People with obesity usually deal with health conditions such as heart disease, hypertension, type 2 diabetes, fatty liver disease, sleep apnea… but physical illnesses are not the only risks they face. Obesity also triggers psychological threats. The prevalence of mental illnesses, such as depression and ideation of suicide, has been widely studied in obese patients. The incidence and severity of these illnesses has been compared between obese patients who have undergone bariatric surgery and obese patients that have had no surgical intervention or that have received treatment with life intervention programs. Awareness of these risks is a big step towards reflection upon candidacy for bariatric surgery, and most importantly, towards prevention. In what comes next of this text, we will review the correlation between obesity, weight loss surgery and depression, and we will highlight the multiple factors that influence upon this equation.
There’s a bidirectional relation between obesity and depression. A depressed person may adopt unhealthy eating habits, such a binging or grazing, which could lead to obesity; and a person with obesity may fall into depression due to negative effects on self-image and self-esteem. It’s kind of a vicious circle. A meta-analysis review of longitudinal studies in 2010 reported that obese individuals have a 55% higher risk of developing depression in comparison with non-obese individuals; but also depressed individuals had roughly the same chances (58%) of developing obesity. The relation between obesity and depression is not univocal, by any means, as many factors might either trigger or inhibit this effect, but high stakes prevail. But overweight and obesity, do not necessarily imply the same risks. The severity of each case also makes a difference. Some studies have reported that higher body mass index scores are reason for higher prevalence of depression. One study suggests a threefold increase in prevalence of depression in patients with a BMI higher than 40, in comparison with patients with a BMI between 35 and 39.9.
Weight loss surgery and depression
Given this scenario, chances are that most patients seeking a bariatric surgery treatment either have a history of depression or might fall into depression in the future. A study has shown that 15 to 32% of patients who seek bariatric surgery treatment report being in a current state of depression, and that 50 to 70% have experienced at least one episode of depression in their lives. Although there’s no direct, scientifically proven link between outcomes of weight loss surgery and depression, it is feared that mental illnesses in patients might lead to treatment failure. By 2005, 86.4% of the programs registered in the American Society for Bariatric Surgery directory required candidates of weight loss surgery to pass psychiatric evaluation in order be elected for their surgical procedure. Insurance companies usually solicit this as well. It’s unquestionable that an optimal mental state is required to sustain the hardships of the post-operation period of any surgery, but furthermore of a bariatric surgery, where most aspects in the life of the patient will experience drastic changes, and where the patient needs to make a conscious commitment to maintain a healthy eating habits. The patient needs to obtain the approval of a psychiatric professional in order to be a candidate for bariatric surgery.
In LIMARP International Center of Excellence for Obesity, we care deeply for our patients and their physical and mental wellbeing. Our programs for obesity treatment include a full psychological evaluation before determining candidacy for bariatric surgery. This evaluation may be done remotely, with online consults. If the patient does not get approval from our psychiatric expert, he or she may continue follow-up consults or be referred to other health care provider of his or her choice. Whenever the patient is ready, re-evaluation takes place in order to go on with bariatric surgery.
The effects of weight loss surgery on depression have been largely researched with short-term and long-term studies that analyze the incidence of depressive symptoms in patients, before surgery, and after surgery in different time periods, such as 6 months, 1 year, 2 years… up to 8 years after surgery. The findings of these studies about weight loss surgery and depression are that a majority of patients reduce their depression symptoms during the first 3 years of post-operation. The first year is the most significant in this amelioration. These benefits are also observed in levels of anxiety, self-esteem, and overall quality of life.
However, these studies also agree in that the benefits of weight loss surgery on depression seem to wear off after 4 years. There are many things that need to be explained about this tendency.
Body mass index
We stated previously that people with a BMI higher than 40 are at higher risk of developing depression, in comparison with people of a BMI between 35 and 39.99. This correlation between BMI and depression has been further acknowledged in patients after 4 years of their surgical intervention. Greater weight loss has correlated to higher rates of depression resolution. Long term recovery from depression has mostly been observed in patients that accomplish weight loss of at least 25% of their initial weight after 4 years of surgery. This has been observed in almost half of patients that accomplished most weight loss. However, more frequent backsliding to depression has been observed on patients who lost less than 25% of their weight 4 years after their surgery, even to similar rates than people with obesity that haven’t received a surgical intervention. The most concerning thing about these findings though, is that even patients that didn’t have any history of depression before their surgery developed depressive symptoms if they failed to lose more than 25% of their weight 4 years or more after their surgery. Reports have found this tendency in 10 to 20% of patients that did not meet this expected weight loss mark. It is a minority, but either way, it has to be prevented for everyone. Further ahead we will talk about preventive measures for mental illness in patients that have gone through bariatric surgery.
