REVIEW URRENT C OPINION
Psychological aspects of bariatric surgery Daniel D. Green a, Scott G. Engel a,b, and James E. Mitchell a,b
Purpose of review Individuals who undergo bariatric surgery typically experience outcomes of marked weight loss and improvements in medical comorbidities and psychological functioning. Unfortunately, a significant minority of patients also experience problems, such as reoccurring or new psychiatric disorders, alcohol or substance abuse, or eating disorders. In the current manuscript, we explore empirical studies published in the past year that are relevant to this topic. Recent findings In the area of psychiatric disorders, we focus on depression and anxiety, with several studies showing initial improvement in depression and anxiety symptoms followed by deterioration in the following years. Research in alcohol use has revealed a trend in which alcohol consumption decreases or ceases immediately following surgery, but often increases over time. Some studies have recently compared alcohol use across different types of surgery, which may help clarify a potential biological component of these problems. Finally, some eating disordered behaviors, which have until now received relatively little attention, have been further studied, with subthreshold loss-of-control eating behaviors receiving increased empirical examination. Summary Stemming from these findings, we suggest several directions to take for future research. With respect to psychiatric disorders, a closer examination of the effect of weight regain on related psychiatric comorbidities would prove valuable in determining the risk of disorder development. The mechanism by which the rate of alcohol consumption is altered following surgery has been proven elusive, and focusing further scrutiny on the differences in consumption between surgical procedures could prove useful in deciphering it. And with regards to eating disorders, a closer examination of both full diagnostic and less common eating disorders following bariatric surgery would be prudent. Keywords alcohol, bariatric surgery, eating disorder, psychopathology, substance abuse
INTRODUCTION Although weight loss and the effects of weight loss on medical comorbidities are the most common primary outcomes in bariatric surgery, it is also well known that the surgical treatment of obesity generally results in marked improvement in psychological functioning as well. However, not all patients experience these improvements to the same extent, and a significant minority of patients experience postsurgical psychiatric problems. The current literature suggests that a small, but significant, proportion of bariatric surgery patients experience problems with the development or recurrence of depression and anxiety disorders, alcohol or substance use, and/or eating disorders or eating pathology. In the sections below, we review the recent literature in these three areas of concern. www.co-psychiatry.com
THE EFFECT OF BARIATRIC SURGERY ON DEPRESSION, ANXIETY, AND RELATED PSYCHOPATHOLOGY Obesity has fairly consistently been linked with a lower health-related quality of life, along with increased risk of psychological distress [1]. However, the impact on the psychological health of the patient has been understudied. Psychiatric problems are common among patients who are candidates for a
Neuropsychiatric Research Institute, Fargo and bUniversity of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota, USA Correspondence to Daniel D. Green, Neuropsychiatric Research Institute, Fargo, ND 58103, USA. Tel: +1 701 365 4947; e-mail: dgreen @nrifargo.com Curr Opin Psychiatry 2014, 27:448–452 DOI:10.1097/YCO.0000000000000101 Volume 27 Number 6 November 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Psychological aspects of bariatric surgery Green et al. &&
KEY POINTS Anxiety and mood disorders generally improve immediately following bariatric surgery, but the improvement often deteriorates over time, potentially associated with weight regain. Although it appears that alcohol use is reduced immediately after surgery, it generally increases over time, and the mechanism for this change is not yet understood. Disordered eating behavior is not uncommon following bariatric surgery, and further research is required in less frequently studied and subthreshold behaviors in the context of bariatric surgery.
bariatric surgery, and although some disorders commonly improve postsurgery, they can also reoccur or occur de novo [2]. Burgmer et al. [3 ] examined data from the multicenter Essen-Bochum Obesity Treatment Study and found that among the 148 patients, depressive symptoms decreased significantly following bariatric surgery, with a peak improvement found 1 year postsurgery. Anxiety disorders showed a significant decrease 1 year postsurgery, yet although at 4 years, there was a 24% recovery rate, there was also a 17% rate of de novo anxiety disorder development. Although the prevalence of depression seems to correlate with level of obesity, anxiety does not appear to do so. Finally, the group found that scores on the mental subscale of the health-related quality-of-life assessment worsened across the second to fourth postoperative years, which they speculated could correlate with consequent weight regain or the patients’ return to the stress of everyday life following a postsurgery ‘honeymoon period’. A study by Hayden et al. [4 ] examined the association between preoperative and postoperative psychopathology with weight loss in a sample of 228 laparoscopic adjustable gastric band (LAGB) patients in a clinic in Melbourne, Australia. They found that preoperative psychopathology was predictive of postoperative psychopathology, but not weight loss, at 2 years postsurgery. They also found a significant decrease in axis I disorders at the 2-year follow-up, with the greatest decrease in anxiety disorders, but did not find a correlation between weight loss and changes in status of psychiatric disorders, including depression. Using the multicenter Longitudinal Assessment of Bariatric Surgery (LABS) consortium study data, this group looked at the effect and course of depressive symptoms in patients (N ¼ 2146) who &
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underwent bariatric surgery [5 ]. The consortium found significant improvement in depressive symptoms, along with a significant reduction in the reported treatment for depression, at the follow-up visits compared with baseline. In a comparison between procedures, both Roux-en-Y gastric bypass (RYGB) and LAGB patients showed similar reductions in depressive symptomatology from baseline to follow-up. However, some deterioration in this improvement was noticed across postoperative years 1–3. It was speculated that this might be attributable to unrealistic expectations, weight regain, comorbidity reoccurrence, nutritional deficiencies, and/or relative antidepressant malabsorption. A group in Taiwan published an article examining patients in an obesity treatment center (N ¼ 841), comparing the prevalence of psychiatric symptoms between nonsurgical and surgical treatments [6 ]. They found a 54.1% prevalence rate of psychiatric disorders presurgery among the surgical group, which was somewhat higher than the nonsurgical group (P ¼ 0.068). This, they mention, was not a dissimilar rate to findings from other cultures and societies. They also found a significantly higher prevalence of mood and eating disorders among women than men, which they attributed to cultural stigma. These recently published studies reviewed above suggest that there may be risk for some forms of psychopathology after bariatric surgery. Another area of potential risk, alcohol and substance abuse, is reviewed next. This is an area that has received considerable attention in the popular press, and several empirical studies on the topic have recently been published. &
