Depression after Bariatric Surgery: Triggers, Identification, Treatment, and Prevention

by Cynthia L. Alexander, PsyD

INTRODUCTION
A recent study in the Archives of Surgery has caught the attention of the bariatric community. It found the suicide rate after bariatric surgery to be at least five times that of the general population.1 This study may be thought of as important preliminary information, but it does not yet adequately explain the relationship between suicide and bariatric surgery. Nevertheless, this new information does highlight a need for bariatric professionals to educate their patients as to the possibility of depression postoperatively.

Psychological Triggers for Depression
“Why would I be depressed when I’m losing weight?”
This is a common response from patients when I discuss the possibility of depression after surgery. Most people approach the surgery with a positive attitude. Thoughts about future weight reduction, health benefits, and improved quality of life are dominant while awaiting surgery. After surgery however, reality does not always live up to the preoperative fantasy, and some patients do experience depression.2 In general, bariatric patients report a higher rate of depression than the non-bariatric population.3 One study found that of preoperative patients with no depression, over one-third of the sample developed depression postoperatively.4

“If I’m losing weight I won’t miss the food.”
This is a commonly held but unrealistic hope. Food not only nourishes our bodies, but it also serves other purposes. Food is present in almost every one of our societal ceremonies. From weddings to funerals, we eat to celebrate and to mourn. Socialization revolves around food as well. Going out to dinner is a popular activity with friends. Almost every major holiday is enhanced with a traditional menu. Postoperative patients often find themselves feeling as though they are on the outside of things. They realize that life goes on as usual, but they cannot participate in a ritual in the same way. This initial realization and subsequent mild depression may be conceptualized as the normal postoperative blues. It is not uncommon to hear, “What was I thinking when I decided to do this?” Many patients tell me they are “mourning the loss of food as a friend.” In my practice, I have observed many patients go through this, but most feel better within 2 to 3 months.

“When I can’t eat after surgery, I’ll lose weight, and then I just won’t go back to my old habits.”
This too is an unrealistic hope for many. It is normal for people to use food to deal with emotions. Some people use it to compensate for a bad day, others to celebrate, and still others to calm anxiety or depression. The tendency to eat for these reasons does not appear to change, although there is a period of a year or two when these cravings and urges may diminish. They do, however, almost always return. Eating disturbances before surgery tend to predict eating disturbances postoperatively following a short dormant period.5 In my groups I see a subset of people dealing with the reality that the surgery does not do all the work, and these postoperative patients are struggling once again to control emotional eating. This realization can lead to feelings of depression. Weight regain may occur during this time, further exacerbating the depression.

“I thought everything would get better after weight loss, but it didn’t.”
Some of our patients come from families that have set them apart for their weight. These are the “identified patients” of the family. There may be the dream that by losing weight, they will finally be accepted, and in some cases this does occur. In others, however, the families do not accept the patient, and may even resort to sabotage. If weight loss was the last hope, depression may follow.

“Everything will be okay if I can just lose the weight.”
In general, research does show that depression related to weight tends to decrease.6,7 Depression related to situational stressors, losses, and/or a biological depression will likely not decrease in the longterm. Presurgery depression has been linked with postsurgery psychological distress.8 There is a strong tendency for patients to attribute their depression to weight. It appears to be ego-syntonic to believe that when the weight is decreased, so too will the depression. For a subset of depressed patients, the weight is actually a symptom of depression rather than the other way around. When the timeline is traced backward, it becomes clear that weight increased directly following the onset of a chronic stressor. For these people, weight loss may be disappointing in that they may still be depressed at goal weight. Bariatric surgery is not a cure for depression.

“I gained weight after I got married. We love to go out to dinner together.”
I often hear this from married patients. Some habits take years to become ingrained. When the patient may want to avoid restaurants for some time, the spouse may begin to resent it. On the other hand, the spouse may be supportive, but the patient begins to feel that a part of the relationship is missing. Either way, an adjustment period for food as a social outlet or for recreation with a spouse is inevitable.
Removing the emphasis on food, especially after many years, can be difficult. During this adjustment period, patients may become depressed as they struggle to find the proper place for food and healthy alternatives to going out to dinner.

