What is Psychiatric Complications of Bariatric Surgery?

Bariatric surgery, which is a surgery for weight loss, is increasingly becoming a common treatment for obesity. Since 1975, the global rate of obesity has almost tripled, leading to a dramatic increase in the number of these surgeries performed internationally. Bariatric surgery can help to improve overall health as it not only assists in weight loss but also positively impacts various other health conditions. These include metabolic syndrome, heart disease, diabetes, stroke, and sleep apnea. Additionally, mental health can also benefit from the surgery, helping to reduce anxiety, decrease depression, and better body image.

There are different types of bariatric surgery performed all over the world. These surgeries are broadly categorized into restrictive, malabsorptive, and combined approaches.

Restrictive procedures are surgeries that limit food intake. One such surgery is the Laparoscopic adjustable gastric banding, where an adjustable band is used to create a small stomach pouch which induces early fullness. Another surgery is the Laparoscopic sleeve gastrectomy, which involves removing a part of the stomach and stapling the rest, so it forms a smaller “sleeve.”

Malabsorptive-type procedures work by changing the way the small intestine absorbs food. An example is the Jejunoileal bypass, where the top part of the small intestine connects to the lower part, while still leaving space for usual absorption.

Combined restrictive and malabsorptive surgeries use techniques from both types of procedures. The Roux-en-Y-gastric bypass (RYGB) makes a small pouch in the stomach and connects it to the small intestine. The Biliopancreatic diversion (BPD) removes a small part of the stomach and creates new paths to the small intestine. A BPD procedure with a duodenal switch involves a sleeve gastrectomy (a surgery where the size of the stomach is reduced) and a duodenoenterostomy (a surgery that connects the first part of the small intestine to the remaining part).

It’s important for patients and healthcare professionals to keep in mind that bariatric surgery can potentially lead to psychiatric issues. These can include depression, anxiety disorders, eating disorders, dissatisfaction because weight loss expectations aren’t met, changes in body image, severe mental health disorders, and even risk of suicide. These issues can vary based on the type of surgery undergone. For example, a study in Taiwan that tracked patients over 12 years found that those undergoing malabsorptive procedures were at 1.5 times the risk of major depressive disorders compared to those undergoing restrictive procedures. Regardless, the risk for depression was heightened in both groups. It’s crucial for healthcare professionals, including surgeons, to be aware of possible psychiatric complications after surgery, do regular screenings, and manage these issues with a team-based approach.

What Causes Psychiatric Complications of Bariatric Surgery?

The chances of mental health issues after weight-loss surgery, also known as bariatric surgery, can be influenced by several things.

One of the biggest risk factors is whether the person had mental health disorders before the surgery. Some of the common pre-existing conditions seen in people undergoing weight-loss surgery are depression, anxiety, substance abuse, and binge-eating disorder. Severe eating disorders like anorexia or bulimia, mental illness symptoms, serious depression, or active substance abuse can make the surgery riskier. However, it’s worth noting that these existing mental health conditions don’t automatically disqualify a person from having the surgery. Instead, a personalized treatment plan may be considered.

Weight-loss surgery is a big life change that can potentially trigger new mental health disorders. This is due in part to the major changes in diet after the surgery, such as eating smaller amounts and trying new kinds of food. Other lifestyle changes, like eating more slowly, only eating at certain times, avoiding late-night snacks, and dealing with physical changes (like loose skin or a condition called “dumping syndrome” where food moves too quickly from the stomach to the small intestine, causing discomfort and other symptoms) can also contribute.

If the person had mental health issues before the surgery, it’s possible they’ll have impacts on the surgery’s outcomes. Research has shown that people with depression tend to lose less weight from the surgery compared to those without depression. Having a history of binge-eating disorder can also affect the weight loss results. And people with a history of alcohol abuse are at higher risk of increasing their drinking two years after the surgery.

After weight-loss surgery, some people may also struggle with a lack of certain nutrients because of changes in how their body absorbs food. The most commonly seen deficiencies include vitamins D and B12, thiamine, folate, iron, and zinc. There’s been research linking vitamin D deficiency to depression. There’s also been research linking a lack of thiamine (due to constant vomiting) to a condition called Wernicke encephalopathy which can cause symptoms like confusion, eye movement issues, and an unsteady gait. And a vitamin B12 deficiency can also lead to neurological changes.

Surgeries that limit food intake, like sleeve gastrectomy, adjustable gastric banding, and vertical gastric banding, generally result in fewer deficiencies compared to surgeries that limit both food intake and absorption, like gastric bypass (RYGB) and duodenal switch (BPD). Every type of surgery comes with the risk of certain deficiencies, but the risk of vitamin B12 deficiency is more than three times higher in surgeries that limit absorption. And mineral deficiencies, like iron and calcium, are more common with surgeries like gastric bypass, because they bypass the part of the gut where these minerals are absorbed. This can lead to anemia in nearly half of all patients after a gastric bypass.

