Behavioral Health Problems among Postsurgical Bariatric Patients: The Need for Continuing Behavioral Health Interventions

Abstract

The aim of this review was to identify the postoperative behavioral health difficulties most often experienced by individuals who have undergone bariatric surgery. As bariatric surgery becomes a more commonly accepted method of treating obesity, more research is emerging regarding the psychological impact of the surgery and subsequent lifestyle changes. While patients who undergo this surgery may be educated on the physical expectations postoperatively, many patients are unaware of the psychological impact they may experience. Even patients who present for surgery with psychological or psychosocial concerns may not expect those problems to maintain, increase, or shift. Rather, they often expect those concerns to dissipate. The literature shows patients may experience difficulties with adjusting to postoperative changes, anxiety and mood disorders, substance dependence and addictive behaviors, as well as intense and dangerous behaviors. This review explores some of the more common psychological difficulties reported by postoperative patients that, ultimately, points to the continued need to include behavioral health providers as members of an integrated bariatric treatment program.

Introduction

Obesity has been declared a disease,¹ and it is often said to be of epidemic proportions or, at the very least, a widespread struggle faced by many.² While genetic and environmental factors are implicated in the etiology of obesity, the psychology of obesity plays a role in its development as well. Many determinants are involved in the etiology of obesity. These antecedents work alone and in combination to alter the likelihood of the development of obesity. These intricate pathways are unique for each individual. Or, as Marcus and Wildes¹^(p742) have put it, “clinical obesity reflects alterations in remarkably complex internal and environmental milieus that combine to form multiple pathways that result in obesity.” In addition to the preexisting conditions with which a preoperative bariatric patient may present, it is important to note that the surgery may cause or reveal conditions that were unknown prior to surgery. As such, even patients who experience few psychological concerns prior to surgery may experience these problems after surgery. There are many potential reasons for this shift, including that the patient may have been utilizing food as a coping tool without realizing it. Below, we explore several common disorders and maladaptive behaviors seen in postoperative patients that evince the need for continuing psychological care following bariatric surgery.

Adjustment to Postsurgical Changes

Patients seeking bariatric surgery often come with hopeful, but sometimes unrealistic, goals regarding how the surgery will impact their life. Many studies have found that quality of life (QoL) and improvements in psychosocial functioning are readily apparent in the initial postsurgical period.³ For the first 2 years following surgery, psychosocial functioning appears to improve. However, these improvements are limited, as improvements occurring beyond the first 2 years have been shown to diminish. Many possible reasons could underlie this regression toward presurgical levels of psychosocial functioning. One reason this pattern exists may have to do with the overtly obvious weight loss. For the first 2 years, weight often decreases very quickly, which may help improve a patient's self-esteem and contribute to the patient becoming more outgoing in social situations. However, after those first 2 years, weight loss stabilizes, and weight regain occurs for many patients,³ which may lead to decreased psychosocial functioning. Another reason that levels of psychosocial functioning may not automatically improve following bariatric surgery has to do with a patient's presurgical expectations, particularly with respect to improvements in interpersonal relationships. “When these reactions of others begin to appear, having believed that their social acceptance was guaranteed by the weight loss, they may feel deeply disillusioned, which in turn can be a demoralizing and discouraging process of weight loss.”⁴^(p338) Finally, a patient may find that, even when social interactions change, it may not always be as imagined. For example, “… patients may have difficulties adapting psychologically to the consequences of bariatric surgery, limitations as well as new possibilities, such as their changing shape and size, and the positive attention they get.”³^(p789) It may appear counterintuitive, but even positive attention can be distressing for some in this postsurgical adaptation period. Ultimately, psychosocial success following surgery is largely dependent upon the patient's ability to adjust to the new lifestyle associated with the surgery,⁵ which may be improved with presurgical preparation and postsurgical care.

