The Mental-Health Toll Of Weight-Loss Surgery

Mollie Hawkins spent an entire year before her gastric-bypass surgery jumping through the hoops of her insurance company's approval process, eating the requisite high-protein diet, and getting lab tests done. All of this was hard enough, but no one told her that once her surgery day had come and gone life would get even harder. Although Hawkins doesn't regret the surgery, her recovery process did come with a heap of emotional struggles and depression as she learned to get used to being an entirely different person. “You're used to commanding so much space in the physical universe and suddenly you are half of that in less than a year," she tells R29 in an email. "Your brain can't catch up that quickly.” The negative mental-health effects of weight-loss (a.k.a. bariatric) surgery are something experts are growing increasingly concerned about. Most recently, a study published in the Annals of Surgery in April of this year found that while people who'd undergone gastric bypass were able to reduce their reliance on medications for things like asthma and diabetes, their use of psychiatric medications increased two-fold. Previous research has also pointed in this direction: A JAMA Surgery study published earlier this year found that the risk for self-harm, including suicide, increased in a group of Canadian patients after bariatric surgery. Another study, published in JAMA in January, looked at over 50,000 patients who underwent weight-loss surgery since 1988; although the majority of patients in the study didn't have psychiatric issues, the rates of mental illnesses were higher within this group compared to the general population. For depression, the rate was doubled. "We can’t pretend that this is not an issue," says Aaron J. Dawes, MD, surgery resident at UCLA and lead author of the JAMA study.

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 [after surgery], 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 [normal] 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.

“It's a bit crazy to me that doctors don't really delve into the potential mental issues that can arise after weight-loss surgery,” says Hawkins, who recently detailed her experience at Salon. “I spent nearly a year jumping through insurance hoops to get approved for surgery, and the number one seed of fear they planted in my head was getting a bowel obstruction or dealing with ‘dumping syndrome’ (where your body essentially rejects sugar). Depression and anxiety were not high on the list of concerns.” And, to make things even more difficult, Hawkins says the recovery process necessarily meant she was denied her go-to coping mechanism: comfort food. “Suddenly I was someone else — physically and emotionally — and not at all prepared for it,” she says. "This is a life-changing operation," adds Dr. Dawes, "and we need to be treating it as such." But, he continues, the actual surgery is just one part of that life change. And following up with patients after surgery has proven to be challenging. Dr. Ghaferi says that although surgeons ideally want to follow up with you for the rest of your life, in reality, most patients drop off the radar after a year. So surgeons frequently have to rely on patients and their primary care providers to notice mental-health problems (with notoriously limited success). “If I'd had the chance to be in counseling or therapy, if any kind of follow-up system beyond checking my vitamin levels had been put in place,” Hawkins says, “I could've saved so much of that time learning how to be OK with myself and all my post-surgery flaws.”

Of course, Dr. Ghaferi emphasizes that a mental-health issue shouldn't necessarily keep anyone from getting the surgery. Instead, he says the priority would be identifying those who could benefit from the kind of follow-up that Hawkins describes — and making sure they get it long-term. Already patients are required to have a support person with them and they have the option to attend support groups. Beyond that, though, Dr. Ghaferi says it's tough to know what a better system would actually look like — and even tougher to make it mandatory. Still, it's clear that we need to be doing a better job of accounting for patients' emotional and mental states at every stage of weight-loss surgery. "For patients that have diabetes, for example, and are having bariatric surgery, we focus on how that might affect surgery and the patient's health and recovery," says Dr. Dawes. "We feel like the same amount of time and energy needs to be spent on mental-health conditions."