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A. Al-Ozairi and H. Alshatti178
16.2 Mental health status
16.2.1 Major Depressive Disorder, Anxiety Disorders and General
Psychological Wellbeing
Several studies noted a major improvement in the mental health status among
participants who suffer from current or previous psychiatric illness. Psychiatric
patients who undergo sleeve gastrectomy showed improvement in their symptoms
after 3–6 months from the surgery [74]. The SOS study, which followed 4047
bariatric surgery candidates for 2 years, found improvement in their general psychological symptoms. Further, they showed significant decrease in their depressive
and anxiety symptoms after one year [37] and even after two or three years, there
seems to be a mental health gain [74, 75].
A systemic review of 40 studies from 1982 till 2002 support the findings about
the improvement in the psychiatric disorders among bariatric surgery participants
who currently suffer from a psychiatric disorder or had a history of a psychiatric illness, particularly depression and anxiety disorders [76]. It was found that
these significant improvements in mental health occurred mainly in patients who
achieved their weight loss goal. Participants who suffered from postoperative
weight regain were associated with increased depression. This reinforces the concept of the association between obesity and the psychiatric disorder, regardless of
the underlying psychopathology [37].
Although the post-surgical weight loss may be associated with improvement in
psychiatric symptoms, mental health gain after the surgery can be attributed to factors other than weight loss alone. This is said because the improvement of the psychiatric symptoms was not exclusive to those who achieved optimal weight loss
after the surgery. There was mental health gain among individuals within the first
few weeks after the surgery, where no significant weight loss achieved yet. Also,
some participants who achieved only post-surgical suboptimal weight loss showed
mental health gain [77]. This means there are other factors affect the improvement
of the mental health post operatively, those include the type of the psychopathology and lifestyle changing, despite the fail to achieve the optimal weight loss.
Interestingly, Sleeve gastrectomy may have an independent effect on depression
and anxiety reduction. The effect of Sleeve gastrectomy on depression and anxiety
can be due to biological factors, such as the reduction of the inflammatory cytokines
as a chronic effect from the surgery. It is known that inflammatory cytokines, like
interleukin-6 and C-reactive protein, play major roles in depression and anxiety disorders, thus their reduction may actually improve the symptoms [74].
The baseline reduction in depression and anxiety symptoms happened among
patients who either changed, stopped, or continued with the same medication.
The change in medications or adjusting the dose is expected during the first 3 to
6 months. Approximately 90% of depression and anxiety patients who improved
after the surgery, their medications were either reduced or discontinued. From 10
to 20% of patients needed to either increase the dose of their medication or switch
to other class, which can be due to the disturbed absorption after the surgery [74].
Psychiatric Evaluation: Pre and Post Sleeve
179
Individuals who suffer from Anxiety benefit from the bariatric surgery as well.
Improvement in Anxiety disorders showed similar improvements to depression
after the surgery. Some studies showed around 50% improvement in anxiety after
the Sleeve gastrectomy [74].
16.3 Suicide
The rate of suicide is noticed to be increasing post bariatric surgically on the long
term, despite the general mental health gain. There is higher than expected suicide
rate among participants after the surgery when candidates were followed-up for
8 years after the surgery [78]. It is difficult to explain why that is exactly and it is
unclear if there is a difference between the types of surgeries.
16.4 Addiction
Substance use disorder and other addictive behaviors are very common among
patients. Several studies showed an increased pattern in the addictive behaviors,
including alcohol use, recreational drug use, smoking cigarette, gambling, sexual
activity, shopping, that are present for at least the first 2 years among bariatric candidates after the surgery [79].
Alcohol use disorder (AUD) is one of the major substance use disorder suffered
among the candidates and most of the studies explored this substance more than
other addictive behaviors. The SOS study showed that AUD is still an issue even
15 years after the surgery [80]. The alcohol use might not just be a resistant problem but also the consumption might increase after a while. Longitudinal observational studies showed increase consumption of alcohol from the second year after
the surgery when compared to 1 year before and after the surgery. Furthermore, a
rate of 7.9% among the participants showed a new onset of AUD after the surgery
[81].
There are several factors were noticed to be predicators of AUD after the surgery, those include males, family history of substance use disorder, history of
AUD notably 1 year prior the surgery, and history of nicotine use prior the surgery
[82]. The previous factors are also considered to increase the risk of developing
substance use disorder after the surgery with the addition to history of food addiction and the consumption of high glycemic or high fat food before the surgery
[83]. The relation of pre-surgery food addiction and the increased rate of substance
use disorder after the surgery could be explained by the concept of “Addiction
transfer”, which is defined as the replacement of one addictive behavior with
another. This patter is seen among bariatric patients who are addicted to food or
suffer from a pathological eating behavior such as emotional eating, after the surgery they replace that pathological behavior into something else such as alcohol
consumption, smoking cigarette, or gambling [84].
A. Al-Ozairi and H. Alshatti180
One of the common addictive behaviors is cigarette smoking. It is noticed that
after the surgery, cigarette smoking is reduced more among older adults than a
younger population. New-onset smoking can go up to 12% post-surgery [85].
16.5 Eating Disorders
Evaluating eating disorders after the surgery can be challenging. This is because
they present in a different way than the classical presentation and they may not
fulfil the criteria. For example, vomiting after surgery is common, but some
patients vomit as a compensatory method for shape or weight concerns. After the
surgery, eating huge amount of food at the same time uncontrollably, which is a
criterion for binge eating, is difficult. Despite that, few months after the surgery
participants reported feeling loss of control similar to that of binge eating disorder without the consumption of large amount of food [53]. Participants may suffer from marked fear of gaining weight or concerns about their shape after the
surgery. This may lead to extreme diet restriction and causes anorexia. Although,
many patients continue to have eaten disorders after the surgery, there are individuals reported improved symptoms. This could be due to following the recommended strict diet plan which may normalize the individual’s eating pattern
overtime [86].