Anxiety and Mood Disorders

Anxiety disorders and mood disorders, in particular major depressive disorders, are prevalent among patients seeking bariatric surgery. Following surgery, these disorders often remain underlying problems and, without treatment, often become prominent problems. The absence of treatments specifically for an individual's psychological disorder and unrealistic expectations combined with weight fluctuations, even when weight changes are acceptable, may impact changes in psychological functioning following surgery. According to van Hout et al., for the first year, during the dramatic weight loss and psychosocial changes, psychopathology may decrease as the person becomes engrossed in their changing lives and feels excited about the results of the surgery.³ Maddi et al. examined the differences between pre- and postoperative means of MMPI-2 scale scores of 52 bariatric patients.⁶ Among other changes, the researchers found that the mean score for depression decreased by 7.36 (p=0.001), and the mean score for hysteria decreased by 8.83 (p=0.001). They declared “… the number of participants who met the test criteria for an actual psychiatric disorder went from higher than the MMPI-2 estimate of the population norm before surgery, to less than that norm after surgery.”⁶^(p683) However, it is important to remember that the study completed by Maddi et al. assessed patients only at the 1 year mark following surgery.⁶ Unfortunately, the decrease in psychopathology often does not last if the change in psychopathology is solely due to the surgery. While some changes may occur, “…patients may be disappointed that their lives do not dramatically improve once they have lost weight, and that many of their presurgical problems persist, realizing that some underlying emotional problems were not related to weight.”³^(p789) Omalu et al. explained that even when weight loss was acceptable and sustained, after 36 months many patients returned to their presurgery levels of anxiety and mood disorders.⁷ This suggests psychological disorders may be independent of obesity and, thus, need to be treated as such following surgery for both the patient's physical and psychological health. Physical and psychological health are intertwined: “… the presence of significant psychopathology that is independent from the degree of obesity, such as major depression, may inhibit patients' ability to make dietary and behavioral changes necessary for the most successful outcome possible.”⁸^(p51)

Substance Dependence and Addictive Behaviors

Substance dependence and addictive behaviors in general play a role in the treatment of obesity both before and after surgery. One way that issues surrounding dependency become more problematic following surgery is that many addictive behaviors are considered coping tools. Davies found that patients seeking bariatric surgery often use food as a coping tool, sometimes to the point of addiction.⁹ In order to avoid developing alternative addictive behaviors, learning new coping tools after bariatric surgery is essential.¹⁰ “It is important that compulsive eating is not replaced by an equally unhelpful behavior such as smoking, alcohol consumption, drug use, or any other form of compulsive behavior.”⁹^(p101) Unfortunately, without proper postsurgical follow-up, patients may resort to dysfunctional coping tools. “‘Addiction transfer’ is a popular, mass media-created term that refers to the idea that patients who undergo bariatric surgery may develop additions to substances, gambling, sex, and so forth to replace their preoperative ‘addiction’ to food.”⁸^(p54) There is also an understanding that substance abuse rates may decrease at first and then later increase, so it is important that the bariatric patient is educated on this information. Research has shown that while substance abuse typically decreases in the first year after surgery, many clients experience an increase that exceeds their presurgical consumption during the second year after surgery and onward.¹¹ This may be due to a multitude of factors, including addiction transfer, a lack of coping skills, and difficulty adjusting to psychosocial changes postoperatively. Additionally, research is showing that clients, particularly bariatric clients who have undergone the Roux-en-Y gastric bypass (RYGB) procedure, experience physiological sensitivity to alcohol changes after surgery. “There is evidence that some bariatric surgical procedures (i.e., RYGB and sleeve gastrectomy) alter alcohol pharmacokinetics. Given a standardized quantity of alcohol, postoperative patients reach a higher peak alcohol level compared to case controls or their preoperative values.”¹¹^(p2518) A lack of postsurgical follow-up that monitors psychological health can become very problematic because patients may unknowingly use excessive substances, including alcohol, leading to major health problems, including death.