ALCOHOL AND SUBSTANCE ABUSE FOLLOWING BARIATRIC SURGERY A study by King et al. [7] again using LABS data examined alcohol use of 1945 bariatric surgery patients presurgery and up to 2 years postsurgery. On the basis of the self-reported data gathered using the Alcohol Use Disorders Identification Test, they found that alcohol-use disorders significantly increased from the first to the second postoperative year. The study also found that the patients who underwent RYGB surgery were those who had an increased likelihood of alcohol-use disorders. Examining the data by a surgical procedure also showed a significant decrease in the number of drinks regularly consumed in the first postoperative year in patients who underwent RYGB compared with those who underwent LAGB. Svensson et al. [8 ], using data from the longterm Swedish Obesity Subjects Study, examined the
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Eating disorders
amount of alcohol consumed by 2010 patients and a matched nonpatient control group (N ¼ 2037), in addition to self-reported alcohol-use problems in both groups. They found that across all time points, those individuals who underwent bariatric surgery had the highest proportion of at least medium risk intake (40–60 g per day in men, 20–40 g per day in women), and in receiving an alcohol-abuse diagnosis. When comparing operations, they found a significant increase in both alcohol-intake and alcohol-abuse diagnoses in RYGB patients when compared with those who underwent vertical banded gastroplasty, which also resulted in elevated risk. They found that LAGB, in general, did not significantly increase any alcohol risk parameters. Echoing King et al.’s study, the data showed a general decrease in alcohol consumption during the first postoperative year, with an increase in consumption in the following years. In a study by Lent et al. [9 ], alcohol use before and after bariatric surgery was examined by assessing the number of drinks consumed rather than the amount of alcohol or symptoms of dependence. Alcohol use was assessed during a 6–12-month preoperative preparation program and at a point that was greater than 365 days postsurgery. Patients were found to have a significant reduction in alcohol consumption postoperatively. When Lent et al. examined the number of patients who consumed only one to four drinks, they found results similar to those seen by King et al. [7]. ¨ stlund et al. [10 ] examined data from bariatric O surgery patients from 1980 to 2006 and compared those who underwent RYGB surgery (N ¼ 4161) with those who underwent a purely restrictive procedure (N ¼ 6954). They found a significantly increased rate of inpatient care for alcohol-abuse diagnoses in the RYGB patient’s postsurgery, and no difference between the two groups presurgery. They also examined substance abuse, and found an increased rate of inpatient care for substance-abuse diagnoses in the RYGB group both before and after surgery. These empirical findings are highly suggestive that some patients are at risk for alcohol-related problems after surgery. We now review a third domain of potential problems experienced by some bariatric surgery patients: eating disorders and disordered eating behavior. &
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EATING DISORDERS, DISORDERED EATING BEHAVIOR, AND BARIATRIC SURGERY Among obese patients seeking bariatric surgery, past literature has shown disordered eating behavior to 450
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be common. For example, past studies have shown that binge eating occurs in as much as 69% of presurgery patients [11], and a diagnosis of binge eating disorder (BED) was found in approximately half of one sample of presurgery patients (49%) [12]. Further, behaviors, such as grazing [13] and night eating [14], have been shown to be relatively common in prebariatric surgery patients. Additionally, there has been some research, indicating that eating disorders such as anorexia nervosa or bulimia nervosa can emerge postsurgery [15]. The following recently published studies have continued to examine the occurrence of these behaviors, both pre and post. Prevalence rates of eating disordered behaviors among bariatric surgery patients have been of particular interest. The LABS consortium recently published a study, examining these rates up to 30 days prior to surgery (N ¼ 2266) [16 ]. Using a self-report, loss-of-control eating was found to be fairly common (43.4%), as was BED (15.7%). This study also found a 17.7% rate of night eating syndrome, and 2.0% of the patients met criteria for bulimia nervosa, which, if identified as part of the standard preoperative evaluation, would have resulted in denial or delay in the surgical procedure. Also, individuals with self-reported BED were nearly twice as likely to report a history of alcohol-use disorder symptoms. Loss-of-control eating and binge eating behaviors have been relatively well researched. A recent review by Meany et al. [17 ] focused on studies that provided data for postsurgery loss of control and binge eating. These authors found that 14 of the 15 reviewed studies indicated that such behaviors are predictive of less net weight reduction, including both less weight loss and/or more weight regain. The authors also noted that loss-of-control eating, which initially improved, worsened over time. A study by Dı´az et al. [18 ] examined the effect of preoperative binge eating behaviors on weight loss and comorbidities using the Bariatric Analysis and Reporting Outcome System Data for 42 LAGB patients were analyzed. They found that preoperative BED did not predict worse weight loss following surgery; however, patients with preoperative BED had lower rates of hypertension resolution. The authors did not examine the effect of postoperative BED. Little research is available for the postoperative emergence of eating disorders. This area was recently summarized in the literature by Marino et al. [19]. In a small case study of patients in an inpatient treatment center (N ¼ 12), Conceic¸a˜o et al. [20 ] reported that a review of medical charts provided information suggesting full syndromal eating &
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Psychological aspects of bariatric surgery Green et al.
