Psychiatrists’ role in bariatric surgery important

Obesity has been officially declared a global epidemic by the World Health Organization. In virtually every region of the world, obesity’s adverse health effects are a well-documented public health crisis that affects people of all ages. In light of poor long-term weight management reported in most traditional diet strategies, attention has shifted to gastric bypass surgery as an effective treatment option for obesity.

Bariatric weight loss procedures are associated with numerous health benefits in patients: dramatic weight loss, rapid improvement in blood glucose levels, blood pressure stabilization, and resolution of obesity-related orthopedic problems. It’s not surprising, then, that gastric bypass surgery is a life-changing event for many patients.

Recently however, it has become clear that “life-changing” interventions do not always mean happy endings. Alongside these encouraging postsurgical outcomes are alarming counterintuitive reports of increased self-harm events. A recent study published in JAMA Surgery by Junaid A. Bhatti, Ph.D., of the department of evaluative clinical sciences, Sunnybrook Research Institute, Toronto, and the department of surgery, University of Toronto, and colleagues reported an increase in suicide attempts among postoperative gastric bypass patients (JAMA Surg. 2015 Oct 7. doi: 10.1001/jamasurg.2015.3414). The study conducted at Sunnybrook found that the rate of self-harm emergencies from attempted suicide was four times higher in these patients, compared with the general population.

Most gastric bypass surgery programs require a pre-op mental health evaluation. This is not enough, according to Dr. Peter F. Crookes, associate professor* of Bariatric Surgery at Keck Hospital of the University of Southern California, Los Angeles. Dr. Crookes’s clinical experiences and my (Dr. Baron’s) 20-plus years of conducting psychiatric evaluations on bypass patients have revealed more vexing issues regarding psychiatric illnesses occurring in morbidly obese patients. The requirement has been established for presurgical psychiatric assessment, but long-term post-surgical emotional and behavioral challenges need to be evaluated as well. In addition to primary mental illness, obese patients are at risk for stress-related exacerbations of preexisting psychopathology. After a body-altering surgical procedure like gastric bypass, maladaptive coping strategies are likely to complicate a patient’s physical AND emotional long-term recovery.

Many factors play into the development of these psychiatric symptoms, not the least of which are coping and emotional support systems. Literature on obesity and psychiatry has revealed connections between weight status and issues, such as childhood trauma, especially sexual abuse in childhood. While some patients claim that their weight loss surgery was the best thing they ever did for themselves, other patients have reported to me after significant weight loss: “I feel like a fat person trapped in a skinny body.” This surgery is not just body altering but can be identity altering. Patients also have reported relationship issues after significant weight loss. Relationship dynamics for both partners can become strained as a result of perceived changes in sexual attractiveness.

Given the short- and long-term consequences, it is essential for psychiatrists and other mental health care providers to work closely with the bypass surgical team at 1 month, 3 months, and 1-year postsurgical follow-up visits. These follow-ups are particularly important for patients who experience depression, relationship stress, or worsened psychiatric symptoms. In 2004, Dr. Crookes coauthored a then controversial study concerning bariatric surgery for obese patients with a formal diagnosis of schizophrenia or schizoaffective disorder (Obes Surg. 2004 Mar;14[3]:349-52). Historically, bariatric surgeons had avoided operating on these patients. However, his study showed that when psychotic symptoms were controlled postoperatively, these patients’ weight loss results were comparable to those of nonpsychotic patients.

Quality of life after gastric bypass depends on much more than a decrease in the number on the scale or clothing label. These reports demonstrate that psychiatrists play an important role in the overall biopsychosocial outcome of the patient.

Dr. Baron is professor of clinical psychiatry and interim chair of the department of psychiatry at the University of Southern California, Los Angeles. He also serves as director of the Global Center for Exercise, Psychiatry and Sports at USC. Ms. In addition, Dr. Baron is former chair of the department of psychiatry at Temple University, Philadelphia, where he directed the psychiatric component of the Bariatric Surgery program. Ms. Uno is a third-year medical student at USC.

*Correction, 10/29/2015: An earlier version of this story misstated the title of Dr. Crookes.

