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Mental Health Aspects of Bariatric Surgery

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– Learn about bariatric surgery
– Explore reasons for the surgery and increase in popularity
– Identify the psychosocial outcomes of bariatric surgery
– Identify common presenting issues in persons seeking bariatric surgery
– Explore current recommendations for assessment protocols and presurgical preparation for bariatric surgery
– Identify postoperative mental and physical health issues which may occur and need to be addressed
Types of Bariatric Surgery
– Bariatric surgeries all aim to make the stomach smaller so it can hold less food through removal, banding or bypassing.
– Some surgeries also bypass part of the small intestine which inhibits calorie as well as nutrient absorption

– Long-term weight loss is associated health improvements
– Concerns have been raised about potential ongoing risks of mental health disorders, including substance abuse, self-harm and suicidality, especially following bariatric surgery. In this meta-analysis, surgery was not associated with an improvement in mental health quality of life. Two main hypotheses have been proposed to help explain these findings: (a) patients who choose to undergo bariatric surgery are at a higher baseline risk of psychiatric complications than their non-surgically managed counterparts, or (b) surgery itself increases the risk for adverse mental health outcomes due to potential post-operative issues such as difficult with pain control, complications requiring further treatments, dissatisfaction with weight loss, and weight regain. Therefore, intensive mental health follow-up post-surgery should be routinely considered. Mental health quality of life after bariatric surgery: A systematic review and meta-analysis of randomized clinical trials

Reasons for Bariatric Surgery
– There has been an increasing amount of evidence for bariatric surgery as a more effective treatment for morbid obesity compared to dietary advice, exercise, lifestyle changes and medication. In particular,the procedure is more effective in achieving significant weight loss, longer term maintenance, improvements in physical co-morbidities and reductions in mortality
– Obesity and Cancer Fact Sheet
– Obesity and Eating Disorders Fact Sheet
– Obesity and Heart Disease Fact Sheet
– Obesity and Hypertension Fact Sheet
– Obesity and Lipid Issues Fact Sheet
– Obesity and Osteoarthritis Fact Sheet
– Obesity and Stroke Fact Sheet

Bariatric Surgery Outcomes
– Health and Health-Related Quality of Life Improvement
– Bariatric surgery is associated with sustained weight loss and improved physical health status for severely obese individuals. Mental health conditions may be common among patients seeking bariatric surgery. Mental Health Conditions Among Patients Seeking and Undergoing Bariatric Surgery: A Meta-analysis
– 20-30% of patients undergoing bariatric surgery experience premature weight stabilization or weight regain postoperatively. Cognitive behavioral therapy and predictors of weight loss in bariatric surgery patients.

– Mental Health Related Quality of Life Improvement
– mood often improves in the immediate aftermath of surgery, psychiatric disturbances often re-emerge within two to three years. These patients were almost three times more likely to attempt suicide than a general population
– Another study by Bhatti et al., 2016 looked at self-harm emergencies, including suicide attempts and found that these increased by 50% after RYGB
– De Zwaan et al investigated the course of anxiety and depressive disorders over the first 2 years post surgery in 107 extremely obese bariatric surgery patients using face-to-face interviews conducted before surgery and after surgery. Although prevalence of depressive disorders decreased significantly immediately after surgery, participants with both depressive and anxiety disorders at baseline lost significantly less weight after surgery. Moreover, postoperative depressive disorder was negatively associated with weight loss at their 24 month follow-up. Longer term studies suggest minimal improvements in mental health and psychosocial well-being after surgery compared to behavioral interventions and usual care despite overall significant improvements in physical quality of life, weight loss and co-morbidities
– Alterations in the pharmacokinetics of psychotropic medications after surgery are not well understood, particularly in RYGB patients ((37)).
Interpersonal Outcomes
– After LRGBY, patients usually will experience dumping syndrome (which includes abdominal pain, nausea, vomiting, diarrhea, and diaphoresis). Many patients also experience changes in their social scenes, as many American holidays are centered on a big meal. The way patients interact with the significant people in their lives changes dramatically, and their social structure can be irreparably broken.

Other Issues of Note
– Alcohol may also be absorbed more quickly into the body after gastric bypass or gastric sleeve. The absorbed alcohol will be more potent, and studies have demonstrated that obesity surgery patients reach a higher alcohol level and maintain the higher levels for a longer period than others.
– Any patient who undergoes surgery is usually prescribed some sort of opioid to help cope with the post-operative pain, but new research suggests that bariatric patients are more likely to develop chronic opioid use, and this occurs more often in patients who had postoperative complications or lost less weight. Bariatric patients are also more prone to abuse and are at risk of becoming addicted to alcohol. Studies have shown that drugs, alcohol, and food trigger similar reward responses in the brain, and binge eating can be construed as an “addiction.” Alcohol and drugs could substitute for overeating following bariatric surgery.

