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Psychological health

Preoperative psychological evaluation is critical

Healthcare professionals must manage patients’ post-surgical expectations

Healthcare teams need to recognise the higher prevalence of psychological distress in obese patients seeking surgery, according to a literature review published in the Journal of Obesity.

The authors from the University of Alberta, Canada, state that preoperative evaluation before surgery is critical in identifying and following, those at risk of persistent or worsening psychopathology after surgery.

They explain that the negative reactions of these patients to adverse events may be accentuated as their psychological distress is greater, compared to obese individuals in the community.

Although the efficacy of bariatric surgery is often expressed as postoperative weight loss, an important and often overlooked outcome is an evaluation of the impact of surgery on psychological health. The authors stress that this is an important outcome measure, as it could contribute to the patient’s overall concept of wellbeing.

The review paper assessed the literature on the impact of bariatric surgery on psychological functioning of morbidly obese patients.  The investigators identified 27 articles, including six literature reviews, two systematic reviews, and 19 primary studies using both MEDLINE and PubMed databases with the following search terms: morbid obesity, bariatric surgery, psychology, psychological health, and mental health.

They report that extremely obese individuals are almost five times more likely than their average weight counterparts to have suffered from a major depressive episode in the past year. The correlation between these two conditions is multifactorial.

Body image dissatisfaction was also heavily correlated with symptoms of depression and they found that obese individuals are also subjected to prejudice and discrimination, which is likely to cause or aggravate depression.

The inability to lose weight is likely to aggravate depressive illness, hopelessness, and poor self-esteem and could perhaps contribute to additional weight gain, the authors report.

Importantly, they note that 25–30% of bariatric patients report depressive symptoms at the time of surgery and up to 50% report a lifetime history of depression.


The authors note that several studies have reported overall postoperative improvement in depressive symptoms, self-esteem, health-related quality of life, and body image.

The Swedish Obese Subjects study reported a significant decrease in depression and anxiety in the year after surgery compared to obese controls treated with diet and exercise counselling.

“These psychological gains reflect those found in patients who have achieved weight reduction with behavioural or pharmacologic treatment,” the authors write. “It is likely that postoperative improvements in psychological health can be attributed to more than just weight loss and self-concept as a result of weight loss.”


Interestingly, they found that pre-operative patient expectations have an impact on psychological health, especially if the expectations are not met (despite significant weight loss).

“Although more research is needed to determine mental health status several years after bariatric surgery, follow-up must be conducted long term after surgery to assess and support the patient’s psychological well-being,” the authors write.

With regards to suicide following surgery, the authors report that it is difficult to compare suicide rates in post-bariatric patient populations to the general population due to the significant variation in cohort characteristics and length of follow-up in these studies.


The literature review seems to suggest that weight loss surgery improves self-esteem, self-confidence, and expressiveness, which appear to be correlated with major improvements in body image and weight-loss satisfaction after surgery.

However, body image dissatisfaction following surgery due ‘sagging skin’ has been reported and patients who recorded greater satisfaction after surgery were found to have lost less weight than their dissatisfied counterparts, but their ‘sagging skin’ was less pronounced.

“Bariatric surgeons must therefore counsel their patients prior to surgery regarding common postoperative skin changes in order to mitigate psychological distress,” write the authors. “As patients seek out body-contouring surgery to address skin issues, plastic surgeons also play an important role in discussing the benefits and limitations to plastic surgery.”

The investigators also revealed that bariatric surgery may also lead to important psychological benefits in the paediatric population. Recent studies have reported improvements in psychological health (depression, anxiety, and self-concept) after RYGB for patients four months and up to two years postoperatively.

Although a study by Zeller et al suggests that a change in weight, reduction of comorbidities, or a patient’s revitalised self-concept may override the patient’s concern with actual weight status when assessing psychological health.


“Although the impact of bariatric surgery on psychological health is often overshadowed by the significant reduction in physical comorbidities,” the authors write. “It is important to investigate the former as obesity is strongly correlated with psychological distress and may have a marked effect on quality of life.”

The paper claims that bariatric surgery can result in improvements in psychopathology, depressive symptoms, eating behaviour, body image, and health related quality of life. However, undesired physical outcomes post-surgery such as lack of weight loss, weight regain and undesirable skin changes can result in psychological failure if expectations are not met.

“The preoperative evaluation is therefore critical to identify and follow those at risk of persistent or worsening psychopathology after surgery,” the authors conclude. “It will also serve to detail the necessity of postoperative behavioural and lifestyle change and its effect on weight loss. Long-term intensive postoperative follow-up to evaluate and support lifestyle change can have a tremendous effect on weight loss as well as physical and psychological comorbidities.”

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