Changes in the gut microbiome, the community of bacteria and other microorganisms in our gut, can affect mood and behavior. They influence gut hormones that can increase the rewarding effects of alcohol after weight-loss surgery. It’s also been found that alcohol and drug use are linked to changes in gut health, potentially affecting mood and behavior in a negative cycle.

After weight-loss surgery, some people might move from one addiction to another. For example, patients who used to cope with stress or emotional issues by overeating may turn to alcohol or drugs when they can’t eat as much due to their surgery. Alcohol is the most commonly reported substance used after surgery, and some patients have even died from cirrhosis, a disease that causes scarring of the liver. The risk of suicide also increases after surgery, potentially due to various factors, including lifestyle changes, dissatisfaction with weight loss, or believing that the surgery alone will solve all their prior problems.

Risk Factors and Frequency for Psychiatric Complications of Bariatric Surgery

People who are considered for weight loss surgery, or bariatric surgery, often experience mental health issues like depression, anxiety, and certain eating disorders such as binge eating. In fact, more than 15% of these individuals experience these conditions. Other mental health issues, like psychoses, are less common but can still occur. This is especially true among veterans, who also often experience conditions like post-traumatic stress disorder.

Research has shown that bariatric surgery can indeed reduce rates of depression, anxiety, and eating disorders among patients. However, there is a downside. Some patients develop issues with controlling their eating habits within two years after their surgery. This isn’t the same as having a binge-eating disorder, but it could still be a problem.

There’s also an increased risk of self-harm, suicide, and alcohol disorders among people who’ve had this surgery. One study even found that the risk of suicide was 64% higher among people who’d had the surgery compared to those who hadn’t. Other studies support these findings. For instance, one found that alcohol use rates ranged from about 7.6% to 11.8% among patients who had undergone bariatric surgery.

Signs and Symptoms of Psychiatric Complications of Bariatric Surgery

Before someone can be considered for weight loss surgery, they need to undergo a thorough mental health assessment. The purpose of this is to gain an understanding of the patient’s mental health situation and how it may change after surgery. This assessment might look at:

Current symptoms that might have influenced the decision to get weight loss surgery, like eating disorders that have led to significant weight gain.
An overview of their social history. This is to gather more information about their current life situation and whether they will be able to stick to the care required after surgery. This can be influenced by their occupation, their level of education, and their history of substance use. Additionally, it should be evaluated whether they have access to firearms.
Previous mental health history should be documented. Information like past diagnoses, episodes of self-harm, previous hospitalizations, and different medicines they’ve tried should be included in this.
Details about their medical and surgical history. This includes any previous diagnoses and hospitalizations, the medications they’re currently taking, and any surgeries they’ve had and their results.
A review of family history of mental health conditions and medicines used.
An examination of their current mental state. This looks at their appearance, their orientation, their mood, how they process thoughts, any hallucinations they might be experiencing, how good their judgment and insight are, their speech and motor skills, and their cognitive abilities.

After the surgery, patients will also need to have both their physical and mental health regularly checked. Things the doctors might look for can include:

Signs of mood disorders, like major depressive disorder. To make this diagnosis, symptoms like feeling unhappy, not finding pleasure in things they usually enjoy, feeling tired, changes in their diet, feelings of guilt, and alterations in their psychomotor skills need to be consistently present for at least 2 weeks.
Monitoring behaviors related to eating disorders, like binge eating, purging, or excessive dieting.
Keeping track of changes in weight to make sure they are progressing healthily.
Checking their mental state for any new or worsening symptoms, like delusions, hallucinations, or paranoia.
Reviewing substance use carefully, particularly for signs of alcohol use disorder, which is a common complication after weight-loss surgery.

This structured process of doing assessments before and after surgery makes sure patients are evaluated in a holistic way. It helps show if they’re ready for weight loss surgery and able to have a successful result.

Testing for Psychiatric Complications of Bariatric Surgery

It’s important for patients who have undergone bariatric surgery to be regularly screened for depression and suicidal thoughts, as these people have a higher risk of suicide. This screening can be easily integrated into routine check-up appointments.

One of the ways that doctors can check for depression is using the Patient Health Questionnaire (PHQ-9). This is a quick, easy to use survey where patients rate how frequently they experience certain depression symptoms, such as lack of enjoyment, sadness, feeling tired, changes in appetite, feeling guilty, lack of motivation, trouble focusing, acting agitated or slow, and having thoughts of suicide. Each symptom is scored from 0 to 3, so the total score can range from 0 to 27.