One explanation for this correlation between BMI decrease after weight loss surgery and depression is the sense of failing to achieve a very desired goal, or having excessively high expectations about bariatric surgery outcomes.
Weight regain
Patients who go through a bariatric surgery lose most weight during the first year of surgery. Some patients might lose half their weight in 1½ or 2 years after surgery. This depends on the kind of surgery the patient received, and the extent to which he or she has adopted and maintained a healthy lifestyle that includes good eating habits and routinely exercises. However, as years pass by, most bariatric surgery patients might experience a slight weight regain. This has come to be expected, because the body adapts to its diet and activities. The severity of the weight regain, though, might trigger depressive symptoms. The experience of weight regain after bariatric surgery may result in feelings of failure that could increase the risk of depression. Surgeons are responsible for letting their patients know that there comes a point after bariatric surgery where the weight loss stops and a slight weight regain is to be expected, although not in all cases. Access to complete information could avoid feelings of disappointment and failure and prevent depression.
Malabsorptive vs restrictive procedures
Research has also identified that some weight loss surgeries pose higher risks than others when it comes to depression. A Taiwanese study found that patients who had received malabsorptive procedures, such as the gastric bypass, had a higher risk of developing a major depressive disorder, almost double the risk, in comparison with patients who underwent restrictive procedures such as the gastric sleeve.
A possible explanation for this is the fact that malabsorptive procedures have a changing effect in the metabolic system of the patient. The gastrointestinal tract suffers alterations after a malabsorptive surgery, which might account for less responsiveness to antidepressant medications. Malnutrition or failing to absorb enough nutrients might also contribute to mental illness if these problems remain undetected.
Perception of little social support
A bariatric surgery demands major changes in the lifestyle of a patient in order to produce its best outcome and most lasting benefits. However, these lifestyle changes do not only affect the patient, they also have an impact on their partner, family relatives and friends. If the patient adopts new habits, such as eating certain foods differently, joining support groups, or exercise classes, or dropping damaging behaviors, such as binging, social drinking or sleeping late, chances are the people that live with the patient will also need to get used to these new changes and will have to adopt new habits themselves, to support with their loved one. This disposition of loved ones to support the patient who has received bariatric surgery can either enhance or deteriorate his mental health.
A study showed that higher depression is associated with significantly less perceived social support, before surgery, and most specially after surgery. Perceived support was further associated with less weight regain, but to a moderate extent. Support from family members had much higher impact in the patients’ mental health, than support from friends. Some couples report losing quality in their relationship when dealing with more conflicts as they fail to adjust together to behavioral changes needed for the patient’s treatment. In the case of un-married patients, they seemed to be more likely to adhere to diet and exercise recommendations to meet their weight loss targets, in comparison with married patients.
However, this study also showed that the factor that seemed to motivate the most social support for bariatric surgery patients was depression itself, which in turned lowered the patient’s perception of support. The awareness of depressive tendencies in the patient elicited more support from family and friends.
When it comes to weight loss surgery and depression, family support definitely plays a significant role. Support from society is also important though. People with obesity often face prejudice, public shame or discrimination. If a patient undergoes bariatric surgery, changes his lifestyle and loses weight, but notices no changes in his social environment, his body image and self-esteem will be at constant risk.
Obesity clinics need to consider the patient’s social support network and its role during the weight loss treatment. Talking with family members and including them in the process achieves greater outcomes for bariatric surgery patients.
Other related factors
Weight loss surgery and depression studies have also analyzed the role of factors such as body image dissatisfaction, self-esteem, shame, and perfectionism. A study revealed that depression, self-esteem and perfectionism accounted for almost half of the variance in body image satisfaction in bariatric surgery female candidates. Gender differences might be another factor in weight loss surgery and depression, but this is harder to substantiate with scientific data, since women are the great majority of patients that seek and obtain bariatric surgery. Differences in body perception, societal demands and overall socialization might play a role in the incidence of depression.
