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Psychological Issues Following Bariatric Surgery
David B. Sarwer, PhD, Anthony N. Fabricatore, PhD, LaShanda R. Jones-Corneille, PhD, Kelly C. Allison, PhD, Lucy N. Faulconbridge, PhD, and Thomas A. Wadden, PhD
Over the past decade, bariatric surgery has grown in popularity as the most efficacious treatment for extreme obesity. During this time, there has also been increased research on the physical and psychosocial outcomes of the procedures. The vast majority of patients who undergo bariatric surgery experience improvements in morbidity and mortality, including improvements in several areas of psychological functioning. Unfortunately, a minority of patients appear to struggle with numerous psychological issues postoperatively. These include suboptimal weight loss, disordered eating, body image dissatisfaction, substance abuse, depression, and suicide. This article provides an overview of these untoward outcomes.
Several comprehensive reviews of the literature1-6 on the psychosocial and behavioral aspects of bariatric surgery have been published. As summarized in these articles, people with extreme obesity who pursue bariatric surgery have high rates of psychopathology. Between 20% to 60% of patients have been characterized as suffering from an Axis I psychiatric disorder, the most common of which were mood and anxiety disorders. Smaller percentages have been diagnosed with substance abuse problems and personality disorders, both of which may impact surgical management and postoperative outcomes.
These findings must be viewed with some degree of caution. Many studies suffered from a range of methodologic problems, including reliance on small sample sizes, failure to use validated assessments of psychopathology, and absence of appropriate comparison groups. One recent study7 avoided some of these methodologic problems, yet confirmed an elevated prevalence of various psychiatric disorders in people seeking bariatric surgery. Among 288 bariatric surgery candidates who were assessed by the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (the results of which were not shared with the surgical team), 38% received a current Axis I diagnosis and 66% were given a lifetime diagnosis. Current anxiety disorders were found in 24% of patients; 16% were found to have a mood disorder. Approximately 29% met criteria for a personality disorder.
Likely as a result of these studies, as well as for other reasons (including requirements from third party payers), the large majority of bariatric surgery programs in the United States require a mental health evaluation prior to surgery.8 While the focus of these evaluations is often on screening for psychopathology, the authors of this article suggest that the evaluations also have a psychoeducational focus. This focus includes an assessment of the behavioral and environmental factors that may have contributed to the development of extreme obesity as well as an assessment of the potential impact of these factors on the patient’s ability to make the necessary dietary and behavioral changes to experience an optimal postoperative outcome (DB Sarwer, PhD, unpublished material, 2008).9
Candidates for bariatric surgery often believe that the preoperative mental health evaluation is designed to rule-out” patients for surgery. Thus, patients may be motivated to minimize psychological distress and present themselves in a favorable light during these evaluations.9,10 In reality, few patients are outright denied bariatric surgery based on the mental health evaluation.11-15 This typically occurs when the patient has significant, untreated psychopathology (including active substance abuse, active psychosis, bulimia nervosa, and severe uncontrolled depression) or exhibits a gross misunderstanding of the purpose of bariatric surgery. By contrast, the most common outcome of the preoperative evaluation, occurring in 70% to 90% of cases, is the unconditional recommendation to proceed with surgery.11-15
Patients who are not unconditionally recommended for surgery are typically asked to enter some additional mental health and/or dietary treatment for a period of time (eg, 3-6 months) and then return for re-evaluation. Upon re-evaluation, >50% of patients (but only 31% of males) were adherent to the recommendations of the mental health professional and, thus, were recommended for surgery.12
Psychosocial Outcomes Following Bariatric Surgery
The outcomes of bariatric surgery are, for the majority of patients, impressive. Within 12-18 months postoperatively, individuals typically lose 20% to 35% of initial body weight.16-19 The weight loss is associated with significant improvements in morbidity and mortality.16-26 Bariatric surgery is also associated with significant improvements in psychosocial status. Most psychosocial characteristics, including symptoms of depression and anxiety, health-related quality of life, self-esteem, and body image, improve dramatically in the first postoperative year.1-6 Many of these benefits appear to endure through the first 4 postoperative years. Longer-term psychosocial outcomes are largely unknown.
Similarly, the impact of bariatric surgery on formal psychopathology is unclear. In a review of the psychosocial literature, Herpertz and colleagues5 drew a thought-provoking conclusion. They suggested that psychosocial distress that is secondary to obesity, such as significant body image dissatisfaction or distress about weight-related limitations in functioning, may facilitate weight loss following surgery. In contrast, the presence of significant psychopathology that is independent from the degree of obesity, such as major depression, may inhibit patients’ ability to make the dietary and behavioral changes necessary for the most successful postoperative outcome possible.