disorders among 12 patients postsurgery. Prior findings in this area have indicated that subthreshold diagnoses are common. The assessment of such behaviors is further complicated by the eating disorder-like nature of behaviors that are recommended to bariatric patients, such as eating multiple small meals a day and vomiting if necessary to relieve plugging.
rewarding, whereas others may find it aversive. Little research on this topic has been done, and further investigation is warranted. Although binge eating in bariatric surgery patients has been investigated most intensively, other disordered eating behaviors are now being studied, and loss-of-control eating, grazing behavior, and night eating behavior have begun to receive increased scrutiny [16 ]. Further, although case studies of full diagnostic eating disorders have been reported, there is a relative paucity of empirical studies examining such problems. In summary, we know that most bariatric surgery patients experience life-changing improvements in a wide variety of domains in their lives. However, some patients do not see such dramatic improvements, and others see that past problems return or new problems develop. Although weight loss and weight loss maintenance and medical comorbidity resolution are the primary foci of most empirical studies in the area, and justifiably so, as a field we need to carefully examine these other problems that bariatric surgery patients may be at risk to develop. &
CONCLUSION Although we highlight three areas of potential problems that bariatric surgery patients may experience after surgery, it is important to note that the vast majority of patients do well after weight loss surgery. Still, a significant minority of patients struggle with such problems, as indicated by the recent research reviewed above, and it is important to study and learn from these patients in hopes of better understanding the correlates, potential causes, and consequences of these problems. Anxiety and mood disorders have been shown in studies to generally improve after bariatric surgery. The recent literature reviewed above suggests that although these forms of psychopathology may decrease after weight-loss surgery, these improvements may be short lived. Findings from both Mitchell et al. [5 ] and Burgmer et al. [3 ] show that although bariatric surgery patients’ depressive symptoms improve soon after surgery, if one follows these patients approximately 2–3 years or longer, it is not uncommon to see some deterioration of these improvements. Although weight regain has been theorized to be a causal mechanism for this, no empirical data currently speak to this matter. A review of the recently published alcohol studies suggests three important findings. First, there appears to be a decrease in or cessation of alcohol consumption in the year following bariatric surgery as recommended by bariatric surgery teams. Second, in the period of time that follows, there appears to be an increase in alcohol consumption, and also increased risk for alcohol problems. Finally, it does not appear that patients who undergo LAGB incur the same risk as those who undergo RYGB. The differences seen in the pharmacokinetics of alcohol between these procedures [21] may play a role in explaining this differential rise. For example, our research group has shown dramatic and rapid rises in blood alcohol concentration following a dose of alcohol in RYGB patients [22]. Related to this, it may be that differences in reinforcement may place some bariatric surgery patients at greater risk for problematic alcohol use after surgery in that some patients may find the sharp, rapid rise to intoxication &&
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Acknowledgements None. Conflicts of interest There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Kubik JF, Gill RS, Laffin M, Karmali S. The impact of bariatric surgery on psychological health. J Obes 2013; 2013:837989. 2. Mu¨ller A, Mitchell JE, Sondag C, de Zwaan M. Psychiatric aspects of bariatric surgery. Curr Psychiatry Rep 2013; 15:397–404. 3. Burgmer R, Legenbauer T, Mu¨ller A, et al. Psychological outcome 4 years after & restrictive bariatric surgery. Obes Surg 2014. [Epub ahead of print] This article focuses on anxiety as well as depressive symptoms and also takes into account health-related quality-of-life changes following surgery. 4. Hayden MJ, Murphy KD, Brown WA, O’Brien PE. Axis I disorders in adjustable & gastric band patients: the relationship between psychopathology and weight loss. Obes Surg 2014; 24:1469–1475. This article examines a full range of psychiatric disorders and compares preoperative and postoperative psychopathology and weight loss. 5. Mitchell JE, King WC, Chen JY, et al. Course of depressive symptoms and && treatment in the longitudinal assessment of bariatric surgery (LABS-2) study. Obesity (Silver Spring) 2014; 22:1799–1806. This article describes the trend of resolution and reoccurance of depressive symptoms in a large sample of the bariatric surgery population. This article also compares surgery types noting a significant difference in depression inventory scores over the first year. 6. Lin HY, Huang CK, Tai CM, et al. Psychiatric disorders of patients seeking & obesity treatment. BMC Psychiatry 2013; 13:1. This article describes a Taiwanese bariatric surgery population and highlights its comparison to western cultural norms. 7. King WC, Chen JY, Mitchell JE, et al. Prevalence of alcohol use disorders before and after bariatric surgery. JAMA 2012; 307:2516–2525.
