Weight Loss Surgery Won't Fix Mental Health Problems in Teens

GLASGOW, Scotland — Adolescents undergoing bariatric surgery should be warned that, over and above weight loss, it will not alleviate mental health problems they may have, urge Swedish clinicians after finding ongoing psychiatric diagnoses and treatment even 5 years after the procedure.

The findings were presented here at the European Conference on Obesity (ECO) 2019 by psychologist Kajsa Järvholm, PhD, from the Childhood Obesity Unit at Skåne University Hospital, Malmö, Sweden.

The researchers studied over 80 adolescents who had undergone bariatric surgery for severe obesity and matched them with similarly obese young people who had been treated conventionally, and followed them for 5 years.

Both at baseline and follow-up, there were no significant differences between surgery patients and controls in terms of psychiatric medication use.

However, adolescents who had surgery were significantly more likely to be diagnosed with a psychiatric condition and to have received inpatient and outpatient psychiatric treatment.

There were nevertheless improvements seen in self-esteem among bariatric surgery patients 5 years after the procedure, and they had marked improvements in eating patterns.

Surgery Cannot Be Standalone Treatment for Obese Adolescents

Järvholm said "what is of concern" is the findings that mood among adolescents undergoing bariatric surgery is still "below norms" 5 years later.

"On the more positive side, we can see more consistent improvements in eating patterns and much fewer adolescents report that they have binge eating at follow-up."

She emphasized that the study indicates surgery cannot be seen as a "standalone treatment" for obese adolescents.

"It won't fix their mental health problems," Järvholm said. "We need to inform our patients that, if they have mental health problems, they should not put all their hopes in losing weight and hope the mental health problems go away."

She urged physicians to continue to monitor the mental health of adolescents who undergo bariatric surgery for several years after the procedure. "It's not enough just to see them the first years when they are happy with the weight loss," she said.

"Even more important, we need to develop interventions...and to find out when is the perfect time to do them," Järvholm added.

Approached for comment, Louise Baur, MD, PhD, professor and head of child & adolescent health, Sydney Medical School, NSW, Australia, session cochair, underlined the benefits of weight loss surgery, but nevertheless recognized its limitations.

She told Medscape Medical News: "Bariatric surgery is an essential part of the treatment range that we need to offer adolescents with moderate to severe obesity...[and] very clearly in several studies leads to quite dramatic improvements in BMI and cardiometabolic outcomes."

But she stressed that "clearly it's not a simple solution for quite complex mental health issues...and these young people need to be followed and monitored, probably lifelong."

"We need to recognize that they might have ongoing psychological problems" and young people "need to be offered treatment" if such problems are identified.

Baur added that she is nevertheless left with a "sense of hope," as there were improvements in some mental health parameters among the patients, even if "they were still not at where we would like everyone to be."

Study Looked at Long-Term Psychiatric Outcomes in Teens

Järvholm said studies in adults indicate that, in the first year following bariatric surgery, mental health either remains stable or declines. However, there are little outcomes data on long-term mental health following surgery, particularly in adolescents.

As reported by Medscape Medical News, Järvholm and colleagues showed in a previous study that, in the 2 years following gastric bypass surgery, adolescents experienced substantial improvements in mental health, although a subgroup had substantial depressive symptoms.

To look at mental health outcomes over a longer period, they studied adolescents who had undergone bariatric surgery and an age-matched group of conventionally treated severely obese individuals.

The surgery patients were required to be aged 13-18 years, have a body mass index (BMI) ≥ 40 kg/m², or ≥ 35 kg/m² with comorbidities, and to have failed conventional treatment.

The team examined self-reported mental health and eating-related problems using a range of questionnaires, and measured BMI at baseline and at 1, 2, and 5 years.

In addition, they collected data on prescribed and collected drugs from the Swedish Prescription Drug Register, and inpatient and outpatient hospital care from the National Patient Register for mental and behavioral disorders.

Eighty-one surgery patients and 80 controls were included in the study, of whom 65% and 56%, respectively, were female.

