Depression after gastric sleeve

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Results

There were 4793 participants with bariatric surgery recorded; 1324 participants with bariatric surgery first recorded < 1 year after the start of the patient record were excluded, as were 14 participants aged < 20 years at the index date, and 401 participants with either no BMI record before surgery or BMI values < 30 kg/m2 prior to surgery. Nine participants with a record of gastric band removal before the index date were also excluded. There were then 3045 participants identified as having bariatric surgery for obesity and 3045 matched controls. Bariatric surgery procedures included LAGB in 1297 (43%), GBP in 1265 (42%), SG in 477 (16%) and six of undefined type. Utilisation of bariatric surgery increased over the period and LAGB accounted for 97% of 104 procedures before 2006, but only 20% of 924 procedures from 2012 onwards, with increasing use of GBP and SG. The median year of procedure was 2010 and, consequently, only a minority of participants contributed more than 3 years of follow-up data.

Characteristics of the surgery and control participants at the index date are presented in Table 27. The majority of surgical procedures were conducted in women (79%) and in participants with morbid obesity (65%). The mean age at surgery was 45.9 years. Participants undergoing bariatric surgery more frequently had T2DM (29% vs. 14%; p < 0.001), hypercholesterolemia (35% vs. 25%; p = 0.022) and were more likely than controls to be prescribed antihypertensive drugs and statins.

TABLE 27

Comparison of baseline characteristics of BS participants and controls. Figures are frequencies (column %) unless otherwise indicated

Table 28 shows the number of participants analysed by year before and after surgery. There were 63% contributing to follow-up after the end of 2 years and 31% in the fifth year of follow-up. In the year prior to surgery, 36% of surgery participants met the criteria for prevalent clinical depression in comparison with 21% of control participants (Figure 10 and see Table 28). In the 2 years following surgery, this reduced to 32% in the participants who underwent surgery before rising to pre-surgery levels (37%) in the seventh year of follow-up. Rates of depression in control participants remained stable. In the surgery group, 41% of participants were prescribed antidepressants in the year leading up to surgery, falling to 36% in the subsequent year. The proportion of participants prescribed antidepressants began to rise again after the first year and surpassed pre-surgery levels in the fifth year following bariatric surgery.

TABLE 28

Changes before and after surgery in diagnosis and treatment of depression. Figures are frequencies for person-years and row per cent for depression and antidepressant prescribing

FIGURE 10

Prevalence of clinical depression for bariatric surgery cases (black) and controls (green) for 3 years before and 7 years after index date.

Table 29 presents the results of the multiple logistic regression model for the outcomes of clinical depression and antidepressant prescribing. Compared with control participants, the between-group effect shows that bariatric surgery participants were more likely to be diagnosed with clinical depression (OR 2.02, 95% CI 1.75 to 2.33; p < 0.001) or to be prescribed antidepressant drugs (OR 1.97, 95% CI 1.72 to 2.25; p < 0.001). There was evidence of increasing trends in diagnosis of depression and prescription of antidepressant drugs over the study period. Estimation of the effect of time since surgery, in comparison with all person-time without surgery from both groups, revealed a reduction in clinical depression and antidepressant prescribing in the first 3 years following the procedure. The adjusted relative odds of clinical depression were 0.82 (95% CI 0.78 to 0.87; p < 0.001) and 0.83 (95% CI 0.76 to 0.90; p < 0.001) in the first 2 years following the procedure. Similar changes were observed for the related outcome of antidepressant prescribing. However, from the fourth postoperative year onwards there was no longer any evidence for a reduction in clinical depression or antidepressant prescribing.

TABLE 29

Logistic regression analysis of the association of bariatric surgery with clinical depression and antidepressant prescribing

There was no evidence that the effect of bariatric surgery varied by type of procedure (test for interaction, p = 0.2885). Table 30 presents the prevalence of depression for each of the three procedures included in the study, after omitting six with undefined procedure type. There were more participants with LAGB at long durations of follow-up while fewer than 25% of participants receiving SG, and 35% receiving GBP, contributed data after the end of 3 years’ follow-up because these procedures were utilised more recently. The effect in each subgroup was generally similar to the one observed overall, and in the absence of an interaction effect, possible subgroup differences were not explored further.

TABLE 30

Clinical depression following different bariatric surgical procedures

There was no evidence that the effect of bariatric surgery on clinical depression varied by type of procedure (test for interaction, p = 0.2885).

Table 31 shows the results divided by depression status in the preoperative year. Among participants who were not depressed in the preoperative year, the prevalence of depression increased to 18% in the sixth postoperative year, while up to 9% were depressed 2 years before the procedure. Among participants who were depressed in the preoperative year, the prevalence of depression was generally close to 75% postoperatively. However, in the second preoperative year, 77% were depressed. These results are consistent with depression being episodic and frequent in this population.

TABLE 31

Prevalence of depression by year following bariatric surgery divided by presence or absence of depression in preoperative year

Many people having surgery for severe obesity also have mental health conditions, particularly depression and binge-eating disorder, a new review finds.

