Friday, October 26, 2007

Mental Health and WLS Revisited

I did a post early on this subject. In light of new research,I felt compelled to go more in depth on some things. Living life after having WLS is difficult enough on your mental health. Throw in the added complication of a severe mental illness and it can be devastating to some.

The nutritional deficits coupled with all the body image changes make for a difficult journey for the strongest of minds. The rapid weight loss phase can trigger depression in someone without a history of mental illness. Remember, I'm not a writer, but let me see if I can explain this properly.

Estrogen is stored in the fat cells. When you lose weight, especially rapidly like with WLS, that estrogen is released. Thus your estrogen levels fall. Low estrogen levels can be a reason for depression in women. Low estrogen triggers the brain to release MAO, an enzyme in the brain which breaks down and destroys the neurotransmitter, serotonin. Likewise estrogen increases the destruction of this enzyme MAO . The lower our MAO enzyme levels the better we probably feel, since MAO breakdowns serotonin. Serotonin levels can dictate if we feel depressed or not. Low levels of estrogen in women are associated with the premenstrual syndrome, postnatal depression and post-menopausal depression. Research studies show promising results in combating the depression brought on by this one factor after WLS. They use an estrogen patch. Like some of the birth control patches.

In my earlier post I reported that mental illness is present in many of those seeking WLS:

Overall, 66.3% of subjects had a lifetime history of at least one axis I disorder and 37.8% were currently diagnosed with such a disorder. The most common lifetime axis I disorder was major depressive disorder, seen in 42% of subjects. Binge eating disorder was the most common current disorder and had a prevalence of 16.0%.

A lifetime history of an axis II disorder was noted in 28.5% of subjects, the most common being avoidant personality disorder, which was seen in 17.0%.
The majority of reputable bariatric centers have a lengthy screening process for all surgery candidates. Which a psychological evaluation plays an important role. A recent study shows 1 in 5 potential surgery candidates fail to meet these guidelines:

The most common reasons people were not allowed to go through with the procedure included overeating to cope with stress or emotional distress, having an eating disorder, and uncontrolled mental problems, such as depression.

Most patients who were deferred from bariatric surgery after their initial psychological evaluation were referred for psychiatric treatment. The researchers write that they will conduct a future study to look at how many of these patients accepted psychiatric referral and went on to have the surgery.

"The goal of the psychiatric evaluation is not to keep patients from having the surgery. Rather, the goal is to determine if there are any problems that might interfere with the success of surgery, and have the patient get treatment for these problems," says researcher Mark Zimmerman, MD, of Rhode Island Hospital, in a news release. "In so doing, the patient is more likely to have a positive outcome from surgery that is delayed to allow time to address the problems."
In my case, it was my pdoc who actually played a major part in me getting the surgery in the first place. He began encouraging it when I first started seeing him. I had never considered it until he began speaking of it. He also wrote a glowing report, even despite my history of an eating disorder along with my Bipolar Disorder.

He was well aware of the risks the surgery posed to my mental health. For the first year I was followed very closely. I saw him once an month and my therapist once a week. My routine prior to surgery had been to see him twice a year and my therapist once a month. The second year I was still followed closely. Gradually increasing he times between visits as he deemed appropriate.

Luckily, he had the forethought to do this. I had a serious bout of depression beginning in my third month. Which was controlled with an additional medication and therapy. Going from my second year into my third brought on another very serious bout of depression. That one was brought on by adding carbs back into my eating plan. Coupled with the ineffectiveness on my medications due to the malabsorption issues. I ended up hospitalized for awhile to get things back under control.

Another issue I deal with is the changing of seasons. Fall going into winter, being extremely difficult in the past. Many people go through same thing each year. Most just refer to it as the "winter blues". In my case and many more, it is so much more than that. They call it Seasonal Affective Disorder or SAD. Kinda fitting, don't you think. This is from NAMI:
Most people with SAD are women whose illness typically begins in their twenties, although men also report SAD of similar severity and have increasingly sought treatment. SAD can also occur in children and adolescents, in which case the syndrome is first suspected by parents and teachers. Many people with SAD report at least one close relative with a psychiatric condition, most frequently a severe depressive disorder (55 percent) or alcohol abuse (34 percent).

Symptoms of winter SAD usually begin in October or November and subside in March or April. Some patients begin to slump as early as August, while others remain well until January. Regardless of the time of onset, most patients don’t feel fully back to normal until early May. Depressions are usually mild to moderate, but they can be severe. Very few patients with SAD have required hospitalization, and even fewer have been treated with electroconvulsive therapy.

The usual characteristics of recurrent winter depression include oversleeping, daytime fatigue, carbohydrate craving and weight gain, although a patient does not necessarily show these symptoms. Additionally, there are the usual features of depression, especially decreased sexual interest, lethargy, hopelessness, suicidal thoughts, lack of interest in normal activities, and social withdrawal.
The reasoning behind the onset of SAD is simple. It is a lack of sunlight. Treatment options can include an added antidepressant and therapy. But the best treatment is light therapy. In the winter months people are not outside in the sunshine as much. Due to the tilt of the earth, UV exposure is decreased, even if you do get outside. You can help your symptoms by making sure you get enough Vitamin D. I've done some lengthy posts on the benefits of Vitamin D (Part 1, Part 2, Part 3, Part 4).