Scores of over 10 indicate the patient might be moderately depressed and should consider counseling or medication. A score above 15 means the patient might need active treatment with medication and therapy. If a patient scores over 20, they will likely need to urgently start medication and be referred to a mental health professional. It’s important to note that any positive response to the question about thoughts of suicide should result in an immediate assessment of the patient’s risk level.

There are other methods to assess suicide risk, such as the Columbia Suicide Scale. If a patient is at an immediate risk of suicide, it’s important that a psychiatrist is immediately consulted, and a stay in the hospital may be necessary. Along with depression screening, it’s important to keep an eye on the patient’s eating habits, particularly for signs of eating disorders, and to monitor their weight trends.

The doctor should also check if the patient has started to use substances post-surgery. A useful tool for assessing substance use is the Screening, Brief Intervention, and Referral for Treatment (SBIRT) tool. If the patient shows symptoms of anxiety, a thorough health history and physical examination are necessary to rule out any physical causes, such as dumping syndrome. Heart-related causes of palpitations should also be explored, since imbalances in electrolyte levels can occur after surgery. Basic tests like an electrocardiogram (ECG), metabolic panel, and checks for magnesium and phosphorus levels can help identify potential abnormalities.

Treatment Options for Psychiatric Complications of Bariatric Surgery

Doctors need to consider a patient’s history of weight loss surgery when prescribing medication. Weight loss surgeries can change how your body absorbs and metabolizes not just food, but also vitamins, minerals, and medications. Your stomach size is reduced and empties more quickly, which can impact how drugs are absorbed. It’s generally better to use medications that release their active ingredients immediately rather than ones that release them slower, or over time.

Also, the amount of stomach acid you produce may decrease after weight loss surgery, which can influence certain medications that rely on stomach acid to work properly. Moreover, certain drugs, such as ones that dissolve in fat, may need to be adjusted after losing weight since they can build up in your fat tissue.

Weight loss surgery, especially Roux-en-Y Gastric Bypass (RYGB), can also affect how your body breaks down certain medications. Certain enzymes that help process medications may speed up or slow down their activity after weight loss surgery, which in turn can alter the effectiveness of these medications. That’s why it’s important for doctors to closely monitor a patient for any changes to their psychiatric symptoms or side effects after weight loss surgery.

One key consideration doctors need to take into account is how weight loss surgery, like the RYGB procedure, can cause decreased effectiveness of antidepressants and some other types of medications. This might mean that the dose of these drugs may need to be increased.

When it comes to Medicare’s prescription drugs, their absorption into the body might change after weight loss surgery. For instance, it might be recommended that certain medications be administered as injections, so absorption is not affected. Certain blood tests can be helpful in guiding the appropriate treatment.

Mood-stabilizing drugs could also be affected. These include medications like valproic acid, carbamazepine, oxcarbazepine, and lamotrigine, which might require monitoring and dose adjustments after weight loss surgery. Similarly, lithium, a common medication for bipolar disorder, can also potentially reach unsafe levels after weight loss surgery, particularly if there are dehydration issues. This kind of imbalance would need to be carefully monitored.

Weight loss surgery can also impact the effectiveness of birth control pills. As such, when prescribing medications that can cause birth defects, like valproic acid or lithium, doctors need to discuss alternative forms of birth control with their patients.

When treating depression, choosing an antidepressant that doesn’t lead to weight gain is generally preferred. Certain antidepressants may not be suitable after weight loss surgery due to potential side effects and other considerations. Careful management is needed to select the correct medication for each individual patient.

If a patient develops symptoms of a neurological condition called Wernicke encephalopathy, often linked to prolonged vomiting or poor absorption of certain nutrients, immediate treatment with an IV form of the nutrient thiamine is crucial, followed by ongoing oral supplementation.

Substance use can become a problem after weight loss surgery, with alcohol use disorder being the most common. The treatment for this may include medications, as well as behavioral therapies such as cognitive, dialectal, and acceptance and commitment therapies.

When doctors are trying to understand psychiatric complications following weight-loss surgery, they should consider several possibilities including:

Micronutrient Deficiencies: Symptoms similar to depression can be caused by low levels of critical nutrients like vitamin D and iron, especially after surgeries that affect the absorption of nutrients. These deficiencies would need to be addressed immediately.
Thyroid Disorders: Changes in thyroid function can lead to symptoms that look like anxiety or depression. Major weight loss and changes in diet after surgery can impact hormone levels produced by the thyroid, possibly necessitating changes in thyroid medication.
Wernicke Encephalopathy: A condition caused by a lack of vitamin B1, this presents with confusion, coordination problems, and sight issues, which can sometimes be confused with mental disorders. Monitoring vitamin B1 levels and providing supplements if needed is very important.
Electrolyte Imbalances: Disturbances in electrolytes can produce symptoms similar to anxiety disorders, such as a racing heartbeat and a feeling of impending doom. A thorough metabolic panel is essential to identify any issues.
Dumping Syndrome: This condition may show symptoms similar to a panic attack, including a fast heartbeat and dizziness. Consider this particularly in patients showing such symptoms after surgery.