16.6 Psychotropic Medication
Bariatric patients who use psychotropic medications may continue their medications after the surgery. The most common psychiatric treatment used among those
patients are antidepressants. It is estimated that 35% of bariatric patients use at
least one antidepressant on daily basis [87]. After the sleeve gastrectomy, the
improvement in depression and mental gain noticed to occur among patients who
either continued the same medication, switched their antidepressant into another
class, or modified their dose [74]. Also, some patients experienced side effects
of their usual medications that were not experienced before, or some found out
that their usual treatment did not have a positive effect as before. This suggests
that the procedure affects the current psychotropic medication by interfering with
the pharmacokinetics of those medications. The effect of the bariatric surgery on
the pharmacokinetics should be understood and considered when following up
the participants after the surgery to optimize the positive effect and minimize the
adverse effects.
All the bariatric surgeries affect the pharmacokinetics of the medications on
various levels depending on the type of the surgery, but mainly they affect the
absorption of the medications into the blood circulation since they make anatomical and functional alterations in the gastrointestinal (GI) track. The modification can be restrictive, malabsorptive, or a combination of both. The sleeve
Psychiatric Evaluation: Pre and Post Sleeve
181
gastrectomy procedure has mainly a restrictive modification on the GI system
since major part of the stomach is removed.
16.7 Postoperative Pharmacological Considerations
To avoid drug toxicity, major side effects, or having sub-therapeutic levels of
the psychotropic medications after the sleeve gastrectomy, certain modifications
should be considered depending on the clinical situation of the patient. It is not
recommended to automatically change the doses or switch the treatment just
because they are undergoing a gastric sleeve. Instead, close monitoring of the
patient prior to the surgery and the use of baseline screening instruments, like
the aforementioned PHQ-9 instrument for depression are highly recommended.
If any early signs of reduced effectiveness of the medication, or signs of medication withdrawal, experiencing side effects, or signs of relapse occur then treatment
modifications are considered.
The methods of treatment modifications are vary depending on the clinical situation and the type of the pharmacological treatment. One way is changing “controlled”, “extended”, and “sustained release” medications to “immediate release”
drugs before or after the surgery to improve the rate of absorption. The goal of the
controlled release drugs is to achieve the therapeutic effect and minimize dividing
the doses throughout the day by prolongating the disintegration time of the drug.
The extended release forms may have reduced absorption after the surgery [88].
With switching to the immediate release, it is recommended to divide the doses to
several times per day to ensure achieving the therapeutic effect of the drugs.
Some psychotropics mediations come in liquid form or as orally disintegrated
tablets. Those forms can be used instead of the tablet form in psychiatric patients
undergoing a bariatric surgery, since they skip the process of disintegration and
thus improving the absorption and metabolism of the active substance.
Unfortunately, not all psychiatric treatments are available in different forms.
If the patient is on those medications and experienced early signs of relapse or
sub therapeutic effectiveness, then other methods may be considered such as
increasing the dose, dividing the dose throughout the day, or crushing the pills (if
applicable).
Before taking the decision of modifying the pharmacological treatment of the
psychiatric patient undergoing sleeve gastrectomy, assessing the mental health
status of the patient and close monitoring should be done on regular basis. Some
studies showed that the bioavailability of some psychotropic medications may normalize or even increase in some bariatric participants after a period of 6 month.
This means that although those patients may experience signs of reduced effectiveness of their treatment, some of them might experience side effects of the
drugs due to their increased blood level after 6 months after the surgery. This was
noticed especially among patients who had increased doses of their antidepressants after a bariatric surgery due to signs of decreased absorption [89].
A. Al-Ozairi and H. Alshatti182
17 Conclusion
The Sleeve gastrectomy is one of the most successful methods of weight loss
for obese individuals worldwide. The presence of psychiatric illness is common
among this population and cannot be ignored. Also, a positive association exists
between psychiatric illness and obesity, which means the bariatric surgery could
also improve the mental health status of those individuals. The most common psychopathologies are mood disorders, anxiety, eating disorders, and substance use
disorder. Having a mental illness is not a contraindication of the surgery in 97%
of patients, but it can be challenging, and may interfere with the surgical outcome.
Untreated or uncontrolled psychiatric illness may result in achieving only suboptimal weight loss, especially if the psychopathology affects the cognitive function
of the patient. Those patients may not follow the postoperative recommendation
and may not fully fathom the importance of lifestyle changes to this operation life
changing operation. Thus, psychiatric evaluation prior making the decision of having the operation is crucial.
Sleeve gastrectomy benefits patients via quality of life, a noticeable mental
health gain and patients with depression or anxiety show further improvement,
while others are able to stop their medications. Despite the improvement in general mental health and in major psychiatric disorders, there are few setbacks.
Patients with history of suicide, substance use, or addictive behavior may experience worsened symptoms or transfer their preoperative addictive behaviors to
another.
Lastly, the psychiatric evaluation before the sleeve gastrectomy is necessary for
all. It is important to avoid relapses of the present psychiatric issues, rectifying any
false expectations, improving the mental health status, and implementing behavioral changes that help the participant reach the optimal weight loss and have the full
care needed before and after the surgery.
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