Light therapy is really the best line of defense to combat SAD. Especially in very debilitating cases such as mine can be. Here is what a light therapy box looks like:

Bright white fluorescent light has been shown to reverse the winter depressive symptoms of SAD. Early studies used expensive "full-spectrum" bulbs, but these are not especially advantageous. Bulbs with color temperatures between 3000 and 6500 degrees Kelvin all have been shown to be effective. The lower color temperatures produce "softer" white light with less visual glare, while the higher color temperatures produce a "colder" skylight hue. The lamps are encased in a box with a diffusing lens, which also filters out ultraviolet radiation. The box sits on a tabletop, preferably on a stand that raises it to eye level and above. Such an arrangement further reduces glare sensations at high intensity, and preferentially illuminates the lower half of the retina, which is rich in photoreceptors that are thought to mediate the antidepressant response. Studies show between 50% and 80% of users showing essentially complete remission of symptoms, although the treatment needs to continue throughout the difficult season in order to maintain this benefit. Here's some more info from NAMI:
There are three major dosing dimensions of light therapy, and optimum effect requires that the dose be individualized, just as for medications.
  • Light intensity. The treatment uses an artificial equivalent of early morning full daylight (2500 to 10,000 lux), higher than projected by normal home light fixtures (50 to 300 lux). A light box should be capable of delivering 10,000 lux at eye level, which allows downward adjustments if necessary.
  • Light duration. Daily sessions of 20 to 60 minutes may be needed. Since light intensity and duration interact, longer sessions will be needed at lower intensities. At 10,000 lux – the current standard – 30-minute sessions are most typical.
  • Time of Day of exposure. The antidepressant effect, many investigators think, is mediated by light’s action on the internal circadian rhythm clock. Most patients with winter depression benefit by resetting this clock earlier, which is achieved specifically with morning light exposure. Since different people have different clock phases (early types, neutral types, late types), the optimum time of light exposure can differ greatly. The Center for Environmental Therapeutics, a professional nonprofit agency, offers an on-line questionnaire on its website,, which can be used to calculate a recommended treatment time individually, which is then adjusted depending on response. Long sleepers may need to wake up earlier for best effect, while short sleepers can maintain their habitual sleep-wake schedule.

Side effects of light therapy are uncommon. Some patients complain of irritability, eyestrain, headaches, or nausea. Those who have histories of hypomania in spring or summer are at risk for switching states under light therapy, in which case light dose needs to be reduced. There is no evidence for long-term adverse effects, however, and disturbances experienced during the first few exposures often disappear spontaneously. As an important precaution, patients with Bipolar I disorder – who are at risk for switching into full-blown manic episodes – need to be on a mood-stabilizing drug while using light therapy.
Mental health is extremely important for anyone. The changes your body goes through post WLS make things difficult even for those with no prior history. Also the many changes you go through psychologically after WLS is another debilitating factor. Their changes in your body image, dealing with the loss of food, addiction transference, loss of friends, as well as host of other things.

The LivingAfterWLS site is chock full of numerous articles dealing with the psychological changes after surgery. These are just a few of my favorites. You can see all of them by visiting the Library:

For those preparing for WLS and those already well on their journey, paying attention to your mental health is important. Just as making sure you get in your proper nutrition. I feel it is MORE important. They didn't do surgery on your head. That aspect you must take care yourself. One, follow up post op with a therapist. Two, find a good support group. three, get your family involved in follow up support too. Significant others, spouses go through many changes of their own. Even though it is YOUR journey, everyone around you is effected. Personally I feel all of this should be mandatory for all post ops for at least the first year. Online support, like the LivingAfterWLS Neighborhood can be a viable alternative to the bariatric center support group meetings. It can also be used in conjunction with those too. Further help is as close as your local mental health center.

Since you have taken the steps to regain your health, don't lose your mental health in the process. I have much more to share on the subject of mental health and WLS. So I will end up breaking it down into another post or two.

I'm off now on my camping trip. Then I'm taking a break from the internet. I should return sometime in December. Take care everyone.


Sherrie said...

BG you are spitting out some REALLY good posts, good stuff :)

celadon said...

Bama, I want to thank you for your thorough and candid discussion of SAD. My darling grandson has it, coupled with a history of severe depression, chemical imbalances, and bi-polar disorder that run in my husband's family and alcoholism to top it off. I think that he will be more able to cope with the frightening things that could happen to him in the future if he is made aware of how to recognize the behavior before it gets out of hand. Thankfully he doesn't care for alcohol and is seeing his therapist weekly to learn to cope with other things in his life that he has no control over. Your explaination was much more informative to me than Jake's therapist was. I hope you don't mind if I go back through your blog and read, read, read. It is helping me more than I can say.

Anonymous said...

Members of families that have a disturbed domestic environment are known to be easy preys of depression. In the countries like the USA people with a turbulent domestic life not only suffer depression but they are also known to have strong suicidal tendencies.