Keeping these possibilities in mind and conducting appropriate tests can help doctors accurately diagnose and treat these complications.

What to expect with Psychiatric Complications of Bariatric Surgery

Several studies have shown that, after bariatric surgery (a type of operation on the stomach or intestines to help a person lose weight), any depression symptoms initially improve, before possibly returning after about 2 to 3 years. That’s why it is essential to monitor depression and watch for any behavior that might indicate self-harm closely after surgery. Patients showing these signs should be referred for the appropriate treatment. As the risk of suicide might be higher after surgery, it is important to continue treatment until the patient and their doctor can make a collective decision about stopping medication and psychotherapy.

For those undergoing bariatric surgery, it’s quite common to experience eating disorder symptoms. Screenings should be done to detect these during follow-up appointments. Although patients may not fulfill strict criteria for binge-eating disorder after surgery – due to their now smaller stomach size – they may exhibit behaviors like eating when not hungry, overeating, or feeling guilty about their food intake.

Also, the tendency to consume alcohol is common among those seeking bariatric surgery and may continue after the surgery. Currently, information is insufficient to conclude if a patient will recover from or fall back into alcohol addiction after bariatric surgery. But the available data indicate that there is a significant number of deaths from alcoholic cirrhosis (a disease where healthy liver tissue is replaced with scar tissue, preventing the liver from functioning properly) after bariatric surgery.

Numerous studies highlight an increased risk of suicide after surgery. Screening for suicidal thoughts and behaviors that could lead to suicide is a crucial step to reduce this risk. Also noteworthy is that overall mental health problems, including depression, eating disorders, and substance abuse, can negatively impact post-surgery weight loss. Also, the expected weight loss might not match the actual result, which could lead to dissatisfaction and additional stress.

Possible Complications When Diagnosed with Psychiatric Complications of Bariatric Surgery

Bariatric surgery, often seen as a revolutionary treatment for individuals struggling with severe obesity, can also lead to various mental health issues, including an increased risk of suicide. It’s important to pay careful attention to this. After the surgery, mental health problems can either get worse (for example, in cases where individuals already had conditions like depression or anxiety) or new disorders can develop, like substance use or eating disorders.

The significant changes in a person’s body weight and physical state after surgery can cause emotional upset, concerns about body image, and changes in personal identity—all of these factors can lead to mental distress. Quickly losing a lot of weight can also cause mood swings and can affect the way person thinks, which might impact their mental health. Moreover, it’s common to suffer from nutritional deficiencies after bariatrectomy, which can also negatively affect brain function and make mental symptoms worse.

Healthcare professionals need to be aware of these potential issues. They should check for signs of these conditions, provide necessary care, and refer patients to specialized mental health practitioners for further treatment.

Common Mental Complications After Bariatric Surgery:

Exacerbated depression or anxiety
Development of new disorders such as substance use or eating disorders
Emotional distress due to drastic changes in body weight and physical state
Body image concerns
Changes in personal identity
Mood swings and cognitive effects due to rapid weight loss
Nutritional deficiencies affecting brain function

Preventing Psychiatric Complications of Bariatric Surgery

It’s crucial for individuals who’ve undergone weight loss surgery (bariatric surgery) to be aware that they might experience some changes in their psychological or emotional state afterward. This awareness is essential for the patient’s overall happiness, and it can help prevent serious mental health issues from developing.

After the surgery, there can be many changes to a person’s way of life and physical body. Sometimes, these changes may increase the risk of psychological problems. Patients need to be informed about the possibility of experiencing different emotional states, changes to their eating habits, increased use of substances like alcohol or drugs, or even thoughts about suicide.

Promoting open communication between patients and their healthcare providers is also very important. This provides opportunities for patients and doctors to have honest conversations about any psychological changes. Additionally, it can allow doctors to spot potential problems early and provide treatment more quickly.

When patients understand all these risks, they’re better equipped to keep an eye on their mental health and ask for help when they need it. This vigilance can greatly reduce the risk of health complications related to mental health issues and even prevent life-threatening situations. Therefore, thorough education about potential psychological changes is a critical part of the care plan following weight loss surgery. This ensures patients are ready to deal with any mental health problems and helps prevent negative outcomes.