoms. Both studies used a generalized anxiety score for all surgery recipients, but did not identify the actual proportion of candidates with clinically significant anxiety disorder pre- and post-bariatric surgery.

Eating Disorders and Body Image Dysmorphia

Among bariatric surgical recipients, binge eating has received the most attention of all the eating disorders. Wadden and colleagues have noted that both bariatric surgery and lifestyle modification are associated with a sharp reduction in the subjective number of binge-eating days among obese patients in the 6 months after intervention.19 However, there was no statistically significant difference detected between the bariatric surgical or lifestyle modification groups. Further research with long-term follow-up is needed.

Sexual Dysfunction

Sexual dysfunction is a complex biopsychosocial phenomenon that has a major effect on the bariatric population. The prevalence of sexual dysfunction is 60% among female candidates of bariatric surgery.34 Bond and colleagues found that 68% of female patients with sexual dysfunction resolved this comorbidity within 6 months after surgery.35 Sexual dysfunction and bariatric surgery has been investigated to a lesser extent in male patients. One study at least has demonstrated an improved score on the Brief Male Sexual Function Inventory during a mean follow-up length of more than 1 year after gastric bypass surgery.36

Psychiatric Pharmacology in Bariatric Surgery

According to independent studies by both Sarwer and colleagues and Seaman and colleagues, 34% of patients listed for bariatric surgery use antidepressants, anxiolytics, or anti-psychotic medication.14,37 The malabsorptive element of bariatric surgery is known to alter absorption of micro- and macronutrients; this phenomenon is hypothesized to extend to medication. Seaman and colleagues37 demonstrated that 10 of the 22 studied psychiatric medications had less dissolution in the post-RYGB environment using an in vitro model. Theoretical as well as in vitro findings reinforce the recommendation that careful clinical monitoring of drug dosing and clinical effect and measured levels of all medications be applied in postoperative patients.

Conclusion

The prevalence of obesity continues to increase worldwide. With the coexistence of psychiatric illness and obesity, an improved understanding of the effect of a patient’s mental health may allow improved outcomes in the future (Sidebar 1, see page 502).

Sidebar 2.

Preoperative Planning
  • More than 60% of bariatric surgical candidates have psychiatric comorbidity.
  • Most centers use psychiatric screening as part of a preoperative workup.
  • No absolute contraindication to bariatric surgery based on treated psychiatric disease.

Course of Psychiatric Comorbidities After Bariatric Surgery
  • A decreased rate of depressive affective disorders is seen after bariatric surgery.
  • Anxiety symptoms trend downward after bariatric surgery, but there is no statistically significant decrease in rate of anxiety disorder.
  • Both bariatric surgery and lifestyle modification are associated with decreased rates of binge eating.

Postoperative Care
  • 34% of bariatric surgery patients use psychiatric medications.
  • 50% of psychiatric medications have reduced dissolution in a model of malabsorptive surgery; careful clinical judgment should be used for dose modification in the post-surgical period.

A patient’s psychiatric illness may need re-assessing as contraindication to surgery. Conversely, bariatric surgery in obese patients has been suggested as correlative to improved mental health in the short term. Further research is needed to clarify the role of bariatric surgery as a treatment option in this patient population.

References

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  27. Pull CB. Current psychological assessment practices in obesity surgery programs: what to assess and why. Curr Opin Psychiatry. 2010; 23:30–36. doi:10.1097/YCO.0b013e328334c817 [CrossRef]
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  30. de Zwaan M, Enderle J, Wagner S, and colleagues. Anxiety and depression in bariatric surgery patients: A prospective, follow-up study using structured clinical interviews. J Affect Disord. 2011;133(1–2):61–68. doi:10.1016/j.jad.2011.03.025 [CrossRef]
  31. Zeller MH, Reiter-Purtill J, Ratcliff MB, Inge TH, Noll JG. Two-year trends in psychosocial functioning after adolescent Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2011Mar5. [Epub ahead of print] doi:10.1016/j.soard.2011.01.034 [CrossRef]
  32. Assimakopoulos K, Karaivazoglou K, Panayiotopoulos S, Hyphantis T, Iconomou G, Kalfarentzos F. Bariatric surgery is associated with reduced depressive symptoms and better sexual function in obese female patients: a one-year follow-up study. Obes Surg. 2011; 21:362–366. doi:10.1007/s11695-010-0303-z [CrossRef]
  33. Masheb RM, White MA, Toth CM, Burke-Martindale CH, Rothschild B, Grilo CM. The prognostic significance of depressive symptoms for predicting quality of life 12 months after gastric bypass. Compr Psychiatry. 2007; 48:231–236. doi:10.1016/j.comppsych.2007.01.005 [CrossRef]
  34. Bond DS, Vithiananthan S, Leahey TM, et al. Prevalence and degree of sexual dysfunction in a sample of women seeking bariatric surgery. Surg Obes Relat Dis. 2009;5(6):698–704. doi:10.1016/j.soard.2009.07.004 [CrossRef]
  35. Bond DS, Wing RR, Vithiananthan S, and colleagues. Significant resolution of female sexual dysfunction after bariatric surgery. Surg Obes Relat Dis. 2011;7:1–7. doi:10.1016/j.soard.2010.05.015 [CrossRef]
  36. Dallal RM, Chernoff A, O’Leary MP, Smith JA, Braverman JD, Quebbemann BB. Sexual dysfunction is common in the morbidly obese male and improves after gastric bypass surgery. J Am Coll Surg. 2008;207(6):859–864. doi:10.1016/j.jamcollsurg.2008.08.006 [CrossRef]
  37. Seaman JS, Bowers SP, Dixon P, Schindler L. Dissolution of common psychiatric medications in a Roux-en-Y gastric bypass model. Psychosomatics. 2005;46:250–253. doi:10.1176/appi.psy.46.3.250 [CrossRef]

