Mood Disorders and Bariatric Surgery Patients: Pre- and Post- Surgery Clinical Course- An Overview

Abstract

a common etiology between obesity and depression for several reasons: unhealthy diets that include energy dense foods promote the development of both pathologies, reduced physical activity and sedentary lifestyle are commonly described in obese and depressed patients, impaired sleep and/or circadian cycles damage mood and increase body weight, recurrent psychological stress and early life trauma seem to contribute to a late-onset obesity and depression [4]. People with Bipolar Disorder (BD) also present a higher prevalence of overweight (BMI 25.0-29.9), generalized obesity (BMI ≥ 30.0), and central obesity, when compared with the general population [5]. The elevate rate of obesity is a risk factor for cardiovascular disease, the most common cause of premature mortality in the population with BD [6]. Several factors are involved as a reason of obesity in populations with BD, the most important seem the chaotic eating patterns or loss of control over eating, neuroendocrine dysfunction, lack of access to primary medical care, genetic predisposition, psychotropic treatment [7-10]. In addition to an increased risk of obesity, patients with mental illness seem to seek more frequently medical or surgical treatment for obesity [11,12]. Bariatric Surgery (BS) represents a treatment option in subjects with morbid obesity who fail to maintain weight loss through behavioural programs, or in those for which the weight loss achieved through behavioural programs is insufficient to improve obesity-related comorbidities. This type of surgery achieves weight loss through a combination of restrictive (sleeve gastrectomy, laparoscopic adjustable gastric banding-LAGB) and malabsorptive (biliopancreatic diversion) and mixed (Roux en-Y Gastric Bypass-RYGB) procedures [13]. Several researches have reported that approximately 22%-56% of people seeking BS meet criteria for a mental disorder [14-17]. The most frequent psychiatric disorder is an existing depressive disorder, followed by binge eating disorder and substance abuse/dependence [18,19].

How bariatric surgery affects psychotropic drug absorption

“…As illustrated in the Table [6][7][8][9][10][11][12][13][14][15][16][17][18][19] (page 42), each type of bariatric surgery may impact drug absorption differently depending on the mechanism by which the stomach is restricted. Drug malabsorption is a concern for clinicians with patients who have undergone bariatric surgery.…”

“…Small pouch is created from top portion of stomach First portion of small intestine is divided and connected to newly created small stomach pouch Decrease in effective surface area for drug absorption 9 Increase in gastric pH 10 Decrease in gastric and distribution volume 10 Shorter absorption time 10 Shortened passage through intestine 10 Reduction in drug concentration absorbed 10 Reduced gastric mixing limiting drug disintegration 7 SSRI AUC levels 1 month after surgery drop and return to baseline for most patients by 6 months 11 No change in AUC, C max , or T max for venlafaxine 12 Potentially less significant reductions in bioavailability of SNRIs than SSRIs due to solubility characteristics 8 Sleeve gastrectomy (vertical sleeve gastrectomy; gastric sleeve procedure) 13 Removes approximately 80% of stomach 6 Performed by making 5 to 6 small incisions in the abdomen; procedure completed laparoscopically 14 Procedure results in a narrow, tubular stomach pouch or "sleeve" 6 Reduces amount of food that can be consumed due to smaller volume of stomach pouch 6 Increased transit time of drugs 15 Increased gastric pH leads to decreased absorption of weakly acidic drugs and increased absorption of basic drugs 16 Reduced bioavailability with extended-release formulations 16 Reduced gastric mixing limits drug disintegration 7 Reduced gastric emptying (reduced rate but not reduced overall magnitude of drug absorption) 7 Lithium: decreased stomach surface area, impaired gastric motility, decreased gastric volume, and reduced GI transit time lead to potential decreased drug dissolution and absorption, which has a significant impact on serum drug levels 17,18 Laparoscopic adjustable gastric band Band is implanted around top part of stomach 6 Creates 2-compartment stomach with food only filling top portion upon eating 6 Reduces hunger, ultimately decreasing calorie intake 6 Least invasive weight loss surgery 6 No reduction in intestines or other absorptive surface area 6 Accelerated gastric emptying 15 Increased gastric pH 7…”

Late-Onset Manic Episode after Bariatric Surgery

“…The old adage that prevention is the best treatment definitely is valid here. Guidelines concerning screening are already implemented, but there seems to be lack of long term follow-up [12,13,14].…”

Perfil psicopatológico de pacientes com obesidade candidatos à cirurgia bariátrica: análise de classes latentes e fatores associados

“…Depressive symptoms have been investigated among patients seeking the bariatric procedure through assessment scales (Duarte-Guerra et al, 2016;Schutt et al, 2016). Further emergence of post-operative manic/hypomanic symptoms are described in several studies Ahmed et al, 2013;Godini et al, 2016), as well as their frequent co-occurrence with additional psychiatric conditions (Da Silva et al, 2015). Because the exact effect of gastroplastic surgery on stability of mood disorders is not fully understood , some bariatric centers have included nonstabilized depressive and manic phases as contraindicative to undertake surgery (Bauchowitz et al, 2005).…”