Ideation of suicide
When we talk about the relation between weight loss surgery and depression, the ideation of suicide and self-harm is the most dangerous risk that may arise from this equation. However, the stronger predictor for suicide ideation after bariatric surgery is a previous history with suicidal ideation before the surgical intervention. In this regard, it is very important to consider previous background in attempted suicide or self-harm to provide constant follow up and support for bariatric surgery candidates. Even in this issue, bariatric surgery is recognized for ameliorating depressive symptoms and improving quality of life during the first and second year of post-surgery. Ideation of suicide in these cases might arise later, after 3 to 4 years, when the honey moon phase of the treatment is almost over, or when patients experience weight regain. However, research shows that this suicidal ideation is low, passive, and at a minimal baseline. Most of the patients did not endorsed any active suicidal intent, but the ideation of it is a depressive symptom that needs to be prevented.
Alternatives for mental illness prevention
We have described the relation between weight loss surgery and depression as bidirectional with obesity, changes in BMI, weight regain and other social factors. These correlations exist and have been proven with different methods in large populations of bariatric surgery patients during the last decade. But this picture should not be interpreted as being the top common denominator between patients of bariatric surgery. Studies have identified the tendency of depression development in minorities inside subgroups of their research population. Percentages vary from 20 to 10% of patients that experienced weight loss surgery and depression at a long term of 4 years or more after surgery. This percentage is lower when it comes to suicide ideation, from 10 to 3%, depending the methodology of each study.
Regardless of the percentage, the need of prevention measures is undisputable. The main objective of treatments for obesity is the patient’s wellbeing in the short, medium and long term. At LIMARP International Center of Excellence for Obesity, our programs include various stages, such as prevention, education, treatment and follow-up maintenance.
Psychological therapy
At our clinic, we provide psychological therapy for every patient that seeks either non-surgical or surgical treatment for obesity. Our psychological team will make sure you are mentally prepared to start your surgical treatment. We will provide you with all the information you need to be fully aware of the risks and of the realistic goals and outcomes you might expect after your bariatric surgery. We offer therapy at our facilities in Tijuana, Mexico, but we also provide therapy sessions with videoconference meetings and phone calls. After your surgical procedure, we provide follow up psychological therapy each month during the first year. After that, therapy sessions are usually provided every three months. This could change, depending on the patient’s personal needs.
Support groups
Support groups are a great strategy for sharing experiences between people who have faced similar problematics and issues. In these group gatherings, people are more empathetic towards one another because they can relate to each other’s experiences and share insights and advice. At LIMARP, we get you in contact with post-surgery online support groups. Having a group of people that can listen and understand what you’re going through eases anxiety and keeps you aware that you are not alone.
Seek support from loved ones
Sometimes feelings of inadequacy might lead to isolation. Talk to your loved ones about your needs and feelings. Keeping constant dialogue, sharing activities and collaborating in mutual goals strengthens your relationships and enriches your support network. Remember to keep in contact with your friends and plan outings or indoor activities you can all enjoy.
Continue your psychiatric treatment
If you have been in receiving treatment related to mental illness or depression, talk to your psychiatrist about changes in medication or doses that consider your obesity treatment.
Eat healthy
Eating healthy is key to losing weight after surgery, but it is also fundamental to prevent depression and other mental illnesses. It’s very important to make sure you are receiving enough nutrients, calories and hydration every day. A lack of any of these goals could create complications and trigger depressive symptoms. Make sure you always attend your follow-up consults with your doctor.
Get enough sleep
Getting enough sleep helps your brain to keep healthy. Sleep at least 8 hours a day and try going to bed at the same time every night, and getting up in the morning at roughly the same hour. Establishing a routine for going to bed and getting up in the morning might help achieve this habit.
Exercise regularly
Exercising helps you achieve your weight loss goals after bariatric surgery, but it also helps your mental health by keeping your body active. Our team of experts at LIMARP, can assist you in the development of a physical activity plan designed specially for you.
Dedicate time just for you
There are other wellness activities that might help you stay focused and reduce anxiety. Meditation, yoga or mindfulness programs might be a good complimentary strategy focus on your wellbeing. If you’re not convinced about this type of activities, search for a hobby that can set your mind at ease and reduce stress. Drawing, sewing, knitting, singing, dancing, gardening, arts & crafts are just some examples of simple activities that could help. Connect with what you like and feel free to explore. Don’t press yourself in getting perfect results for these activities; just experience them to allow your mind focus on the present moment, channel your motivation, and enjoy the process.
Contact us
If you would like more information about weight loss surgery and depression, contact us at LIMARP International Center of Excellence for Obesity, located at Tijuana, México. Our team of experts will be very glad to help.