The mean age of participants at study entry was approximately 16 years in the two groups, and mean baseline BMI was 45.5 kg/m² in the surgery group and 42.2 kg/m² in controls.

As expected, mean BMI at the 5-year follow-up was substantially lower in surgery patients, at 32.3 kg/m², while it remained relatively stable among controls, at 41.7 kg/m².

Researchers found the use of psychiatric drugs was comparable between surgery patients and controls at baseline, and higher than that seen in the general population.

For example, 20% of surgery patients and 15% of controls had taken any psychiatric drugs, including 10% and 11%, respectively, who had taken psycholeptics.

After 5 years of follow-up, the use of psychiatric drugs had increased substantially in both surgery patients and controls, and remained comparable between the two groups, at 43% and 34%, respectively.

More Surgery Patients Needed Psychiatric Care

When the team looked at psychiatric diagnoses and inpatient or outpatient hospital care, they found a different picture, however.

At baseline, there was, again, no significant difference between surgery patients and controls, with 20% and 18%, respectively, having a psychiatric diagnosis.

Furthermore, 7% of surgery patients and 5% of controls required inpatient psychiatric care, and 17% and 15%, respectively, received outpatient care.

At 5 years, surgery patients were, however, significantly more likely than controls to be diagnosed with a psychiatric condition (36% vs 21%; P = .041).

Surgery patients were also significantly more likely to require inpatient care than controls (11% vs 2%; P = .03) and to be treated as a hospital outpatient (36% vs 21%; P = .041).

Järvholm pointed out, however, that "as this is not a randomized study, we do not know if this is caused by the surgery or not."

"There might be other differences between the groups, or we might be better at catching and offering treatment."

Turning to self-reported mental health, the researchers saw that there were few changes in scores between baseline and 1-, 2-, or 5-year follow-ups for adolescents who had undergone weight loss surgery.

However, the latter did experience a significant improvement in self-esteem scores between baseline and 5 years (P = .006), as well as in activation (P = .018), suggesting a greater willingness to actively participate in treatment.

There were also significant improvements in eating-related problems in surgery patients between baseline and the 5-year follow-up, including for binge eating (P < .001), emotional eating (P < .001), uncontrolled eating (P < .001), and cognitive restraint (P = .001).

The team did not find any baseline factors that predicted changes in BMI during follow-up.

However, lower self-esteem and mood, and greater binge eating, emotional eating, and uncontrolled eating at 2 years were all associated with less BMI loss at 5 years, as were more binge eating and emotional eating at 5 years.

"Bariatric surgery seems to provide long-term improvement only in eating-related problems, but does not seem to alleviate the substantial mental health problems," say Järvholm and her team.

"Adolescents undergoing bariatric surgery had significantly more in- and out-patient care for mental problems than their matched controls."

It's Good to Talk

During the post-presentation discussion, John Roger Andersen, PhD, Western Norway University of Applied Sciences, Førde, asked Järvholm how physicians can identify patients who are not doing well after surgery and engage them in treatment as partners.

She suggested that physicians "have to screen for mental health problems much more than we do today in obesity treatment, and that's not only for those who want to undergo surgery. We have to do it in all obesity treatment."

Järvholm added that "we need to talk much more about mental health problems and inform adolescents that they can get other treatments for mental health problems than just losing weight."

And following surgery, a multidisciplinary bariatric team must be prepared to offer long-term follow-up, she stressed.

"We are living in a society that tells us that you will become happy if you lose weight, and everyone is 'tricked' by this."

"Sometimes when we refer our adolescents to psychiatric care, they talk a lot about weight loss, saying: 'If you try to lose some weight you will feel more positive about yourself.'"

But "it doesn't seem to be the truth," she concluded.

The research was funded by the Swedish Research Council, Vinnova, Swedish Heart-Lung Foundation, Research Council of Region Västra Götaland, and Swedish Freemason Child Foundation. Torsten Olbers has reported receiving payment from Johnson & Johnson, Novo Nordisk, Mölnlycke, and Merck.

ECO 2019. Presented April 30, 2019. Abstract OS2.05.

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