The analysis of 68 studies found that almost one-quarter of obesity surgery candidates had a mood-related disorder, usually depression. Another 17 percent had binge-eating disorder, researchers report Jan. 12 in the Journal of the American Medical Association.

Obesity surgery, known medically as bariatric surgery, can be an option for people who are severely overweight — typically 100 pounds or more.

And while doctors have known that patients often have mental health symptoms as well, it has not been clear just how common that is, said study author Dr. Aaron Dawes.

“What was striking to us is that depression and binge-eating disorder were both more than twice as common as they are in the general U.S. population,” said Dawes, a general surgery resident at the University of California, Los Angeles.

Weight loss a losing battle for most obese people

The good news was that the review found no clear evidence that mental health conditions hindered patients’ weight loss after surgery.

That’s reassuring, Dawes said, because there have been some concerns about that possibility.

There are different forms of obesity surgery, but all generally alter the digestive tract to limit the amount of food a person can eat. Surgery candidates, Dawes noted, have to commit to a new way of eating, both to lose weight and stay healthy — and there have been questions about whether people in poorer mental health can manage the post-surgery changes.

“This analysis does not support the notion that these patients do worse,” Dawes said.

On the other hand, he added, the findings show how important it is to consider obesity surgery candidates’ mental health.

“Doctors need to be aware that mental health conditions are common among these patients, and refer them for treatment if necessary,” Dawes said.

It is standard for patients to have some sort of mental health screening before undergoing weight-loss surgery.

That’s typically done by a mental health professional, who would then advise the surgery team on how to move ahead if the patient does have a psychiatric condition, said Dr. Bruce Wolfe, a bariatric surgeon at Oregon Health & Science University, in Portland.

“Mental health disorders are definitely prevalent among individuals with severe obesity, so that evaluation is important,” said Wolfe, who was not involved in the study.

But, he stressed, a mental health diagnosis does not automatically disqualify someone from having surgery, as patients sometimes fear.

Man who lost 650 pounds will be “different person” after surgery

A person with moderate depression would be managed differently from someone having suicidal thoughts, for example, Wolfe said. The suicidal patient would not be a candidate for surgery; the depressed patient might have the procedure and receive depression therapy — though there’s still the question of whether that should happen before or after surgery, he noted.

As for binge-eating disorder, he said, it might seem like the condition would preclude people from obesity surgery, since they have to limit their food intake strictly.

But, as the current review shows, studies have found that people with the disorder fare as well as other patients, Wolfe said.

That might be partly because some get therapy for their binge-eating, Wolfe said. But he said the surgery also has effects on the nervous and hormonal systems that may help ease bingeing.

Based on the review, people with depression can also improve after surgery. Across seven studies, prevalence of depression dropped by anywhere from 8 percent to 74 percent after surgery. The severity of patients’ depressive symptoms also fell — by 40 percent to 70 percent.

“We’re not suggesting that anyone have bariatric surgery to treat their depression,” Dawes said. But, he added, it’s encouraging that depression became less common post-surgery.

According to Dawes, the fact that mental health conditions were so common in this study might help lift some of the “stigma” patients can feel.

“You’re not alone,” he said.

Wolfe agreed. “Mental health conditions should be considered another potential comorbidity of severe obesity, just like diabetes or high blood pressure,” he said.

The Mental-Health Toll Of Weight-Loss Surgery

Part of the problem is that although patients looking at weight-loss surgery go through significant physical examinations, they go through minimal — if any — mental-health screening. And while any major surgery may come with emotional challenges, these patients could be especially vulnerable to new issues or an exacerbation of existing ones. At this point, it’s becoming clear that we don’t have an adequate system to make sure they get the help they need. Patients who go into the bariatric-surgery process with an established need for therapy, will usually return to that, says Amir Ghaferi, MD, assistant professor of surgery at the University of Michigan. “But for patients who may have new diagnoses pop up , there is no rigorous or routine method for treatment.” We live in a society that often paints losing weight as the ultimate solution to every problem. Our obsession with shows like Biggest Loser, before-and-after Instagram transformations, and countless ads for weight-loss supplements only strengthens the idea that this change can be a quick, simple fix. So it’s no surprise that, after what is often a lifetime of weight-based stigma, many bariatric-surgery patients may come to believe their lives will become better quickly and all at once. However, after surgery, things don’t usually pan out that way. Instead, Dr. Ghaferi says that with surgery, patients may lose 50-70% of their weight in about a year. But “even with that amount of weight loss, most people don’t get down to a ‘normal’ BMI,” he explains. “A lot of people are still classified as overweight.” Generally a patient will be warned about these realities in some way, as part of making sure they give informed consent. But in a series of recent focus groups in his clinic, Dr. Ghaferi says he’s found that most people may simply hear what they want to hear during this process. “For a lot of the dangerous or bad stuff,” he says, “patients may minimize it and say, ‘That won’t happen to me.’ It’s human behavior.” That mindset — plus patients’ high standards for success — may set them up for severe disappointment. No one is really sure how exactly to address that disappointment, but one thing that could help is if surgeons had more explicit discussions with patients about the potential mental-health effects.

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