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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Eating disorders 8. Svensson PA, Anveden A, Romeo S, et al. Alcohol consumption and alcohol problems after bariatric surgery in the Swedish obese subjects study. Obesity 2013; 21:2444–2451. This article is unique in its use of self-report measures of alcohol consumption and emphasizes the decrease–increase pattern of alcohol consumption seen following bariatric surgery. This article also concludes that banding-type surgeries did not have an affect on alcohol consumption. 9. Lent MR, Hayes SM, Wood GC, et al. Smoking and alcohol use in gastric & bypass patients. Eat Behav 2013; 14:460–463. This article is unique in its use of number of drinks rather than disorder testing to test alcohol consumption. ¨ stlund MP, Backman O, Marsk R, et al. Increased admission for alcohol 10. O & dependence after gastric bypass surgery compared with restrictive bariatric surgery. JAMA Surg 2013; 148:374–377. This article measures inpatient care for substance treatment and finds that nonrestrictive surgeries specifically are associated with alcohol-abuse treatment. 11. Adami GF, Gandolfo P, Bauer B, Scopinaro N. Binge eating in massively obese patients undergoing bariatric surgery. Int J Eat Disord 1995; 17:45– 50. 12. Mitchell JE, Lancaster KL, Burgard MA, et al. Long-term follow-up of patients’ status after gastric bypass. Obes Surg 2001; 11:464–468. 13. Colles SL, Dixon JB, O’Brien PE. Grazing and loss of control related to eating: two high-risk factors following bariatric surgery. Obesity 2008; 16:615–622. 14. Allison KC, Wadden TA, Sarwer DB, et al. Night eating syndrome and binge eating disorder among persons seeking bariatric surgery: prevalence and related features. Obesity 2006; 14:77S–82S. 15. Engel SG, Mitchell JE, de Zwaan M, Steffen KJ. Eating disorders and eating problems pre and post bariatric surgery. In: Psychosocial assessment and treatment of bariatric surgery patients. New York: Routledge; 2011.
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16. Mitchell JE, King WC, Courcoulas A, et al. Eating behavior and eating disorders in adults before bariatric surgery. Int J Eat Disord 2014. [Epub ahead of print] This article features prevalance rates for many disordered eating behaviors in a large bariatric surgery sample. 17. Meany G, Conceic¸a˜o E, Mitchell JE. Binge eating, binge eating disorder and && loss of control eating: effects on weight outcomes after bariatric surgery. Eur Eat Disord Rev 2013; 22:87–91. This article reviews 15 past articles on the effect of loss of control and binge eating on weight loss outcomes following bariatric surgery and finds that 14 of the 15 support the idea that those eating behaviors are associated with less weight loss or more weight regain. 18. Dı´az EG, Arzola ME, Folgueras TM, et al. Effect of binge eating disorder on the & outcomes of laparoscopic gastric bypass in the treatment of morbid obesity. Nutri Hosp 2013; 28:618–622. This article is the first to use the baratric analysis and reporting outcome system standard parameters in investigating the outcome of bariatric surgery in patients with and without BED. 19. Marino JM, Ertelt TW, Lancaster K, et al. The emergence of eating pathology after bariatric surgery: a rare outcome with important clinical implications. Int J Eati Disord 2012; 45:179–184. 20. Conceic¸a˜o E, Orcutt M, Mitchell J, et al. Eating disorders after bariatric & surgery: a case series. Int J Eat Disord 2013; 46:274–279. This case study highlights the complex nature of distinguishing disordered eating behaviors and suggested eating behaviors following bariatric surgery. 21. Klockhoff H, Na¨slund I, Jones AW. Faster absorption of ethanol and higher peak concentration in women after gastric bypass surgery. Br J Clin Pharmacol 2002; 54:587–591. 22. Steffen KJ, Engel SG, Pollert GA, et al. Blood alcohol concentrations rise rapidly and dramatically after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2013; 9:470–473. &
Volume 27 Number 6 November 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Psychological aspects of bariatric surgery Daniel D. Green a, Scott G. Engel a,b, and James E. Mitchell a,b
Purpose of review Individuals who undergo bariatric surgery typically experience outcomes of marked weight loss and improvements in medical comorbidities and psychological functioning. Unfortunately, a significant minority of patients also experience problems, such as reoccurring or new psychiatric disorders, alcohol or substance abuse, or eating disorders. In the current manuscript, we explore empirical studies published in the past year that are relevant to this topic. Recent findings In the area of psychiatric disorders, we focus on depression and anxiety, with several studies showing initial improvement in depression and anxiety symptoms followed by deterioration in the following years. Research in alcohol use has revealed a trend in which alcohol consumption decreases or ceases immediately following surgery, but often increases over time. Some studies have recently compared alcohol use across different types of surgery, which may help clarify a potential biological component of these problems. Finally, some eating disordered behaviors, which have until now received relatively little attention, have been further studied, with subthreshold loss-of-control eating behaviors receiving increased empirical examination. Summary Stemming from these findings, we suggest several directions to take for future research. With respect to psychiatric disorders, a closer examination of the effect of weight regain on related psychiatric comorbidities would prove valuable in determining the risk of disorder development. The mechanism by which the rate of alcohol consumption is altered following surgery has been proven elusive, and focusing further scrutiny on the differences in consumption between surgical procedures could prove useful in deciphering it. And with regards to eating disorders, a closer examination of both full diagnostic and less common eating disorders following bariatric surgery would be prudent. Keywords alcohol, bariatric surgery, eating disorder, psychopathology, substance abuse