Obesity has been officially declared a global epidemic by the World Health Organization. In virtually every region of the world, obesity’s adverse health effects are a well-documented public health crisis that affects people of all ages. In light of poor long-term weight management reported in most traditional diet strategies, attention has shifted to gastric bypass surgery as an effective treatment option for obesity.

Bariatric weight loss procedures are associated with numerous health benefits in patients: dramatic weight loss, rapid improvement in blood glucose levels, blood pressure stabilization, and resolution of obesity-related orthopedic problems. It’s not surprising, then, that gastric bypass surgery is a life-changing event for many patients.

Recently however, it has become clear that “life-changing” interventions do not always mean happy endings. Alongside these encouraging postsurgical outcomes are alarming counterintuitive reports of increased self-harm events. A recent study published in JAMA Surgery by Junaid A. Bhatti, Ph.D., of the department of evaluative clinical sciences, Sunnybrook Research Institute, Toronto, and the department of surgery, University of Toronto, and colleagues reported an increase in suicide attempts among postoperative gastric bypass patients (JAMA Surg. 2015 Oct 7. doi: 10.1001/jamasurg.2015.3414). The study conducted at Sunnybrook found that the rate of self-harm emergencies from attempted suicide was four times higher in these patients, compared with the general population.

Most gastric bypass surgery programs require a pre-op mental health evaluation. This is not enough, according to Dr. Peter F. Crookes, associate professor* of Bariatric Surgery at Keck Hospital of the University of Southern California, Los Angeles. Dr. Crookes’s clinical experiences and my (Dr. Baron’s) 20-plus years of conducting psychiatric evaluations on bypass patients have revealed more vexing issues regarding psychiatric illnesses occurring in morbidly obese patients. The requirement has been established for presurgical psychiatric assessment, but long-term post-surgical emotional and behavioral challenges need to be evaluated as well. In addition to primary mental illness, obese patients are at risk for stress-related exacerbations of preexisting psychopathology. After a body-altering surgical procedure like gastric bypass, maladaptive coping strategies are likely to complicate a patient’s physical AND emotional long-term recovery.

Many factors play into the development of these psychiatric symptoms, not the least of which are coping and emotional support systems. Literature on obesity and psychiatry has revealed connections between weight status and issues, such as childhood trauma, especially sexual abuse in childhood. While some patients claim that their weight loss surgery was the best thing they ever did for themselves, other patients have reported to me after significant weight loss: “I feel like a fat person trapped in a skinny body.” This surgery is not just body altering but can be identity altering. Patients also have reported relationship issues after significant weight loss. Relationship dynamics for both partners can become strained as a result of perceived changes in sexual attractiveness.

Given the short- and long-term consequences, it is essential for psychiatrists and other mental health care providers to work closely with the bypass surgical team at 1 month, 3 months, and 1-year postsurgical follow-up visits. These follow-ups are particularly important for patients who experience depression, relationship stress, or worsened psychiatric symptoms. In 2004, Dr. Crookes coauthored a then controversial study concerning bariatric surgery for obese patients with a formal diagnosis of schizophrenia or schizoaffective disorder (Obes Surg. 2004 Mar;14[3]:349-52). Historically, bariatric surgeons had avoided operating on these patients. However, his study showed that when psychotic symptoms were controlled postoperatively, these patients’ weight loss results were comparable to those of nonpsychotic patients.

Quality of life after gastric bypass depends on much more than a decrease in the number on the scale or clothing label. These reports demonstrate that psychiatrists play an important role in the overall biopsychosocial outcome of the patient.

Dr. Baron is professor of clinical psychiatry and interim chair of the department of psychiatry at the University of Southern California, Los Angeles. He also serves as director of the Global Center for Exercise, Psychiatry and Sports at USC. Ms. In addition, Dr. Baron is former chair of the department of psychiatry at Temple University, Philadelphia, where he directed the psychiatric component of the Bariatric Surgery program. Ms. Uno is a third-year medical student at USC.

*Correction, 10/29/2015: An earlier version of this story misstated the title of Dr. Crookes.

