The Complex Association Between Bariatric Surgery and Depression: a National Nested-Control Study

No association between history of psychiatric treatment and postoperative weight reduction after bariatric surgery

PURPOSE

The objective of the study was to assess whether the history of psychiatric treatment was associated with (1) body weight and BMI on admission for bariatric surgery, (2) weight loss > 5 kg prior to bariatric surgery, and (3) postoperative body weight reduction.

METHODS

Data from medical records of all consecutive patients admitted for surgical treatment of obesity in the 2nd Department of General Surgery Jagiellonian University Medical College were obtained. There were 1452 records of patients who underwent bariatric surgery between 2009 and 2021 included in the study.

RESULTS

History of psychiatric treatment was found in 177 (12%) of the sample and was inversely associated with body weight and BMI on admission for surgery in women. Men with history of psychiatric treatment were 54% less likely to lose > 5 kg before the surgery (OR = 0.46 95% CI = 0.24-0.88). Both in men and women %TWL did not differ significantly by history of psychiatric treatment (Me: 40.7 vs. 45.9; p = 0.130 and Me: 27.0 vs. 23.9; p = 0.383, respectively). After adjustment for covariates no association was found between history of psychiatric treatment and body weight reduction one year after surgery.

CONCLUSION

Although men with preoperative history of psychiatric treatment had lower odds of losing weight before the surgery, psychiatric treatment did not differentiate the effectiveness of bariatric treatment in 1 year of observation. Bariatric surgery appears to be an effective obesity care for people treated for mental disorders.

LEVEL OF EVIDENCE

III Evidence obtained from cohort or case-control analytic studies.

Assessing how bariatric surgery, emotional eating, and depression could affect each other: A cross-sectional study

Emotional eating (EE) has been found to be associated with depression, anxiety, excessive weight, obesity, and unhealthy eating habits. EE could also be associated with recurrent weight gain. To date, the factors predicting success following bariatric surgery remain uncertain. In addition, there is a paucity of data regarding the associations between EE, percent of total weight loss (TWL), and depression after bariatric surgery. The aims of this study were to evaluate the relationship between EE behavior, depression, and TWL, and to identify other factors, such as the type of bariatric surgery, that may have an impact on EE, depression and TWL after bariatric surgery. A self-report questionnaire was administered to 253 patients who underwent bariatric surgery between 2014 and 2021 at the Department of General Surgery, Faculty of Medicine, Gazi University. In total, 115 patients agreed to participate and completed the questionnaire. The administered scales consisted of the Sociodemographic Data Form, Emotional Eating Scale (EES), and Beck Depression Inventory (BDI). The participants were divided into the Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) groups. The RYGB and SG groups included 79 (68.8%) and 36 (31.3%) patients, respectively. A significant difference was found in terms of age (P = .002) and gender (P = .033). The BDI scores (P = .499) and TWL (P = .068) did not differ significantly. The EES score was higher in the SG group (P = .020). Between the groups with and without EE, age (P = .004) and BDI scores (P = .004) were significantly different. In correlation analyses, EES score was related to BDI score(ρ = 0.402, P < .001) and age(ρ = -0.348, P = .002) in the RYGB group. In regression analyses, TWL was associated with age (β = -0.366, P < .001) and surgery type (β = -6.740, P < .001), EES score was associated with BDI score (β = 0.149, P = .009) and age (β = -0.154, P = .006), and BDI score was associated with EES score (β = 0.419, P = .009) and age (β = -195, P = .041). In patients with moderate-to-severe depression, TWL was higher than in those without depression (P = .025). The effect of emotional eating and depression on TWL was not detected. Emotional eating and depression trigger each other in the individuals who underwent bariatric surgery. Young individuals who undergo bariatric surgery are more vulnerable to emotional eating and depression than older patients.