INTRODUCTION Although weight loss and the effects of weight loss on medical comorbidities are the most common primary outcomes in bariatric surgery, it is also well known that the surgical treatment of obesity generally results in marked improvement in psychological functioning as well. However, not all patients experience these improvements to the same extent, and a significant minority of patients experience postsurgical psychiatric problems. The current literature suggests that a small, but significant, proportion of bariatric surgery patients experience problems with the development or recurrence of depression and anxiety disorders, alcohol or substance use, and/or eating disorders or eating pathology. In the sections below, we review the recent literature in these three areas of concern. www.co-psychiatry.com
THE EFFECT OF BARIATRIC SURGERY ON DEPRESSION, ANXIETY, AND RELATED PSYCHOPATHOLOGY Obesity has fairly consistently been linked with a lower health-related quality of life, along with increased risk of psychological distress [1]. However, the impact on the psychological health of the patient has been understudied. Psychiatric problems are common among patients who are candidates for a
Neuropsychiatric Research Institute, Fargo and bUniversity of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota, USA Correspondence to Daniel D. Green, Neuropsychiatric Research Institute, Fargo, ND 58103, USA. Tel: +1 701 365 4947; e-mail: dgreen @nrifargo.com Curr Opin Psychiatry 2014, 27:448–452 DOI:10.1097/YCO.0000000000000101 Volume 27 Number 6 November 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Psychological aspects of bariatric surgery Green et al. &&
KEY POINTS Anxiety and mood disorders generally improve immediately following bariatric surgery, but the improvement often deteriorates over time, potentially associated with weight regain. Although it appears that alcohol use is reduced immediately after surgery, it generally increases over time, and the mechanism for this change is not yet understood. Disordered eating behavior is not uncommon following bariatric surgery, and further research is required in less frequently studied and subthreshold behaviors in the context of bariatric surgery.
bariatric surgery, and although some disorders commonly improve postsurgery, they can also reoccur or occur de novo [2]. Burgmer et al. [3 ] examined data from the multicenter Essen-Bochum Obesity Treatment Study and found that among the 148 patients, depressive symptoms decreased significantly following bariatric surgery, with a peak improvement found 1 year postsurgery. Anxiety disorders showed a significant decrease 1 year postsurgery, yet although at 4 years, there was a 24% recovery rate, there was also a 17% rate of de novo anxiety disorder development. Although the prevalence of depression seems to correlate with level of obesity, anxiety does not appear to do so. Finally, the group found that scores on the mental subscale of the health-related quality-of-life assessment worsened across the second to fourth postoperative years, which they speculated could correlate with consequent weight regain or the patients’ return to the stress of everyday life following a postsurgery ‘honeymoon period’. A study by Hayden et al. [4 ] examined the association between preoperative and postoperative psychopathology with weight loss in a sample of 228 laparoscopic adjustable gastric band (LAGB) patients in a clinic in Melbourne, Australia. They found that preoperative psychopathology was predictive of postoperative psychopathology, but not weight loss, at 2 years postsurgery. They also found a significant decrease in axis I disorders at the 2-year follow-up, with the greatest decrease in anxiety disorders, but did not find a correlation between weight loss and changes in status of psychiatric disorders, including depression. Using the multicenter Longitudinal Assessment of Bariatric Surgery (LABS) consortium study data, this group looked at the effect and course of depressive symptoms in patients (N ¼ 2146) who &
&
underwent bariatric surgery [5 ]. The consortium found significant improvement in depressive symptoms, along with a significant reduction in the reported treatment for depression, at the follow-up visits compared with baseline. In a comparison between procedures, both Roux-en-Y gastric bypass (RYGB) and LAGB patients showed similar reductions in depressive symptomatology from baseline to follow-up. However, some deterioration in this improvement was noticed across postoperative years 1–3. It was speculated that this might be attributable to unrealistic expectations, weight regain, comorbidity reoccurrence, nutritional deficiencies, and/or relative antidepressant malabsorption. A group in Taiwan published an article examining patients in an obesity treatment center (N ¼ 841), comparing the prevalence of psychiatric symptoms between nonsurgical and surgical treatments [6 ]. They found a 54.1% prevalence rate of psychiatric disorders presurgery among the surgical group, which was somewhat higher than the nonsurgical group (P ¼ 0.068). This, they mention, was not a dissimilar rate to findings from other cultures and societies. They also found a significantly higher prevalence of mood and eating disorders among women than men, which they attributed to cultural stigma. These recently published studies reviewed above suggest that there may be risk for some forms of psychopathology after bariatric surgery. Another area of potential risk, alcohol and substance abuse, is reviewed next. This is an area that has received considerable attention in the popular press, and several empirical studies on the topic have recently been published. &