While the majority of studies suggest that the psychosocial outcomes of bariatric surgery are largely positive, the authors of this article note that these investigations generally reported group outcomes and not changes for individual patients. The positive changes in psychosocial status are not universal. Just as some patients experience medical complications, some will also experience poor behavioral or psychological outcomes. (Sogg and colleagues27 discuss untoward psychological outcomes with regard to marital and sexual behavior, whereas the current article focuses on depression and suicide, suboptimal weight loss, disordered eating, body image dissatisfaction, and substance abuse.)
Depression and Suicide
Numerous studies have identified a relationship between depression, suicidality, and obesity. A large epidemiologic study28 found that obese women were significantly more likely to experience suicidal ideation and to make suicide attempts than their normal-weight counterparts. (Interestingly, obese men were less likely to report suicidal thoughts or behaviors than normal-weight men.) This study, however, did not take obesity severity into account. People with extreme obesity have been found to be 87% to 122% more likely to attempt suicide than people in the general population.29
Recently, Adams and colleagues25 examined mortality and causes of death over a mean of 7 years in 7,925 postoperative bariatric surgery patients and 7,925 non-patient controls who were matched for age, gender, and body mass index (BMI). All-cause mortality was significantly reduced in surgery patients compared to controls. However, nearly twice as many surgery patients (n=43) as controls (n=24) died by suicide. Although that difference was not statistically significant, the trend is both surprising and troubling.
Small case series have also documented suicides.30-32 Whereas the yearly suicide rate in the general population is 11.0 deaths per 100,000 people,33 Waters and colleagues,32 found three suicide deaths, over a 36-month period, in 157 bariatric surgery patients. Omalu and colleagues34 recently reported three suicides in the first 2 years following bariatric surgery. They noted that each of those patients had a history of severe depression before surgery that persisted postoperatively and despite maintaining weight losses of 25% to 41% of their initial weight.
Given the relationship between extreme obesity and suicide, and the generally salutary effects of bariatric surgery on psychological distress, reports of suicide after bariatric surgery are largely counterintuitive. In the absence of additional information on the relationship between bariatric surgery and suicide, these findings underscore the importance of ensuring that patients who have psychiatric disorders receive appropriate mental health assessment and treatment before and after bariatric surgery.
Suboptimal Weight Loss
Approximately 20% of people who undergo bariatric surgery fail to reach the typical postoperative weight loss or begin to regain large amounts of weight within the first few postoperative years.18,19 As seen in the Swedish Obese Subjects trial, both gastric banding and gastric bypass patients began to regain weight between the first and second postoperative years. At 10 years postoperatively, approximately 10% of patients who underwent gastric bypass and 25% of patients who underwent gastric banding failed to maintain at least a 5% reduction in initial weight. Suboptimal weight losses are typically attributed to poor adherence to the postoperative diet or a return of maladaptive eating behaviors, rather than to surgical factors.1-2,4
Numerous studies have found that adherence to the postoperative diet is poor (DB Sarwer, PhD, unpublished material, 2008).35,36 Caloric intake often increases significantly during the postoperative period (DB Sarwer, PhD, unpublished material, 2008).35,38 Participants in the Swedish Obese Subjects trial (the majority of whom underwent vertical gastric banding) consumed approximately 2,900 kcal/day prior to surgery.18 Intake decreased to approximately 1,500 kcal/day 6 months after surgery but increased to approximately 2,000 kcal/day 10 years later. This increased caloric intake likely contributed to weight regain these patients began to experience starting in the second postoperative year.
Bariatric surgery requires regular, if not life-long, follow up. Patients who undergo gastric bypass are recommended to return to the bariatric surgery program at least every 6 months in the first 2 postoperative years and annually thereafter.39 Adjustments of a gastric band can require follow-up appointments as regularly as every 4-6 weeks in the first postoperative year and quarterly through the first 3 postoperative years.40 These postoperative visits can be used not only to monitor patients’ weight loss (and overall psychosocial status) but to counsel patients on issues related to dietary adherence and eating behavior as well.41,42 Clinical reports have suggested that postoperative follow up with the bariatric surgery program is frequently suboptimal and can negatively impact weight loss, sometimes within the first postoperative year.42-45 In a recent report, only 40% of patients returned for each of their annual follow-up visits with the surgeon within the first 4 years of surgery. Those who returned for all of their annual follow-up visits lost significantly more weight than those patients who did not return; the latter regained weight between the first and third postoperative years.41
The direction of the relationship between postoperative follow up and weight loss is unknown. Did patients lose less weight because they lacked the support and care offered during follow-up visits, or did they fail to return because they were embarrassed over suboptimal weight loss? Clinicians are advised to prepare patients for the possibility of less-than-desired weight loss and weight regain when they counsel patients preoperatively and to normalize these outcomes should they occur postoperatively.