Psychosocial Aspects of Metabolic and Bariatric Surgeries and Endoscopic Therapies

Obesity is a prevalent progressive and relapsing disease for which there are several levels of intervention, including metabolic and bariatric surgery (MBS) and now endoscopic bariatric and metabolic therapies (EBMTs). Preoperative psychological assessment focused on cognitive status, psychiatric symptoms, eating disorders, social support, and substance use is useful in optimizing patient outcomes and minimizing risks in MBS. Very little is known about the psychosocial needs of patients seeking EBMTs, though these investigations will be forthcoming if these therapies become more widespread. As MBS and EBMT inherently alter the gastrointestinal (GI) tract, considerations for the longer-term GI functioning of the patient are relevant and should be considered and monitored.

Pregnant Women Following Bariatric Surgery: a Focus on Maternal Mental Health and Its Impact on Birth Outcomes

PURPOSE

Bariatric surgery is associated with elevated risks for adverse birth outcomes, such as small-for-gestational-age infants (SGA). Maternal mental health is a critical regulator of fetal growth, but it is largely overlooked in pregnant women post-surgery. This study aimed to examine the associations between maternal mental health and birth outcomes in pregnant women post-bariatric surgery.

MATERIALS AND METHODS

This was a retrospective analysis of medical records of women who had a singleton delivery following Roux-en-Y gastric bypass or sleeve gastrectomy. Mental health measures included depression/anxiety and substance use (cigarettes, alcohol, opioids, and marijuana). Birth outcomes were fetal growth restriction, SGA, low birthweight, and preterm birth. Logistic regressions were used to assess the associations between maternal mental health and each of the birth outcomes. A post hoc logistic regression was conducted to assess factors that influenced maternal marijuana use.

RESULTS

Participants (N = 179) were mostly white (64.6%), non-Hispanic (84.5%), with a mean age of 32.7 ± 4.6 years, and mean body mass index of 37.2 ± 8.4 kg/m² at conception. Maternal marijuana use significantly increased the odds for fetal growth restriction, SGA, low birthweight, and preterm birth. Cigarette use increased the risk for low birthweight. Conversely, alcohol use was protective of low birthweight and preterm birth. A post hoc analysis revealed that married women were less likely to use marijuana than those who were single, divorced, or widowed.

CONCLUSION

This analysis identified marijuana and cigarette use as risk factors for adverse birth outcomes post-bariatric surgery. Future studies with larger sample sizes are needed to confirm study findings.

DEVELOPMENT AND VALIDATION OF A PSYCHOLOGICAL SCALE FOR BARIATRIC SURGERY: THE BARITEST

BACKGROUND

It is recommended that bariatric surgery candidates undergo psychological assessment. However, no specific instrument exists to assess the psychological well-being of bariatric patients, before and after surgery, and for which all constructs are valid for both genders.

AIMS

This study aimed to develop and validate a new psychometric instrument to be used before and after bariatric surgery in order to assess psychological outcomes of patients.

METHODS

This is a cross-sectional study that composed of 660 individuals from the community and bariatric patients. BariTest was developed on a Likert scale consisting of 59 items, distributed in 6 constructs, which assess the psychological well-being that influences bariatric surgery: emotional state, eating behavior, quality of life, relationship with body weight, alcohol consumption, and social support. Validation of BariTest was developed by the confirmatory factor analysis to check the content, criteria, and construct. The R statistical software version 3.5.0 was used in all analyses, and a significance level of 5% was used.

RESULTS

Adjusted indices of the confirmatory factor analysis model indicate adequate adjustment. Cronbach's alpha of BariTest was 0.93, which indicates good internal consistency. The scores of the emotional state, eating behavior, and quality of life constructs were similar between the results obtained in the community and in the postoperative group, being higher than in the preoperative group. Alcohol consumption was similar in the preoperative and postoperative groups and was lower than the community group.

CONCLUSIONS

BariTest is a reliable scale measuring the psychological well-being of patients either before or after bariatric surgery.