Common Presenting Issues
– The PHQ revealed a prevalence of 84 % for mental health disorders, 50 % of the participants had three or more mental health disorders.
– Studies have shown a prevalence of Binge Eating Disorder (BED) of 10 to 27% and a prevalence of Night Eating Syndrome(NES) between 2% and 20% increasing with BMI.
– Night Eating Syndrome is characterized by a shift in the circadian pattern of eating, resulting in frequent night awakenings linked to nocturnal eating and a lack of appetite in the morning.

Presurgical Assessment and Preparation
– Assessor Qualifications
– ·Psychosocial evaluation by a credentialed expert in psychology and behavior change for all WLS candidates (category C).
– Assessment by a social worker, psychologist, or psychiatrist with a strong background in the current literature on obesity and WLS, and some experience in the pre- and postoperative assessment and care of WLS patients (category D).
– An evaluator, who, preferably, is on staff or affiliated with the WLS center; this relationship can facilitate communication, maintain the support network, and provide continuity of care (category D).
– Availability of mental health resources beyond the standard postoperative period of 6 months (category D) to address long-term complications (this recommendation can be met in a variety of ways, e.g., on-staff mental health professional, referral network).

– Additionally, individuals who choose bariatric surgery instead of nonsurgical interventions tend to have high-risk baseline characteristics which are associated increased post-operative incidence of mental health disorders.
– Patients belonging to the surgical group reported a higher frequency of drinking soda (p-<-0.01), more use of unhealthy weight-reduction methods (p-<-0.001), and a family history of obesity (p-<-0.01). In addition, they had a longer history of dieting (p-<-0.001), participated more often in organized weight loss programs (p-<-0.01), and had more often lost >10 kg (p-<-0.01) (Table 2). The surgical group reported higher general self-efficacy (p-<-0.001), reflecting a stronger belief that their actions would result in a successful outcome, whereas the non-surgical patients indicated they more frequently were influenced by others in their decision to seek treatment (p-<-0.001). The surgical patients had more specific plans for changing their eating behaviors, as well as plans for coping with barriers and setbacks (p-<-0.001). Moreover, they expected their well-being and social competence to improve to a greater degree in the next three years. Presurgical Assessment and Preparation - Assessment Domains - the patient's understanding of the surgery and the necessary lifestyle changes; expectations regarding the results; the ability to adhere to operatory recommendations; eating behavior (weight history, diet, exercise, binge eating (diet, habit, emotional), night eating syndrome); psychiatric comorbidities (current and previous); reasons to undergo the surgical procedure; social support; substance use; socioeconomic status; conjugal satisfaction; cognitive functioning; self-esteem; history of trauma/abuse; quality of life and suicidal ideation weight, diet and nutritional history; 2) current eating behaviors; 3) medical history and weight related medical problems; 4) understanding of surgical procedures, risks and postoperative regime; 5) motivation and expectations regarding surgical results; 6) relationships and support system; 7) psychiatric functioning social, occupational, recreational and physical impairment due to weight, awareness of eating habits, sense of control over eating, (psyBari is a 115 item instrument that was developed in 2010, but the website is currently blocked and there is no way to access/purchase the instrument) - Severe preoperative psychopathology and patient expectation that life will dramatically change after surgery can also negatively impact psychological health after surgery. - substance use/abuse/dependence, eating disorders, psychotic disorders, depression and suicide are the most common mental health contraindications to surgery - 67.4% of patients (after surgery)felt poorly prepared, psychologically, before the surgery. Psychological assessment is also considered a unique opportunity to perform the psychoeducation of the patient about the changes resulting from the surgery, offer psychological support and prepare the candidate for behavioral modifications that must occur in the postoperative period - people with morbid obesity on a waiting list for bariatric surgery improved their physical health during the 2 years after attending a tailored patient educational course. - In addition to the contraindications stated above, other factors that can postpone or rescind the surgery are: a lack of understanding regarding the risks, benefits and results of the surgical procedure; a reluctance to adhere to the postoperative recommendations; severe mental retardation; multiple suicide attempts or a recent suicide attempt; active symptoms of obsessive-compulsive disorder and bipolar disorder; severe life stressors; and nicotine use Postoperative Physical Health - In the early postoperative period, the main goals of office visits are to assess proper nutrition status, identify maladaptive eating disorders, evaluate potential complications (internal hernia, ulcers, etc), monitor status of comorbidities, encourage regular exercise, discuss weight loss progress, and check laboratory values (vitamin B1, vitamin B12, magnesium, phosphorous, blood counts, albumin, and a metabolic profile). Postoperative Physical Health - In the early postoperative period, the main goals of office visits are to assess proper nutrition status, identify maladaptive eating disorders, evaluate potential complications (internal hernia, ulcers, etc), monitor status of comorbidities, encourage regular exercise, discuss weight loss progress, and check laboratory values (vitamin B1, vitamin B12, magnesium, phosphorous, blood counts, albumin, and a metabolic profile). - When you leave the hospital, you will receive prescriptions for several medications. Some of these medications will be taken for a few months after surgery, and others you will take for life. One is an acid reduction medicatio, called a "proton pump inhibitor" (PPI) such as Omeprazole (Prilosec), helps prevent uclers. If you have a gallbladder, you will be prescribed a medication called Ursodiol to help prevent formation of gallstones. All of your pills should be crushed and capsules opened. You will not be able to absorb whole pills as well as you did before surgery, and pills may have difficulty passing through your new digestive system. - Dumping, which occurs only after LRGBY, can be viewed as a negative adverse effect, but it can be used by the patient as a teaching tool. The surgical weight loss program retrains patients to lead a healthy lifestyle. - dumping syndrome occurs when food, especially sugar, moves from your stomach into your small bowel too quickly. Most people with dumping syndrome develop signs and symptoms, such as abdominal cramps and diarrhea, 10 to 30 minutes after eating. Other people have symptoms one to three hours after eating, and still others have both early and late symptoms. Generally, you can help prevent dumping syndrome by changing your diet after surgery. Changes might include eating smaller meals and limiting high-sugar foods. - Adults undergoing bariatric surgery who meet relatively low thresholds of PA (e.g., -8 high-cadence minutes/day, representative of approximately 1h/week of moderate-vigorous intensity PA) are less likely to have recently received treatment for depression or anxiety compared to less active counterparts. Postoperative Physical Health - The main goals after any bariatric gastric surgery are threefold: (1) to maximize weight loss and absorption of nutrients, (2) to maintain adequate hydration, and (3) to avoid vomiting and dumping syndrome. - Much of the nutritionist's work is related to informing patients how to eat properly and how to judge fluid, protein, carbohydrate, and fat intake. The importance of self-monitoring by means of keeping daily food records is emphasized from the initial visit. - Ghrelin (your hunger hormone) decreases after bypass surgery, but within 6-9 months it stabilizes and food urges start coming back. Some complain that initially "You are on a really strict regimen of eating six times day," she says. But "I have no desire to eat." Others who are emotional eaters and even though I can't eat as much, the reasons I eat are still there." Since you’ll be eating smaller meals, and avoiding certain foods, this new plan is not conducive to a quick stop for fast food like so many of us are used to. Postoperative Physical Health - Because Roux-en-Y gastric bypass is a malabsorptive operation, it carries greater risk for nutritional deficiencies than the restrictive procedures. Due to malabsorption in the shortened digestive tract in procedures such as the jejunoileal bypass, roughly 30% of patients develop conditions due to malnutrition, such as anemia and osteoporosis, according to the National Institute of Diabetes and Digestive and Kidney Diseases. Chronic malnutrition problems occur because nutrients are absorbed differently following surgery. Symptoms are fatigue, aching muscles, and tingling feet, calves, or hands. This is because malabsorptive procedures cause food to bypass parts of the duodenum and jejunum, where most iron and calcium are absorbed. Menstruating women are especially prone to developing anemia because insufficient vitamin B12 and iron are absorbed. Decreased absorption of calcium may cause osteoporosis and metabolic bone disease. - Thiamin deficiency is caused by inadequate dietary intake, as primary absorption sites may be bypassed.23 Clinical presentations have included acute Wernicke encephalopathy (nystagmus, ophthalmoplegia, ataxia, and confusion), lower limb hypotonia, seizures, polyneuropathy, unsteady gait and ataxia, and hearing loss. Severe deficiency is associated with beriberi. Dry beriberi is the development of a symmetric peripheral neuropathy characterized by sensory and motor impairments mostly of the distal extremities, as demonstrated by difficulty in rising from a squatting position. Treatment for acute deficiency manifested by cardiovascular or neurologic signs involves administration of supplemental thiamine, starting with 100 mg/d intravenously for 7 days - The nutritional or bariatric surgery outcome can be improved by treatment focusing on the emotional regulation such as psychotherapy, life style change and also psychopharmacological interventions for impulsivity. - (Vyvanse) is the first FDA-approved drug to treat binge eating disorder in adults also SSRIs, SNRIs and Topiramate, an antiseizure medication might work better for binge eating than antidepressants, but it can cause serious side effects (like problems with memory) The available data for SNRIs suggest that agents modifying noradrenaline may play a role in reducing impulsivity and improving the symptoms of ADHD and binge eating disorder - standardized assessments may not reveal other psychosocial experiences (e.g. marital discord or judgment by former friends), which may contribute to general wellbeing and achieved weight loss. Providers may consider asking patients questions such as “How has your weight loss changed your relationships-” or “Has anyone judged you negatively for having weight loss surgery-” - Opportunities to promote favorable psychosocial outcomes through