“He’s not the same person since the surgery.”
Irritability after surgery is common, and I hear from spouses that the first few months may be accompanied by certain temporary personality changes. The tendency to snap at the people closest to us during times of stress may play out with the bariatric patient as they navigate the initial stressful postoperative months. Difficulties in relationships have been reported, including divorces, contributing to feelings of depression. Again, there may be the fantasy of excitement over weight loss overriding all else, but the reality is often very different.

“The hardest part is doing all the tests to get ready for surgery. After surgery should be much easier.”
Some people underestimate the amount of stress they will go through during the first few postoperative months. If a person is already under stress, the addition of surgery may be overwhelming. Depression is not uncommon under these circumstances. If a person meets criteria for clinical depression preoperatively, the added stress of the surgery may exacerbate the depression. Since pills are very difficult to take postoperatively, some patients on antidepressants may be off their medication for a period of time after surgery, and this too may increase symptoms.

“I sure found out who my real friends were after I had surgery.”
Friends may be supportive, or may avoid the patient, or may even sabotage. Often it is difficult to find a way to relate to a friend if the favorite pastime was eating out in restaurants together. It may be an eye-opening experience watching friends and family react to the weight loss. Relationships with friends, family, and even spouses have been strained or even ended in the aftermath of bariatric surgery.

“I had complications, and I was in and out of the hospital for weeks.”
Few patients think that they will be one of the unlucky few that experience complications. For these patients, it is a daily struggle not to fall into a depressed state. Patients imagine coming home from surgery and beginning their new life, not being readmitted to the hospital.

Recommendations
Mild depression after surgery is not uncommon, especially if there are complications and hospital readmissions. Severe depression is much less common. Suicidal ideation is a serious red-flag that should be immediately addressed. All patients should receive education before surgery as to the possibility of depression, and the higher rates of suicide in this population. They should also be given education on the symptoms of depression, and concrete steps to follow to get help if they notice they are becoming depressed.

Most bariatric programs have many patients, and it is unrealistic to monitor the ongoing mental health of every patient. At Cleveland Clinic, we give patients education about the possibility of depression after bariatric surgery, and they are strongly encouraged to call if there is a problem or question.

How to Identify Depression
A person need not have all of these symptoms to be considered depressed, but having at least five of the following symptoms within a two-week period, including either sadness (1) or anhedonia (2), is indicative of clinical depression:9
1. Depressed mood most of the day, nearly every day
2. Anhedonia—markedly diminished interest or pleasure in almost all activities most of the day, nearly every day
3. Insomnia or hypersonmia nearly every day (take sleep apnea into consideration)
4. Psychomotor agitation or retardation
5. Fatigue or loss of energy (more than would be expected after surgery)
6. Feelings of worthlessness or excessive guilt
7. Diminished ability to concentrate, or indecisiveness
8. Recurrent thoughts of death or suicide
9. Significant changes in appetite (take surgery into consideration)
10. Irritability or increased somatic complaints without physical cause.

Treating Depression
1. Individual therapy. The many changes a person experiences after surgery and stressful adaptations may lead to depression. Therapy is the best way for a person to sort through these changes and alleviate depression. There are many psychologists, but identifying one with bariatric background may be a challenge. A referral from a center of excellence is a good place to start. Another alternative is calling the 800 number on the back of the insurance card. This may be helpful, as a professional with bariatric experience can be requested. Weekly therapy for 6 to 12 weeks should be sufficient in most cases.
2. Add an antidepressant. Therapy and an antidepressant together is the best and fastest means of alleviating depression.10 Antidepressants generally take 2 to 3 weeks to produce results.
3. Support groups. Every center of excellence provides support groups for patients. Patients should be encouraged to attend as many as possible.
4. Emergency assistance. If a patient is seriously considering suicide, he or she should call 911 immediately, or go directly to an emergency department. Depression skews the thinking so that suicide appears on the surface to be a solution. Thoughts cannot be trusted when in a depressed state. Patients should be educated to protect themselves by giving the professionals a chance to help.