CME Educational Objectives

  1. Identify the prevalence of psychiatric comorbidity among bariatric surgical candidates.

  2. Know the outcomes of modern bariatric surgical interventions for morbid obesity.

  3. Understand the natural course of psychiatric disease after bariatric surgery.

Sidebar 1.

  • BMI < 35 kgm/m2.
  • Age < 18 years or > 65 years.
  • Medical condition that makes surgery too risky.
  • Clinically significant or unstable mental health concerns.
  • Unrealistic postsurgical target weight; and unrealistic expectations of a surgical treatment.
  • Not tried or optimized lifestyle or medical treatments.
  • History of poor compliance with lifestyle, medical, or mental health interventions.
  • Pregnancy, lactation, or a plan for pregnancy within 2 years of potential surgical treatment.
  • Lack of safe access for surgeon to abdominal cavity or gastrointestinal tract.
  • Smoking.

Sidebar 2.

Preoperative Planning
  • More than 60% of bariatric surgical candidates have psychiatric comorbidity.
  • Most centers use psychiatric screening as part of a preoperative workup.
  • No absolute contraindication to bariatric surgery based on treated psychiatric disease.

Course of Psychiatric Comorbidities After Bariatric Surgery
  • A decreased rate of depressive affective disorders is seen after bariatric surgery.
  • Anxiety symptoms trend downward after bariatric surgery, but there is no statistically significant decrease in rate of anxiety disorder.
  • Both bariatric surgery and lifestyle modification are associated with decreased rates of binge eating.

Postoperative Care
  • 34% of bariatric surgery patients use psychiatric medications.
  • 50% of psychiatric medications have reduced dissolution in a model of malabsorptive surgery; careful clinical judgment should be used for dose modification in the post-surgical period.

Authors

Shaheed Merani, MD, PhD, is a Resident in General Surgery with Department of Surgery, University of Alberta, Edmonton, Canada. Richdeep S. Gill, MD, is a Resident in General Surgery with Department of Surgery, University of Alberta, Edmonton, Canada. Arya M. Sharma, MD, PhD, FRCPC, is Professor of Medicine and Chair in Obesity Research and Management at the University of Alberta, Edmonton, Canada; the Medical Director with Alberta Health Services Edmonton Region’s interdisciplinary Weight Wise Program; and Scientific Director with Canadian Obesity Network. Daniel W. Birch, MD, FRCSC, is Professor with Department of Surgery, University of Alberta; and Medical Director with Center for the Advancement of Minimally Invasive Surgery (CAMIS), Royal Alexandria Hospital, Edmonton, Alberta, Canada. Shahzeer Karmali, MD, FRCSC, is Assistant Professor of Surgery with Department of Surgery, University of Alberta; and with the Center for the Advancement of Minimally Invasive Surgery (CAMIS), Royal Alexandria Hospital, Edmonton, Alberta, Canada.

Drs. Merani, Gill, Sharma, Birch, and Karmali have disclosed no relevant financial relationships.

Address correspondence to: Shahzeer Karmali, MD, FRCSC, Royal Alexandra Hospital, Room 405, Community Services Center, 10240 Kingsway, Edmonton, Alberta, Canada, T5H 3V9; fax: 780-735-6652; email: .shahzeer@ualberta.ca

10.3928/00485713-20110921-10

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