post-surgical mental healthcare may include support groups, couple’s therapy, or one-on-one counseling. Post-Operative Lifestyle Changes - Mealtime guidelines are provided to encourage fluid intake and to maximize satiety between meals.22 Five guidelines for fluid consumption are as follows: - No liquids at meals; wait at least 30 minutes after a meal to start fluids. It is important to avoid overfilling and stretching the stomach pouch. - Sip beverages; do not use a straw, which increases swallowed air. - The daily goal is at least 1.4 L (6 cups) of fluids. This should include high-protein liquid supplement, skim milk, and sugar-free noncarbonated beverages. Decaffeinated coffee or tea is preferred. - Stop eating and drinking when a full feeling occurs. Overfilling the stomach pouch will cause it to stretch, which often leads to increased intake. - Avoid carbonated beverages, as the gas bubbles may stretch the pouch. - Following bariatric surgery, patients are forced to reduce the amount of food intake and to change their diets [39]. They are instructed to eat only three small meals a day, to eat very slowly, to chew food extremely well, to eat small amounts, to stop eating when they are getting ‘full’, and to avoid high-calorie foods and liquids. However, preference for high-calorie soft food, such as ice-cream, is one of the main reasons for therapeutic failures. Postoperative Mental Health - Mean body mass index (BMI) and the duration of follow-up appear to be significant moderators of negative psychological outcomes. - For most patients, this is a time of emotional turmoil. Many patients have difficulty with the extreme and instant lifestyle changes. If patients were previous stress eaters and become stressed after surgery, they no longer have the ability to eat for stress relief. - Patients complaining of weight regain should be referred back to the bariatric team to be evaluated for surgical complications or for excess calorie intake. At the other end of the spectrum are patients who may be struggling with their body image and self-esteem, causing them to skip meals or even to starve themselves. These patients are terrified that they will gain weight back and will benefit from regular visits with a therapist to help them overcome their fears and create a healthy body image. Weight loss surgery is merely a tool that helps people get a new start toward maintaining long-term good health. The surgery alone will not help someone lose weight and keep it off. Long-term Management of Patients After Weight Loss Surgery - A number of psychosocial issues including inadequate weight loss or weight regain, potentially superimposed on a unrealistic expectations, lack of improvement in quality of life after surgery, continued or recurrent physical mobility restrictions, persistence or recurrence of sexual dysfunction and relationship problems, low self-esteem, and a history of child maltreatment including sexual abuse. Other factors could include inadequate absorption of psychiatric medications and systemic imbalances due to nutritional changes causing alterations in gut microbiota and the gut-brain axis.. - positive psychosocial outcomes could be obtained post-surgery by implementing trainings explicitly encouraging the use of adaptive ER-strategies Emotion regulation and mental well-being before and six months after bariatric surgery. - This study supports the use of CBT in helping patients preparing for bariatric surgery to reduce DE and to improve mental health. Areas for Support and Coaching - Change in Self Perception - “When I Look in the Mirror” - Many patients reported discordance between their objective post-surgical weight and their perceived body image and identity. One patient stated, “I think for me the mind body experience is so separate. The body loses weight but the mind still stays [the same]” and another endorsed a sense of lost self-identity, stating “once I lost over 100 pounds, and looked in the mirror at myself, I didn’t know that person looking back, and that frightened me.” In several instances, participants described persistent dissatisfaction with their body image despite marked weight loss and comments from others that “you look so good.” - I Have More Confidence” - Many individuals described increased self-confidence after weight loss, which resulted in an increased ability to engage professionally and socially. - “I Used Food to Cope” - Some participants expressed insight into the psychological factors that contributed to their pre-surgical weight. Several individuals recognized that they used food to cope with emotional distress, and after surgery, “you have to deal with the real reasons you overeat and why you mistreat your body.” -   - Change in Perception by Others - You Took The Easy Way Out” - not recognized by acquaintances after weight loss. This prompted various emotional responses among focus group participants. While some enjoyed the “actual shock reactions of people” some were saddened by the lack of recognition. One woman said, “I was really upset people who have known me all my life walked right by me.” - “I Am No Longer Invisible” people who used to ignore you now want to be your best friend -   - Change in Relationships - certain relationships strengthened following weight loss, which was often due to increased self-confidence and ability to partake in new activities together. - many participants experienced distress in certain relationships following weight loss. This was often attributed to changes in social activities, which were previously centered around eating. that’s why I married her. I wanted her that size” and another said “I almost got divorced because I was changing so fast.” - many participants experienced jealousy from friends and family due to weight loss.