ALCOHOL AND SUBSTANCE ABUSE FOLLOWING BARIATRIC SURGERY A study by King et al. [7] again using LABS data examined alcohol use of 1945 bariatric surgery patients presurgery and up to 2 years postsurgery. On the basis of the self-reported data gathered using the Alcohol Use Disorders Identification Test, they found that alcohol-use disorders significantly increased from the first to the second postoperative year. The study also found that the patients who underwent RYGB surgery were those who had an increased likelihood of alcohol-use disorders. Examining the data by a surgical procedure also showed a significant decrease in the number of drinks regularly consumed in the first postoperative year in patients who underwent RYGB compared with those who underwent LAGB. Svensson et al. [8 ], using data from the longterm Swedish Obesity Subjects Study, examined the
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&&
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Eating disorders
amount of alcohol consumed by 2010 patients and a matched nonpatient control group (N ¼ 2037), in addition to self-reported alcohol-use problems in both groups. They found that across all time points, those individuals who underwent bariatric surgery had the highest proportion of at least medium risk intake (40–60 g per day in men, 20–40 g per day in women), and in receiving an alcohol-abuse diagnosis. When comparing operations, they found a significant increase in both alcohol-intake and alcohol-abuse diagnoses in RYGB patients when compared with those who underwent vertical banded gastroplasty, which also resulted in elevated risk. They found that LAGB, in general, did not significantly increase any alcohol risk parameters. Echoing King et al.’s study, the data showed a general decrease in alcohol consumption during the first postoperative year, with an increase in consumption in the following years. In a study by Lent et al. [9 ], alcohol use before and after bariatric surgery was examined by assessing the number of drinks consumed rather than the amount of alcohol or symptoms of dependence. Alcohol use was assessed during a 6–12-month preoperative preparation program and at a point that was greater than 365 days postsurgery. Patients were found to have a significant reduction in alcohol consumption postoperatively. When Lent et al. examined the number of patients who consumed only one to four drinks, they found results similar to those seen by King et al. [7]. ¨ stlund et al. [10 ] examined data from bariatric O surgery patients from 1980 to 2006 and compared those who underwent RYGB surgery (N ¼ 4161) with those who underwent a purely restrictive procedure (N ¼ 6954). They found a significantly increased rate of inpatient care for alcohol-abuse diagnoses in the RYGB patient’s postsurgery, and no difference between the two groups presurgery. They also examined substance abuse, and found an increased rate of inpatient care for substance-abuse diagnoses in the RYGB group both before and after surgery. These empirical findings are highly suggestive that some patients are at risk for alcohol-related problems after surgery. We now review a third domain of potential problems experienced by some bariatric surgery patients: eating disorders and disordered eating behavior. &
&
EATING DISORDERS, DISORDERED EATING BEHAVIOR, AND BARIATRIC SURGERY Among obese patients seeking bariatric surgery, past literature has shown disordered eating behavior to 450
www.co-psychiatry.com
be common. For example, past studies have shown that binge eating occurs in as much as 69% of presurgery patients [11], and a diagnosis of binge eating disorder (BED) was found in approximately half of one sample of presurgery patients (49%) [12]. Further, behaviors, such as grazing [13] and night eating [14], have been shown to be relatively common in prebariatric surgery patients. Additionally, there has been some research, indicating that eating disorders such as anorexia nervosa or bulimia nervosa can emerge postsurgery [15]. The following recently published studies have continued to examine the occurrence of these behaviors, both pre and post. Prevalence rates of eating disordered behaviors among bariatric surgery patients have been of particular interest. The LABS consortium recently published a study, examining these rates up to 30 days prior to surgery (N ¼ 2266) [16 ]. Using a self-report, loss-of-control eating was found to be fairly common (43.4%), as was BED (15.7%). This study also found a 17.7% rate of night eating syndrome, and 2.0% of the patients met criteria for bulimia nervosa, which, if identified as part of the standard preoperative evaluation, would have resulted in denial or delay in the surgical procedure. Also, individuals with self-reported BED were nearly twice as likely to report a history of alcohol-use disorder symptoms. Loss-of-control eating and binge eating behaviors have been relatively well researched. A recent review by Meany et al. [17 ] focused on studies that provided data for postsurgery loss of control and binge eating. These authors found that 14 of the 15 reviewed studies indicated that such behaviors are predictive of less net weight reduction, including both less weight loss and/or more weight regain. The authors also noted that loss-of-control eating, which initially improved, worsened over time. A study by Dı´az et al. [18 ] examined the effect of preoperative binge eating behaviors on weight loss and comorbidities using the Bariatric Analysis and Reporting Outcome System Data for 42 LAGB patients were analyzed. They found that preoperative BED did not predict worse weight loss following surgery; however, patients with preoperative BED had lower rates of hypertension resolution. The authors did not examine the effect of postoperative BED. Little research is available for the postoperative emergence of eating disorders. This area was recently summarized in the literature by Marino et al. [19]. In a small case study of patients in an inpatient treatment center (N ¼ 12), Conceic¸a˜o et al. [20 ] reported that a review of medical charts provided information suggesting full syndromal eating &
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Volume 27 Number 6 November 2014
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Psychological aspects of bariatric surgery Green et al.