A subset of bariatric surgery patients suffers from malnutrition. The most common and severe problems appear to be vitamin B12, iron, and folic acid deficiency.39 Calcium, vitamin D, and other vitamin deficiencies appear to be less common.39 Most cases of malnutrition among bariatric surgery patients appear to be responsive to improved dietary adherence or vitamin supplementation.39
Poor adherence to the postoperative diet may also result in gastrointestinal discomfort, including nausea, “plugging,” vomiting, and gastric dumping. “Plugging” has been described as the subjective experience of ingested food becoming lodged in the gastric pouch, which leads to pressure and/or pain in the chest.46 These symptoms typically follow over-consumption of pasta, bread, or dry meats, and were reported by 43% of gastric bypass patients years after surgery.46
One- to two-thirds of patients report postoperative vomiting.43,46 Although vomiting occurs most frequently during the first few postoperative months47 it may continue for several years postoperatively and may be associated with malnutrition.47 Patients may vomit reflexively due to food intolerance or may self-induce vomiting to relieve the discomfort associated with “plugging.” (Self-induced vomiting is not considered a sign of bulimia if it is not motivated by the desire to compensate for excessive caloric intake or by an excessive fear of weight gain.)
Gastric dumping, which occurs with the gastric bypass but not banding procedures, is a constellation of symptoms that can include nausea, flushing, bloating, faintness, fatigue, and severe diarrhea. It typically occurs following the consumption of foods high in sugar and/or fat. Dumping occurs in approximately 50% to 70% of gastric bypass patients.48,49 The aversiveness of dumping may be one factor that contributes to the weight-loss superiority of gastric bypass as compared to gastric banding.
Disordered eating, specifically binge eating and night eating, are thought to be relatively common among candidates for bariatric surgery. Binge-eating disorder (BED) is characterized by the consumption of an objectively large amount of food in a brief period of time (ie, 2 hours) with the patient’s report of subjective loss of control during the overeating episode.50-52 Night-eating syndrome (NES) is defined as a circadian delay in the pattern of eating, characterized by evening hyperphagia (ie, the consumption of >=25% of total daily caloric intake after the evening meal) and/or >=2 nocturnal ingestions (ie, waking during the sleep period to eat) per week. These criteria were recently modified and put forth as the official research criteria for the syndrome at the First International Night Eating Symposium (Minneapolis, Minnesota, April 26, 2008).
The rates of BED and NES among patients seeking bariatric surgery vary as a function of the methodology used to assess their presence.51,53-57 Using the Eating Disorder Examination, widely considered the “gold standard” for the assessment of eating pathology, 39% of gastric bypass candidates reported at least one binge eating episode per week during the prior 3 months.56 The prevalence of NES among bariatric surgery candidates has been estimated at 8% to 27% using questionnaire-based assessment methods.53,57 In contrast, a recent study by Allison and colleagues51 found that <5% of patients met full diagnostic criteria for BED and 2% to 9% for NES, when a questionnaire-based assessment was supplemented with additional interview questions.