The Effect of Bariatric Surgery on Long-term Depression Treatment in Patients With Obesity

OBJECTIVE

In a large multisite cohort of Veterans who underwent Roux-en-Y gastric bypass (RYGB) or laparoscopic sleeve gastrectomy (LSG), initiation of (ie, incident) and persistence of (ie, continuation of preoperative) depression treatment are compared with matched nonsurgical controls.

BACKGROUND

Bariatric surgery has been associated with short-term improvements in depression but less is known about longer term outcomes.

METHODS

In a retrospective cohort study, we matched 1713 Veterans with depression treatment who underwent bariatric surgery in Veterans Administration bariatric centers from fiscal year 2001 to 2016 to 15,056 nonsurgical controls using sequential stratification and examined the persistence of depression treatment via generalized estimating equations. Incidence of depression treatment was compared using Cox regression models between 2227 surgical patients and 20,939 matched nonsurgical controls without depression treatment at baseline.

RESULTS

In surgical patients with depression treatment at baseline, the use of postsurgical depression treatment declined over time for both surgical procedures, but postsurgical patients had greater use of depression treatment at 5 years [RYGB: odds ratio=1.24, 95% confidence interval (CI): 1.04-1.49; LSG: odds ratio=1.27, 95% CI: 1.04-1.56] compared with controls. Among those without depression treatment at baseline, bariatric surgery was associated with a higher incidence of depression treatment compared with matched controls (RYGB: hazard ratio=1.34, 95% CI: 1.17-1.53; LSG: hazard ratio at 1-5 years=1.27, 95% CI: 1.10-1.47).

CONCLUSIONS

Bariatric surgery was associated with a greater risk of postoperative incident depression treatment and greater persistence of postoperative depression treatment. Depression may worsen for some patients after bariatric surgery, so clinicians should carefully monitor their patients for depression postoperatively.

Bariatric surgery, gastrointestinal hormones, and the microbiome: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2022

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) is intended to provide clinicians an overview of bariatric surgery (i.e., bariatric procedures that improve metabolic disease are often termed "metabolic and bariatric surgery"), gastrointestinal hormones, and the microbiome as they relate to patients with obesity.

Methods

The scientific information for this CPS is based upon published scientific citations, clinical perspectives of OMA authors, and peer review by the Obesity Medicine Association leadership.

Results

This CPS includes the pros and cons of the most common types of bariatric procedures; the roles of gastrointestinal (GI) hormones in regulating hunger, digestion, and postabsorptive nutrient metabolism; and the microbiome's function and relationship with body weight. This CPS also describes patient screening for bariatric surgery, patient care after bariatric surgery, and treatment of potential nutrient deficiencies before and after bariatric surgery. Finally, this CPS explores the interactions between bariatric surgery, GI hormones, and the microbiome.

Conclusions

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) regarding bariatric surgery, gastrointestinal hormones, and the microbiome is one of a series of OMA CPSs designed to assist clinicians in the care of patients with the disease of obesity. Implementation of appropriate care before and after bariatric surgery, as well as an awareness of GI hormones and the microbiome, may improve the health of patients with obesity, especially patients with adverse fat mass and adiposopathic metabolic consequences.

The Relationship Between Percentage Weight Loss and World Health Organization-Five Wellbeing Index (WHO-5) in Patients Having Bariatric Surgery

Purpose

The association between bariatric surgery outcome and depression remains controversial. Many patients with depression are not offered bariatric surgery due to concerns that they may have suboptimal outcomes. The aim of this study was to investigate the relationship between baseline World Health Organization-Five Wellbeing Index (WHO-5) and percentage total weight loss (%TWL) in patients after bariatric surgery.

Materials and Methods

All patients were routinely reviewed by the psychologist and screened with WHO-5. The consultation occurred 3.5 ± 1.6 months before bariatric surgery. Body weight was recorded before and 1 year after surgery. A total of 45 out of 71 (63.3%) patients with complete WHO-5 data were included in the study. Data analysis was carried out with IBM SPSS Statistics (version 27) to determine the correlation between baseline WHO-5 and %TWL in patients having bariatric surgery.