disorders among 12 patients postsurgery. Prior findings in this area have indicated that subthreshold diagnoses are common. The assessment of such behaviors is further complicated by the eating disorder-like nature of behaviors that are recommended to bariatric patients, such as eating multiple small meals a day and vomiting if necessary to relieve plugging.
rewarding, whereas others may find it aversive. Little research on this topic has been done, and further investigation is warranted. Although binge eating in bariatric surgery patients has been investigated most intensively, other disordered eating behaviors are now being studied, and loss-of-control eating, grazing behavior, and night eating behavior have begun to receive increased scrutiny [16 ]. Further, although case studies of full diagnostic eating disorders have been reported, there is a relative paucity of empirical studies examining such problems. In summary, we know that most bariatric surgery patients experience life-changing improvements in a wide variety of domains in their lives. However, some patients do not see such dramatic improvements, and others see that past problems return or new problems develop. Although weight loss and weight loss maintenance and medical comorbidity resolution are the primary foci of most empirical studies in the area, and justifiably so, as a field we need to carefully examine these other problems that bariatric surgery patients may be at risk to develop. &
CONCLUSION Although we highlight three areas of potential problems that bariatric surgery patients may experience after surgery, it is important to note that the vast majority of patients do well after weight loss surgery. Still, a significant minority of patients struggle with such problems, as indicated by the recent research reviewed above, and it is important to study and learn from these patients in hopes of better understanding the correlates, potential causes, and consequences of these problems. Anxiety and mood disorders have been shown in studies to generally improve after bariatric surgery. The recent literature reviewed above suggests that although these forms of psychopathology may decrease after weight-loss surgery, these improvements may be short lived. Findings from both Mitchell et al. [5 ] and Burgmer et al. [3 ] show that although bariatric surgery patients’ depressive symptoms improve soon after surgery, if one follows these patients approximately 2–3 years or longer, it is not uncommon to see some deterioration of these improvements. Although weight regain has been theorized to be a causal mechanism for this, no empirical data currently speak to this matter. A review of the recently published alcohol studies suggests three important findings. First, there appears to be a decrease in or cessation of alcohol consumption in the year following bariatric surgery as recommended by bariatric surgery teams. Second, in the period of time that follows, there appears to be an increase in alcohol consumption, and also increased risk for alcohol problems. Finally, it does not appear that patients who undergo LAGB incur the same risk as those who undergo RYGB. The differences seen in the pharmacokinetics of alcohol between these procedures [21] may play a role in explaining this differential rise. For example, our research group has shown dramatic and rapid rises in blood alcohol concentration following a dose of alcohol in RYGB patients [22]. Related to this, it may be that differences in reinforcement may place some bariatric surgery patients at greater risk for problematic alcohol use after surgery in that some patients may find the sharp, rapid rise to intoxication &&
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Acknowledgements None. Conflicts of interest There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Kubik JF, Gill RS, Laffin M, Karmali S. The impact of bariatric surgery on psychological health. J Obes 2013; 2013:837989. 2. Mu¨ller A, Mitchell JE, Sondag C, de Zwaan M. Psychiatric aspects of bariatric surgery. Curr Psychiatry Rep 2013; 15:397–404. 3. Burgmer R, Legenbauer T, Mu¨ller A, et al. Psychological outcome 4 years after & restrictive bariatric surgery. Obes Surg 2014. [Epub ahead of print] This article focuses on anxiety as well as depressive symptoms and also takes into account health-related quality-of-life changes following surgery. 4. Hayden MJ, Murphy KD, Brown WA, O’Brien PE. Axis I disorders in adjustable & gastric band patients: the relationship between psychopathology and weight loss. Obes Surg 2014; 24:1469–1475. This article examines a full range of psychiatric disorders and compares preoperative and postoperative psychopathology and weight loss. 5. Mitchell JE, King WC, Chen JY, et al. Course of depressive symptoms and && treatment in the longitudinal assessment of bariatric surgery (LABS-2) study. Obesity (Silver Spring) 2014; 22:1799–1806. This article describes the trend of resolution and reoccurance of depressive symptoms in a large sample of the bariatric surgery population. This article also compares surgery types noting a significant difference in depression inventory scores over the first year. 6. Lin HY, Huang CK, Tai CM, et al. Psychiatric disorders of patients seeking & obesity treatment. BMC Psychiatry 2013; 13:1. This article describes a Taiwanese bariatric surgery population and highlights its comparison to western cultural norms. 7. King WC, Chen JY, Mitchell JE, et al. Prevalence of alcohol use disorders before and after bariatric surgery. JAMA 2012; 307:2516–2525.
