Keep an Eye on Mental Health After Bariatric Surgery in Teens

Liam Davenport

June 05, 2016

GOTHENBURG, Sweden — Clinically relevant depressive and anxiety symptoms are experienced by a substantial proportion of adolescents up to 5 years after undergoing bariatric surgery for severe obesity, new results from a Swedish study indicate.

Across three presentations at the European Obesity Summit 2016, results from the Adolescent Morbid Obesity Surgery (AMOS) study showed that over 25% of adolescents who had gastric-bypass surgery had clinical symptoms of depression, while 13% had severe depressive and anxiety symptoms.

And although severe obesity-related psychosocial problems were improved in adolescents 5 years after the surgery, compared with before surgery, the peak improvement occurred 1 year after the operation followed by a small decline.

Kasja Järvholm, a clinical psychologist and PhD student in the department of psychology, Lund University, Sweden, who presented the AMOS mental-health data, said: "We think that it's necessary to have continued, repeated monitoring of mental health over several years in adolescents after undergoing bariatric surgery. They need more support than operated adults do, just because they seem to experience more mental-health problems."

She added: "It's really important to assess suicidal ideation and to offer treatment to adolescents with mental-health problems. We should also try to find interventions for those adolescents who do not have a positive outcome after bariatric surgery."

Session cochair Luigi Angrisani, MD, director of the general and endoscopic surgery unit, S Giovanni Bosco Hospital, Naples, Italy, told Medscape Medical News that, for bariatric surgery in the adolescent patient, the ideal situation is to have a "multidisciplinary team with psychological competence and monitoring."

And the key focus has to be the long-term perspective, he said.

"The thing is that obesity surgery is a different specialty from surgery in general, [when] you would expect…to go in, take a risk, and resolve the problem. This is not the story when you treat a chronic disease. Obesity is more like a kidney transplant, in that you may get a…transplant and you may stay with the functioning graft for a number of years, but at some stage you may get graft dysfunction and you get chronic failure again and go back to dialysis.

"It's the same story with obesity," he explained, noting that "you've got quite acceptable 3- to 5-year outcomes but at some stage, perhaps over 10 years, you've got to consider another operation."

He pointed out that the average age of adult patients having bariatric surgery is between 30 and 40 years, and the team carries on treating the patient "for the rest of his [or her] life, from the point of the surgery." For adolescents, that means that the patient and their weight will have to be monitored "for 50 or 60 years."

Dr Angrisani therefore feels that, in adolescent patients, surgeons should first consider performing restrictive, nonaggressive procedures initially to control the patient's weight and comorbidities, but "to keep some techniques in our armamentarium to use in the long run."

He is not the only one to question whether gastric bypass is the best bariatric-surgery option for this age group, given the irreversible nature of the procedure. Some experts believe a reversible option, such as a gastric band, may be preferable in teenagers.

Little Known About Long-Term Mental Health in Teens After Gastric Bypass

The AMOS study is a national, prospective, nonrandomized controlled investigation in which children from Gothenburg, Malmö, and Stockholm were recruited if they were aged 13 to 18 years, had a body mass index (BMI) of ≥ 40 kg/m2 or ≥ 35 kg/m2 plus comorbidity, had failed conservative therapy, and were in Tanner stage >3 of puberty.

The adolescents were assigned to laparoscopic Roux-en-Y gastric bypass or standard nonsurgical intervention. Presenting the clinical results, Andrew Beamish, MD, of the Royal College of Surgeons, London, United Kingdom, said that this surgery appears to be safe and feasible in adolescents with severe obesity. Moreover, it was associated with significant improvements at 5 years in weight, metabolic homeostasis, and inflammation, with similar outcomes as those seen in adults.

In the first of her presentations, Ms Järvholm noted that little is known about the long-term mental-health outcomes of adolescents following bariatric surgery.

Indeed, one of the few papers published in this area details the 2-year results of the AMOS study, which showed that there were significant improvements in mental health in the first year after surgery, which stabilized during the second year (Obesity. 2015;23:1966–1972).

For the current analysis, 63 operated adolescents, with a mean age at surgery of 16.9 years and a mean preoperative BMI of 45.6 kg/m2, were available for analysis, of whom 67% were girls.

The new findings show that mental health was stable from 1 year after surgery to 5 years afterward — Beck Depression Inventory–II and Beck Anxiety Inventory scores collected at both time points showed that there was no significant change in symptom scores between the two (P = .752 and P = .354, respectively). Unsurprisingly, girls reported more symptoms at 5 years than boys.

At 5 years postsurgery, 27% of the adolescents reported depressive symptoms in the clinical range, while 13% reported severe symptoms. Severe anxiety symptoms were reported by 13% of adolescents at 5 years.

"Obviously, we have a subgroup that reports poor mental health 5 years after surgery," Ms Järvholm noted.

Furthermore, 16% of participants reported suicidal ideation 5 years after surgery, with 10% reporting passive suicidal ideation and 6% active suicidal ideation.

More Structured Mental-Health Care Needed for Years After Surgery

Discussing the findings after her presentation, Ms Järvholm observed that, paradoxically, "those with mental-health problems are often those who need the surgery the most."

Noting that individuals with severe mental-health problems lost the same amount of weight as those who had good or average mental health, she said: "It's complicated, but I think that we must have a much more structured aftercare."

She said that, at least in Sweden, a big emphasis was put on the first year after surgery, "when they are doing quite well, so I think — at least as psychologists — we should continue our interventions [after that]."

In her second presentation, Ms Järvholm discussed obesity-related psychosocial problems as assessed during the AMOS study.

She noted that previous studies in adults have suggested that, while such problems improved significantly following surgery, the improvements are related to weight loss per se, with no significant difference between operated and conventionally treated patients.

Here, she examined results in 85 adolescents, of whom 67% were girls, from the AMOS study, who had a mean age of 16.8 years at operation and a mean preoperative BMI of 45.6 kg/m2.

All the adolescents completed the 14-item Obesity-related Problems scale (OP-14) which assesses how weight and body shape affect individuals in social situations, with scores ranging from 0 to 100; increasing score indicates more psychosocial dysfunction.

Five years after the surgery, 22% of the operated adolescents reported severe obesity-related impairment in social situations, compared with 40% before surgery.

And while these psychosocial problems had significantly improved 5 years after surgery, the peak improvement occurred 1 year after surgery, followed by a small decline.

Future studies should explore whether it's possible to prevent this decline, Ms Järvholm said.

And compared with nonoperated controls, there was no significant difference in obesity-related problems, at a mean OP-14 score of 37.1 for operated patients vs 42.1 for nonoperated adolescents (P = .387). Again, girls reported more problems than boys.

Crucially, obesity-related psychosocial problems were significantly associated with depressive symptoms, at an r value of 0.669 (P < .001), and anxiety symptoms, at an r value of 0.589 (P < .001) 5 years postsurgery.

Ms Järvholm concluded: "We think that you should address social impairment due to weight and body shape both before and at every assessment after surgery, and it's especially important in girls."

And "If someone is reporting that they have a reduced quality of life due to their weight or body shape, you should screen for other mental-health problems," she concluded.

Andrew Beamish is a recipient of the David Johnston International Bariatric Research Fellowship funded by the Royal College of Surgeons of England. The authors report no relevant financial relationships.

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European Obesity Summit 2016:June 3, 2016; Gothenburg, Sweden. Abstracts OS10.01, AS6.03, and AS6.04.

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