Tips for Prevention
The following are tips for prevention of depression after surgery:
1. Develop healthy ways to deal with stress. Since the most stressful time is the few months directly following surgery, it is important to develop these strategies prior to surgery. Try a new hobby, develop friendships with other bariatric patients, use positive affirmations, take a yoga class, or listen to music. It is a good idea to purchase a book or CD on stress management.
2. Make the switch from food as the main event to an activity. Making this transition before the surgery may decrease stress postoperatively. Learn to view food as the fuel for your activities. It may be challenging to see friends for putt-putt golf or to attend a play rather than going out to dinner, but the emphasis should now be on the activity. This change is among the most difficult for postoperative patients.
3. Employ and practice healthy and positive self-talk. Keep the health benefits in mind.
4. Exercise often. New research shows that exercise works about as well as an antidepressant if done on a regular basis.11
5. Find a therapist. Even if not depressed, it is always a good idea to have a therapist in place for the first few months postoperatively. This professional will get to know the patient, be able to identify a trend toward depression early, and be the liaison with the physician if the patient wishes to try an antidepressant. If a patient is depressed preoperatively, it is even more important to have a therapist to assist with the first few months.
6. Prepare the family for changes, and ask them to become involved in the decision-making process. Changes will affect everyone in the household. Relationships within the home may be strained during the initial postoperative period. Keep in mind how trying it sometimes is to be a supportive family member, and ask them on a regular basis how they are doing.
7. Difficulty taking medication. If a patient is already on an antidepressant prior to surgery, make him or her aware that taking pills postoperatively will be difficult for some time. The patient should check with the pharmacist about whether the medication may be crushed and mixed with applesauce or yogurt, and should try to get back on the medication as soon as possible after surgery.
8. Prevention based on a history. If there is a history of depression, suicide attempts, suicidal ideation, or inpatient psychiatric hospitalization, the patient should be prepared by having both a psychiatrist and a psychologist. Weekly therapy along with medication management may keep depression at bay, or treat it early to prevent serious problems.
9. Timing of surgery. If already severely depressed, surgery should be postponed until depression decreases whenever possible. Some patients with untreated major depression should receive treatment before surgery.12 For others, waiting may not be an option due to significant health risks.

Conclusion
Most patients will not become depressed after surgery, but the possibility is present. Therefore it is strongly recommended that each patient receive education about postoperative depression, including the recent study showing the elevated rate of suicide.1 It is important that patients do not make the illogical assumption that suicide is a side effect of bariatric surgery. At this point, we do know that there is a potential vulnerability that should be addressed, but we do not yet know all of the facts concerning this finding. Preoperative education should be provided for all patients, along with steps to take if they do become depressed. With adequate education and support, hopefully postoperative depression may be reduced.

References
1. Omalu BI, Ives DG, Buhari AM, et al. Death rates and causes of death after bariatric surgery for Pennsylvania residents. 1995–2004. Arch Surg. 2007;142(10):923–928.
2. Kodama K, Noda S et al. Depressive disorders as psychiatric complications after obesity surgery. Psychiatry Clin Neurosci. 1998;52(5):471–476.
3. Kalarchian MA, Marcus MD. Bariatric surgery and psychopathology. In: Mitchell JE, de Zwaan (eds). Bariatric Surgery. A Guide for Mental Health Professionals. New York, NY: Routledge Publishing;2005:59–76.
4. Ryden O, Olsson SA, Danielsson A, et al. Weight loss after gastroplasty: psychological sequelae in relation to clinical and metabolic observations. J Am Coll Nutr. 1989;8:15–23.
5. de Zwaan M. Weight and eating changes after bariatric surgery. In: Mitchell JE, de Zwaan M. Bariatric Surgery. A Guide for Mental Health Professionals. New York, NY: Routledge Publishing; 2005:77–99.
6. Masheb, RM, White MA, Toth CM, et al. The prognostic significance of depressive symptoms for predicting quality of life 12 months after gastric bypass. Comp Psych. 2007:48(3):231–236.
7. Maddi SR, Fox SR, Dhoshaba DM, et al. Reduction in psychopathology following bariatric surgery for morbid obesity. Obes Surg. 2001:11(6):680–685.
8. Boyer GR. Psychosocial predictors of outcome in bypass surgery [dissertation]. Arizona: Arizona State University; 2006.
9. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Press, Inc., 2000.
10. Mann JJ. The medical management of depression. N Engl J Med. 2005:353(17):1819–1834.
11. Blumenthal JA, Babyak MA, et al. Exercise and pharmacotherapy in the treatment of major depressive disorder. Psychosom Med. 2007:69:587–596.
12. Wadden TA, Sarwer DB, Womble LG, et al. Psychosocial aspects of obesity and obesity surgery. Obes Surg. 2001;81(5):1001–1024.

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