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Eating disorders 8. Svensson PA, Anveden A, Romeo S, et al. Alcohol consumption and alcohol problems after bariatric surgery in the Swedish obese subjects study. Obesity 2013; 21:2444–2451. This article is unique in its use of self-report measures of alcohol consumption and emphasizes the decrease–increase pattern of alcohol consumption seen following bariatric surgery. This article also concludes that banding-type surgeries did not have an affect on alcohol consumption. 9. Lent MR, Hayes SM, Wood GC, et al. Smoking and alcohol use in gastric & bypass patients. Eat Behav 2013; 14:460–463. This article is unique in its use of number of drinks rather than disorder testing to test alcohol consumption. ¨ stlund MP, Backman O, Marsk R, et al. Increased admission for alcohol 10. O & dependence after gastric bypass surgery compared with restrictive bariatric surgery. JAMA Surg 2013; 148:374–377. This article measures inpatient care for substance treatment and finds that nonrestrictive surgeries specifically are associated with alcohol-abuse treatment. 11. Adami GF, Gandolfo P, Bauer B, Scopinaro N. Binge eating in massively obese patients undergoing bariatric surgery. Int J Eat Disord 1995; 17:45– 50. 12. Mitchell JE, Lancaster KL, Burgard MA, et al. Long-term follow-up of patients’ status after gastric bypass. Obes Surg 2001; 11:464–468. 13. Colles SL, Dixon JB, O’Brien PE. Grazing and loss of control related to eating: two high-risk factors following bariatric surgery. Obesity 2008; 16:615–622. 14. Allison KC, Wadden TA, Sarwer DB, et al. Night eating syndrome and binge eating disorder among persons seeking bariatric surgery: prevalence and related features. Obesity 2006; 14:77S–82S. 15. Engel SG, Mitchell JE, de Zwaan M, Steffen KJ. Eating disorders and eating problems pre and post bariatric surgery. In: Psychosocial assessment and treatment of bariatric surgery patients. New York: Routledge; 2011.
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16. Mitchell JE, King WC, Courcoulas A, et al. Eating behavior and eating disorders in adults before bariatric surgery. Int J Eat Disord 2014. [Epub ahead of print] This article features prevalance rates for many disordered eating behaviors in a large bariatric surgery sample. 17. Meany G, Conceic¸a˜o E, Mitchell JE. Binge eating, binge eating disorder and && loss of control eating: effects on weight outcomes after bariatric surgery. Eur Eat Disord Rev 2013; 22:87–91. This article reviews 15 past articles on the effect of loss of control and binge eating on weight loss outcomes following bariatric surgery and finds that 14 of the 15 support the idea that those eating behaviors are associated with less weight loss or more weight regain. 18. Dı´az EG, Arzola ME, Folgueras TM, et al. Effect of binge eating disorder on the & outcomes of laparoscopic gastric bypass in the treatment of morbid obesity. Nutri Hosp 2013; 28:618–622. This article is the first to use the baratric analysis and reporting outcome system standard parameters in investigating the outcome of bariatric surgery in patients with and without BED. 19. Marino JM, Ertelt TW, Lancaster K, et al. The emergence of eating pathology after bariatric surgery: a rare outcome with important clinical implications. Int J Eati Disord 2012; 45:179–184. 20. Conceic¸a˜o E, Orcutt M, Mitchell J, et al. Eating disorders after bariatric & surgery: a case series. Int J Eat Disord 2013; 46:274–279. This case study highlights the complex nature of distinguishing disordered eating behaviors and suggested eating behaviors following bariatric surgery. 21. Klockhoff H, Na¨slund I, Jones AW. Faster absorption of ethanol and higher peak concentration in women after gastric bypass surgery. Br J Clin Pharmacol 2002; 54:587–591. 22. Steffen KJ, Engel SG, Pollert GA, et al. Blood alcohol concentrations rise rapidly and dramatically after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2013; 9:470–473. &
Volume 27 Number 6 November 2014
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