Self-Harming Behaviors

Researchers investigating self-harming behaviors in patients seeking bariatric surgery found that “in this population there appears to be acknowledged behavior that suggests self-regulatory difficulties in various areas (e.g., promiscuity and alcohol abuse).”¹²^(p442) Self-harming behaviors can be defined in numerous ways and are found in many populations, including postbariatric surgery patients. Sansone et al. found that self-harming behaviors are prevalent in bariatric surgery candidates and exist in several forms, including unprotected sexual contacts with multiple partners or high-risk partners, 22.3%; self-defeating thoughts, 20.7%; alcohol abuse, 19.0%; and emotionally abusive relationships, 16.5%.¹² The study completed by Herpertz et al. found that out of 33 patients who were reassessed during a 24-month follow-up after bariatric surgery, one patient made a suicidal gesture.¹³ While this number may seem small, one patient from this population is equivalent to 3%. The U.S. Department of Health and Human Services Centers for Disease Control and Prevention reported in 2008 approximately 0.5% of the U.S. adult population attempted suicide.¹⁴ This number indicates that suicidal gestures in the bariatric population may be as much as six times higher than the national average. Additionally, many individuals who make suicidal gestures or who self-harm do not tell anyone, leaving those gestures unaccounted for. This gives way to a potentially higher percentage of bariatric surgery patients committing acts of self-harm that researchers simply are unable to measure. Heneghan et al. discussed why understanding the links between obesity, self-harm, and bariatric surgery need to be addressed.¹⁵ They explained, “… several large population-based studies have shown that obesity is independently linked to an increased risk of various suicidal behaviors, including suicidal ideation, attempts, thoughts, and suicide mortality.”¹⁵^(p99)

Suicidal Behaviors

Many individuals, including bariatric patients, relate bariatric surgery to healthy overall functioning. It is often assumed that losing the weight should help make life better. This is not necessarily the case for individuals who have struggled to adjust to life after surgery,¹⁶ even if they had no indications of psychopathology prior to surgery. Not only is life not better for patients who have had difficulty adjusting, life is sometimes worse. “There have been recent reports that gastric bypass surgery may increase the chances of suicide.”¹⁷^(p101) Tindle et al. followed postbariatric patients in Pennsylvania and found suicide rates to be higher than age- and sex-matched rates in the United States, averaging 6.6/10,000 over 10 years.¹⁸ These data may slightly underestimate the magnitude of the problem, as there were some causes of death, such as drug overdose, that were listed as accidental but were likely purposeful suicides. To put these data in perspective, the researchers applied it to the total number of individuals receiving bariatric surgery in the United States over the same time-period. “Estimating conservatively using the 2004 Agency for Healthcare Research and Quality rates, if the overall suicide rate of the current study (6.6/10,000 persons-years) were applicable to the total US sample, then there would have been approximately 500 suicide deaths between 2004 and 2010 (excluding deaths from other causes) among those who had bariatric surgery in 2004.”¹⁸^(p1039) Over the course of 10 years, how did these rates—six times that of the national, nonbariatric, suicide average¹⁵—go unnoticed? Is it because the majority of the suicides occur after the accustomed surgical follow-up period? Tindle et al. explained that approximately 70% of the suicides occurred within 3 years of surgery but after the standard 6 month follow-up period.¹⁸ These alarming details further justify the need for postsurgical behavioral healthcare involvement that occurs over a longer period of time than current standard postsurgical medical follow-ups. Sansone et al. showed that the actual process of surgery was significantly related to the suicides when he looked at suicides among obese individuals, both postbariatric and nonbariatric participants, and found that those who had undergone surgery were three times more likely to commit suicide than the nonsurgical matched obese control participants.¹² Researchers are unsure why suicide rates increase following bariatric surgery, but one hypothesis surrounds the malabsorption involved in the Roux-en-Y surgery. Researchers found that “… changes in the pharmacokinetics of psychotropic drugs, owing to a degree of malabsorption after Roux-en-Y gastric bypass, might alter the efficacy of these medications.”¹⁵^(p104) Finally, many researchers have explored whether suicide is related to patients not losing weight fast enough or regaining weight, and have found that there is little relationship between weight change and suicide. As shown by Omalu et al., based on three specific case studies, it is unlikely that suicide is significantly related to “failing” bariatric surgery.⁷ “The three patients in our study committed suicide at 12 months, 27 months, and 26 months post-surgery, despite respective weight losses of 111 pounds, 105 pounds, and 64 pounds at the times of suicide.”⁷^(p449) When studies clearly show that behaviors linked with psychological disorders, such as suicide, rise to rates well above the population norms following bariatric surgery, the need for behavioral health interventions as part of bariatric treatment programs becomes increasingly evident.

