For Some, Depression Follows Bariatric Surgery

For Some, Depression Follows Bariatric Surgery
Volume 32, Issue 2, Page 43 (February 2004)

Nicholas Mulcahy
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NASHVILLE, TENN. -- The euphoria that bariatric surgery patients typically experience in the first 9-12 months after their operation is followed by a period of depression in an estimated 25%-30% of all patients, Dr. George W. Cowan Jr. said at the annual meeting of the American College of Nutrition. The euphoria arises from a patient's steady weight loss, and the depression develops when patients recognize that life's difficulties cannot be entirely solved by the weight loss, said Dr. Cowan, professor of surgery at the University of Tennessee, Memphis.
"For many surgery patients, there is a belief that if they lost weight, their lives would be completely different. However, as it turns out, life's problems are not completely related to weight. So when the euphoria about the weight loss tapers off, depression sets in," he explained.
"The depression can get very serious" because many patients have self-managed their emotional difficulties in the past through eating, said Dr. Cowan, who has performed more than 4,000 bariatric surgeries. "When an obese patient gets frustrated, how does he or she handle stress? He eats. But now the patient, after surgery, will vomit or have dysphagia because he cannot physically accommodate the food," he said. Without the comforts of eating, bariatric surgery patients "internalize their pain" and depression begins.
Even though the surgery and weight loss may not be a magical fix, it is often life changing for patients. The depression can be temporary if well managed by antidepressants, good nutrition, and ongoing social support. But some surgeons who perform bariatric surgery "don't recognize depression postoperatively," he added.
Dr. Cowan recommends protriptyline and bupropion for treating depression in bariatric surgery patients. "Some antidepressants make you gain weight, but these two are very good in not doing so," he said. Compared with bupropion, protriptyline has the advantage of working immediately; bupropion does not have a clinical effect until a week or more.
He recommends a starting dose of protriptyline of 5 mg twice a day--in the morning and early afternoon; if taken later in the day, protriptyline may cause sleep problems.
Patients who have either significant hypertension or tachycardia should not take protriptyline. Bupropion can be used in patients with these conditions.
Dr. Cowan also advises bariatric surgery patients to take 5-hydroxytryptamine (5-HT), a naturally derived amino acid, to help reduce sugar cravings.
Bariatric surgery patients give up sugar yet will develop cravings 1, 2, or even as late as 3 years after surgery. Why? Because the body eventually returns to wanting an old drug of choice," he said. The amino acid should be taken at night because of the supplement's tendency to cause drowsiness. Five-hydroxytryptamine is thought to regulate low serotonin levels and thus to stave off depression as well as food cravings. "About 60% of patients taking 5-HT will stop with the cravings," he noted. Discussing a patient's social support system can offer insight into vulnerability to depression. "In our experience, about 80% of bariatric surgery patients have spouses who have doubts and concerns about the surgery. In some cases, the spouse may be unhelpful and even discouraging," Dr. Cowan observed.
Friends, neighbors, and coworkers tend to congratulate the patient about weight loss in the first 6 months or so, but eventually they drop the subject.
"Many obese people have dysfunctional family lives. So, when encouragement about the weight loss stops coming from others, the painful reality of their lives often may return acutely," he noted.
Support networks of patients who have undergone the surgery can be helpful, Dr. Cowan suggested.
Contributing Writer
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© 2004 International Medical News Group. Published by Elsevier Inc. All rights reserved.
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