Results

Overall, 11 males and 34 females were involved with mean age of 47.5 ± 11.5 and BMI of 46.2 ± 5.5 kg/m². The %TWL between pre- and 1-year post-surgery was 30.0 ± 8.3% and the WHO-5 Wellbeing Index mean score was 56.5 ± 16.8. We found no correlation between %TWL and the WHO-5 Wellbeing Index (r = 0.032, p = 0.83).

Conclusion

There was no correlation between the baseline WHO-5 Wellbeing Index and %TWL 1-year post-bariatric surgery. Patients with low mood or depression need to be assessed and offered appropriate treatment but should not be excluded from bariatric surgery only based on their mood.

Graphical Abstract

The Association Between Bariatric Surgery and Psychiatric Disorders: a National Cohort Study

PURPOSE

Previous studies have shown that bariatric surgery reduces the risk of cardiovascular outcomes. Less is known about the effects of bariatric surgery on psychiatric disorders. This cohort study compared the differential risk of psychiatric disorders between those who did and did not undergo bariatric surgery, from before until after the surgery.

MATERIALS AND METHODS

We used PearlDiver-Mariner, a national all-payor claims database. Patients were followed for 1 year before and after the index date and a difference-in-differences (DiD) study design was executed.

RESULTS

We included 56,661 bariatric surgery patients matched to 56,661 individuals with obesity. Among bariatric surgery patients, the risk of psychiatric was 18% 1 year before and increased to 70% 1 year after surgery. Among individuals with obesity, the risk of psychiatric disorders also increased from 1 year before to 1 year after, but by less (21% versus 46%). DiD analysis suggested that bariatric surgery was associated with a 27 percentage point differential increase in the risk of psychiatric disorders across all patients, representing a 135% relative increase. Results using 3 years as the pre- and post-periods lead to similar inferences.

CONCLUSION

Preexisting psychiatric disorders are similarly prevalent among bariatric surgery patients and individuals with obesity. The prevalence of psychiatric disorders increased over time for both groups, but to a larger extent among bariatric surgery patients. Adequate treatment for psychiatric disorders and appropriate implementation of behavioral health interventions may be needed to reduce the burden of psychiatric disorders following bariatric surgery.

The Impact of Psychiatric History and Peri-operative Psychological Distress on Weight Loss Outcomes 1 Year After Bariatric Surgery

BACKGROUND

To determine if self-reported baseline psychological distress moderates the association between lifetime psychiatric diagnosis and weight loss 1 year after bariatric surgery. An exploratory analysis assessed change in psychological distress from baseline on weight loss at 1 year.

METHODS

A retrospective cohort study using data from the Ontario Bariatric Registry for all individuals undergoing surgery between January 1, 2012, and December 31, 2018, with a complete baseline psychological assessment and 1-year post-operative weight recorded (N = 11,159). Multiple linear regressions assessed the relationship between psychiatric diagnosis and percentage of excess body mass index loss (%EBMIL) at 1-year post-surgery, controlling for baseline body mass index, socio-demographics, medical co-morbidities, and surgical complications. Baseline psychological distress, measured with the EQ-5D-5L anxiety/depression rating, was examined as a moderator of this relationship. %EBMIL was separately regressed on change in psychological distress from baseline to 1 year, controlling for psychiatric diagnosis.

RESULTS

In the adjusted model, psychiatric diagnosis was associated with lower %EBMIL at 1 year (B =  - 1.00, P = .008). Baseline psychological distress was not a moderator, but had a significant main effect on %EBMIL (B =  - .84, P = .001). Those who experienced a decrease in psychological distress at 1 year, or remained low throughout, fared better than those who increased or had persistently high symptoms.

CONCLUSIONS

These findings support use of a self-report assessment for psychological distress prior to bariatric surgery. Addressing active psychological distress prior to and/or following surgery may increase the likelihood of successful outcomes.