Several studies have investigated the relationship between disordered eating prior to surgery and postoperative outcomes. Two studies found that while patients did not report any objective binge episodes postoperatively, a significant minority reported feelings of loss of control consistent with BED.58,59 Kalarchian and colleagues60 observed no binge episodes in the 4 months following surgery. However, 46% of patients have reported either objective or subjective binge eating at longer followup.61
Preoperative binge eating may be related to smaller weight losses or weight regain within the first 2 years after surgery.58,59,61 These suboptimal outcomes may be attributable not only to the binge eating but also the stretching of the gastric pouch, which would allow for increased energy intake over time.62 Individuals who engage in night eating before surgery have been found to continue the behavior postoperatively.57 At least one study has found that more frequent nocturnal eating following bariatric surgery was associated with greater BMI and lower satisfaction with surgery.63
Body Image Dissatisfaction
The massive weight loss seen with bariatric surgery is associated with significant improvements in body image.64-67 Unfortunately, some patients who lose large amounts of weight report residual body image dissatisfaction associated with loose, sagging skin of the breasts, abdomen, thighs, and arms. More than 66% of post-bariatric surgery patients considered the development of excess skin to be a negative consequence of surgery.69 This dissatisfaction likely motivates some individuals to seek plastic surgery to address these concerns.69
According to the American Society of Plastic Surgeons,70 in 2007, almost 67,000 patients underwent body contouring procedures after weight loss. The most common procedures were breast reduction and extended abdominoplasty/lower body life procedures. Little is known about the psychological aspects of the procedures.69,71 Studies of other cosmetic surgical procedures suggest that body image improves postoperatively.72-75 There is concern, however, that some patients who present for body contouring following bariatric surgery may be suffering from body dysmorphic disorder, which is seen in 5% to 15% of cosmetic surgery patients.72-75
Most studies that have examined the relationship between BMI and substance use disorders found lower rates of these disorders among obese individuals.76,77 Scott and colleagues,78 for example, found that the odds of an alcohol use disorder were 40% lower in obese versus normal weight individuals in the general US population. In a sample of bariatric surgery candidates, <2% met criteria for a current substance use disorder.7
Two concerns regarding postoperative substance use have become prominent in the mass media, if not in the scientific literature, namely, changes in alcohol metabolism and “addiction transfer.” To the knowledge of the authors of this article, no pre-postoperative comparisons of alcohol metabolism have been published. However, a comparison of Roux-en-Y gastric bypass (RYGB) patients (2 years postoperatively) and controls found that the former group had higher alcohol breath levels (0.08% vs. 0.05%) and took longer to return to 0 (108 minutes vs. 72 minutes), after consuming 5 ounces of red wine despite having a higher BMI.79 Similarly, Klockhoff and colleagues80 found a higher peak blood-alcohol concentration and a shorter time to reach peak levels among postoperative RYGB patients compared with age and BMI-matched controls. Based on these findings, as well as anecdotal reports, gastric bypass patients should be cautioned that they may experience the effects of alcohol quite differently following surgery.
“Addiction transfer” is a popular, mass media-created term that refers to the idea that patients who undergo bariatric surgery may develop addictions to substances, gambling, sex, and so forth to replace their preoperative “addiction” to food. The authors of this article hasten to point out that “addiction transfer” is not an accepted clinical or scientific term. The term and construct have several shortcomings, as detailed by Sogg.81 Chief among these is that the view of food as an addictive substance, or eating as an addictive behavior, is by no means supported by scientific consensus. Additionally, there is little support for the notion that a treated symptom (eg, compulsive eating) will resurface in a different form (eg, compulsive drinking or shopping) unless the psychological basis for the original problem is resolved.
Currently, there is no empirical evidence that bariatric surgery increases the risk of substance use or other addictive behaviors. Thus, “addiction transfer” cannot be considered a common outcome of bariatric surgery. It is, however, possible that bariatric surgery candidates are at increased risk of problematic substance use. Studies that have found an increased risk of death by suicide following bariatric surgery have also found an elevated risk of accidental death.25,34 It is not known how many of those accidental deaths were substance related.
Bariatric surgery is presently the most powerful tool to treat obesity. For the majority of patients, the surgical procedures produce sizable weight losses that are well maintained and are associated with significant improvements in mortality as well as physical and psychological comorbidities. Unfortunately, these impressive effects are not universal. Suboptimal outcomes are most often attributed to behavioral and psychological reasons rather than surgical ones.
Mental health professionals play a central role in the evaluation of candidates for bariatric surgery. Some also participate in patients’ postoperative care by running support groups or providing individual psychotherapy. Just as there is no standard of practice for conducting preoperative evaluations, there is no consensus regarding which postoperative mental health interventions are most appropriate and efficacious for optimizing surgical outcomes. It is intuitive, for instance, that cognitive-behavioral interventions would be useful for people struggling with disordered eating or body image disturbance postoperatively. However, there has been little, if any, empirical study in these areas or other areas of postoperative mental health care. The development and testing of postoperative interventions are important and logical “next steps” for researchers and practitioners who work with bariatric surgery patients. The anticipated growth of bariatric surgery in the coming years will provide ample opportunity to further consider the role of the mental health professional in the postoperative care of these individuals. PP
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