Obesity has been officially declared a global epidemic by the World Health Organization. In virtually every region of the world, obesity’s adverse health effects are a well-documented public health crisis that affects people of all ages. In light of poor long-term weight management reported in most traditional diet strategies, attention has shifted to gastric bypass surgery as an effective treatment option for obesity.

Bariatric weight loss procedures are associated with numerous health benefits in patients: dramatic weight loss, rapid improvement in blood glucose levels, blood pressure stabilization, and resolution of obesity-related orthopedic problems. It’s not surprising, then, that gastric bypass surgery is a life-changing event for many patients.

Recently however, it has become clear that “life-changing” interventions do not always mean happy endings. Alongside these encouraging postsurgical outcomes are alarming counterintuitive reports of increased self-harm events. A recent study published in JAMA Surgery by Junaid A. Bhatti, Ph.D., of the department of evaluative clinical sciences, Sunnybrook Research Institute, Toronto, and the department of surgery, University of Toronto, and colleagues reported an increase in suicide attempts among postoperative gastric bypass patients (JAMA Surg. 2015 Oct 7. doi: 10.1001/jamasurg.2015.3414). The study conducted at Sunnybrook found that the rate of self-harm emergencies from attempted suicide was four times higher in these patients, compared with the general population.

Most gastric bypass surgery programs require a pre-op mental health evaluation. This is not enough, according to Dr. Peter F. Crookes, associate professor* of Bariatric Surgery at Keck Hospital of the University of Southern California, Los Angeles. Dr. Crookes’s clinical experiences and my (Dr. Baron’s) 20-plus years of conducting psychiatric evaluations on bypass patients have revealed more vexing issues regarding psychiatric illnesses occurring in morbidly obese patients. The requirement has been established for presurgical psychiatric assessment, but long-term post-surgical emotional and behavioral challenges need to be evaluated as well. In addition to primary mental illness, obese patients are at risk for stress-related exacerbations of preexisting psychopathology. After a body-altering surgical procedure like gastric bypass, maladaptive coping strategies are likely to complicate a patient’s physical AND emotional long-term recovery.

Many factors play into the development of these psychiatric symptoms, not the least of which are coping and emotional support systems. Literature on obesity and psychiatry has revealed connections between weight status and issues, such as childhood trauma, especially sexual abuse in childhood. While some patients claim that their weight loss surgery was the best thing they ever did for themselves, other patients have reported to me after significant weight loss: “I feel like a fat person trapped in a skinny body.” This surgery is not just body altering but can be identity altering. Patients also have reported relationship issues after significant weight loss. Relationship dynamics for both partners can become strained as a result of perceived changes in sexual attractiveness.

Given the short- and long-term consequences, it is essential for psychiatrists and other mental health care providers to work closely with the bypass surgical team at 1 month, 3 months, and 1-year postsurgical follow-up visits. These follow-ups are particularly important for patients who experience depression, relationship stress, or worsened psychiatric symptoms. In 2004, Dr. Crookes coauthored a then controversial study concerning bariatric surgery for obese patients with a formal diagnosis of schizophrenia or schizoaffective disorder (Obes Surg. 2004 Mar;14[3]:349-52). Historically, bariatric surgeons had avoided operating on these patients. However, his study showed that when psychotic symptoms were controlled postoperatively, these patients’ weight loss results were comparable to those of nonpsychotic patients.

Quality of life after gastric bypass depends on much more than a decrease in the number on the scale or clothing label. These reports demonstrate that psychiatrists play an important role in the overall biopsychosocial outcome of the patient.

Dr. Baron is professor of clinical psychiatry and interim chair of the department of psychiatry at the University of Southern California, Los Angeles. He also serves as director of the Global Center for Exercise, Psychiatry and Sports at USC. Ms. In addition, Dr. Baron is former chair of the department of psychiatry at Temple University, Philadelphia, where he directed the psychiatric component of the Bariatric Surgery program. Ms. Uno is a third-year medical student at USC.

*Correction, 10/29/2015: An earlier version of this story misstated the title of Dr. Crookes.