Conclusions and Implications

As prevalence rates have skyrocketed over the last decade, the problem of being overweight or obese is becoming a greater public health concern. Fortunately, individuals who are overweight or obese have many treatment options. However, as shown, most of those treatment options lead to only short-term or minimal weight loss. One intervention, bariatric surgery, is often considered the treatment of choice for this population because it results in greater and longer-lasting weight loss. While weight loss is an important focus for overweight and obese patients, psychological comorbidities—both before and after treatment—are crucial, and often overlooked, focuses.

As described, many overweight and obese individuals who qualify for bariatric surgery have pre-existing psychopathology or emerging psychopathology following surgery. Anxiety disorders and mood disorders are among the most common of these concerns. The rates and intensity of these disorders may decrease following surgery. However, that decrease does not always last past the first year. Once a patient's weight loss begins to slow or a patient realizes that their weight was not responsible for the psychopathology they experience, psychopathology often returns—sometimes to rates or intensities greater than before surgery. Along with regression of psychopathology, concerning behaviors such as addictive tendencies, self-harm, suicidal gestures, and suicide may emerge. This information calls for more attention to be paid to the psychological health of bariatric surgery patients.

According to the Bariatric Center of Kansas City, numerous comorbidities presenting in bariatric patients encourage the inclusion of a number of professionals from a variety of specialties when creating the treatment team at most bariatric programs (informational seminar, 2008). The members of this treatment team often include bariatric surgeons, physician assistants, dieticians, and other specialists, sometimes including behavioral healthcare professionals. While the inclusion of behavioral healthcare professionals is becoming more common among bariatric treatment teams, they are not consistently found to be members of this treatment team. In fact, according to the American Society for Metabolic and Bariatric Surgery guidelines, the utilization of behavioral health services is encouraged but not required at any point for a patient undergoing bariatric procedures and, as such, the utilization of these services is inconsistent.¹⁹ The roles behavioral healthcare professionals are found to provide include presurgical psychological evaluations, short-term presurgical psychotherapy, presurgical psychoeducational programs, and postsurgical follow-up. When postsurgical follow-up with a behavioral health provider is available, it can come in several forms, including brief “check-ins” and psychotherapy sessions.²⁰ Brief “check-ins” typically consist of 15 minute clinical assessments in the form of a discussion with the behavioral health professional to ensure patient health and wellness, while bariatric psychotherapy more resembles the typical 45–50 minute therapy frame. For those patients who prefer medical intervention for behavioral health concerns, postsurgical referrals to mental health professionals such as psychiatrists may be appropriate. However, it is important that information regarding the potential changes to the absorption of medications following bariatric surgery be provided as part of the patients' presurgical psychoeducational curriculum. Little research has been published at this time regarding the absorption of psychotropic medications following bariatric surgery, but at least one study has shown postsurgical bariatric patients presenting with a smaller quantity and plasma concentration of sertraline than the nonsurgical control group.²¹ Thus, regardless of the type of mental health intervention, be it behavioral or medical or another alternative, it is essential that the treatment is provided by an appropriate professional. Although at this time there are no specific credentialing requirements for behavioral health professionals who treat bariatric patients, it is important that the provider be knowledgeable about bariatric surgery in general, as well as its psychological and medical impacts.²² “Considering the important role of psychosocial factors in the outcomes of bariatric surgery, the impact of psychosocial variables on [quality of life (QoL)] after surgery, and the fact that the operation can profoundly modify the psychological and social situation [of the patient], mental health professionals should be a part of the process of evaluation and treatment of bariatric surgery patients.”⁵^(p13)

Footnotes

Acknowledgments

We thank John R. Essman, PsyD: Mercy Hospital Bariatric Team in Springfield, Missouri, and Ravi Sabapathy, PsyD: Bariatric Center of Kansas City in Lenexa, Kansas. Portions of the information in this article were gathered in conjunction with doctoral project research completed by Amelia B. Winsby.

Author Disclosure Statement

No competing financial interests exist.

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