Individuals who receive bariatric surgery for weight loss may have an elevated risk for adverse mental health outcomes following the procedure.1 A number of studies have reported increased rates of postoperative depression, anxiety, and eating disorders in patients with bariatric surgery, as well as reports of self-harm, suicide, and alcohol use disorders.2,3
There is inconclusive evidence in the literature, with some research showing increased rates of mental health disorders after bariatric surgery and others showing decreased rates or reporting mixed results.2,4
A repeated cross-sectional study indicated that anxiety and stress worsened, while depression improved, 1 year after bariatric surgery.5 In a Swedish cohort study published in 2024, adolescents who underwent bariatric surgery showed no improvement in mental health “despite substantial weight loss” 10 years following surgery.6
It is important for providers to ensure that patients know these surgeries affect hormone levels, medication absorption, which can change the effectiveness of medications – including psychiatric medications – and may be contributing to the increase in depression and suicidality in patients with weight-loss surgeries.
To learn more about mental health comorbidities and related treatment considerations for patients with a history of bariatric surgery, Psychiatry Advisor interviewed Lisa Du Breuil, LICSW, and Rachel Millner, PsyD, CBTP®, CEDS-S. Lisa Du Breuil is a licensed clinical social worker in Salem, Massachusetts, who specializes in the treatment of eating disorders and mental health concerns following weight loss surgery, and the impact of weight stigma on health.7 Rachel Millner is a licensed psychologist and eating disorders specialist in Philadelphia, Pennsylvania.
What is known about the incidence of depression and other mental health issues in individuals with a history of bariatric surgery? What is known about new-onset vs preexisting depression in this patient population?
Du Breuil: There is clear evidence in the literature that there are higher rates of depression and suicidality following bariatric surgeries.
In a population-based study in Canada, researchers analyzed data from patients who received Roux-en-Y gastric bypass surgery and the incidence of self-harm behaviors requiring emergency medical services in the 3 years before and after surgery. Researchers found a significant increase in postoperative self-harm behaviorsby approximately 50% in the postoperative vs preoperative period.8
In another study, patients with a preoperative history of suicidal behavior had a 17-times increased risk for postoperative suicidal behavior.9
Research also shows that rates of substance use disorders, new or re-emerging eating disorders, disordered eating, distorted body image, and reduced quality of life are also not uncommon after a weight loss surgery.1
Dr Millner: First, a significant amount of research on bariatric surgery and other weight loss methods is funded by companies and researchers who profit from these methods, so there is motivation to present results in a way that frames bariatric surgery in a positive light.
Second, it is rare for weight stigma to be controlled for in the research.10 Therefore, if symptoms of depression and other mental health issues decrease following bariatric surgery, we do not know if the bariatric surgery contributed to this improvement or if it was related to experiencing less weight stigma. Most people have depression symptoms prior to their bariatric surgery because of their perception of body size.
The research is mixed on the incidence of depression following bariatric surgery. We know that the risk for suicidality and alcohol and other addictions increase.1,3 Based on the study, some patients reported an improvement in depression symptoms, while others reported worsening of symptoms.1,2,3
My clinical experience suggests that patients are rarely provided with comprehensive information about bariatric surgery. They often are not warned of the side effects and other considerations. This may result in symptoms of depression post-surgery.
What are the potential risk factors for the development of mental health morbidity in patients receiving bariatric surgery? Are there particular psychosocial stressors or identity-related challenges that may contribute to depressive symptoms?
Du Breuil: It can be challenging for patients to get a realistic picture of what life after weight loss surgery will look like because most information available about bariatric surgeries is on industry-related websites, which often emphasize the more positive possible outcomes. Many industry-related resources often share “success stories” of patients at least 2 years after their surgery, when patients have lost a significant amount of weight but have not yet experienced the commonly occurring weight regain. For example, alcohol misuse usually does not start until 3 to 5 years post-surgery.11
It can take a few years or longer after the surgery “honeymoon” for patients to realize the surgery did not fix their personal issues, such as a marriage or body image. Sometimes patients still have chronic back or knee pain that they were assured would “disappear” with the surgery. It is important for providers to ensure that patients know these surgeries affect hormone levels and medication absorption, which can change the effectiveness of medications – including psychiatric medications – and may be contributing to the increase in depression and suicidality in patients with weight-loss surgeries.12
A commonly reported concern among patients is the presence of excess skin. While some patients report this in relation to cosmetic changes, others report pain. While insurance often covers bariatric surgery, “cosmetic” procedures or supplements may not be covered.
Another factor contributing to mental health issues after weight loss surgery is the experience of being treated differently, especially with regard to body image, where leaner bodies are considered in a positive regard. These experiences can bring up feelings of anger, sadness, and shame.
Bariatric surgeries are also often “the last resort” after years or even decades of dieting and weight regain. When things do not turn out as expected after the surgery, people are left feeling desperate or disappointed, which increases the likelihood of significant mental health morbidities.
Dr Millner: In addition to the increased risk for suicidality, alcoholism, and other addictions following bariatric surgery, there is also a higher incidence of divorce following surgery.13 People having bariatric surgery are rarely screened for an eating disorder, and some already have an eating disorder before surgery that may worsen post-surgery. Others may develop an eating disorder after surgery. If we consider that dieting is a major risk factor for developing an eating disorder, the risk for eating disorders would increase significantly following bariatric surgery.14
How does mental health morbidity affect long-term outcomes and quality of life in patients following bariatric surgery?
Du Breuil: Mental health morbidity may affect various outcomes after weight loss surgery. People often need help with “making peace” with the reality of post-surgery life and what it takes to care for oneself after bariatric surgery. They often need supplements specifically designed for patients undergoing this surgery, which can be expensive. Pain management can be challenging, as nonsteroidal anti-inflammatory drugs (NSAIDs) are not recommended, and acetaminophen needs to be used cautiously. Malnutrition is also a risk, and regular monitoring of micronutrient levels is needed.
Some patients find they cannot drink alcohol safely anymore or that certain foods do not agree with their “new stomach,” and that can be frustrating or even create feelings of grief and loss. Even with optimal outcomes, patients can feel stressed with the changes.
Dr Millner: There is little evidence available in the literature about long-term outcomes; however, it is reasonable to anticipate that patients with depression or other mental health concerns prior to surgery may continue to experience the same symptoms following surgery. It seems like quality-of-life improvements are primarily seen within the first 2 years after surgery, followed by a decrease.15
What should clinicians consider when managing individuals after bariatric surgery?
Du Breuil: Patients need a safe space to talk about their experiences from surgeries, with mental health providers providing support as needed.
Learning more about weight-inclusive approaches like the Health at Every Size® model can be helpful for providers. Getting consultations and referrals to clinicians with expertise in working with patients with all body types may be valuable. Other resources include the Association for Size Diversity and Health directory, which lists clinicians who may have expertise in working with patients with bariatric surgery, as well as the website Weight Loss Surgery Considerations and the Bariatric Surgery Informed Consent Resource created by Medical Students for Size Inclusivity.16
Dr Millner: Mental health providers need to address their own weight stigma to best support people having bariatric surgeries.
Other resources that can be given to patients after weight-loss surgery is Weight-inclusive Care and Body Trust®, which do not intend to pathologize body size and do recognize the impact of weight stigma. However, it is important to remember that systemic weight bias and oppression have historically had an impact on individuals and that the “diet culture” may be misleading them about their weight and body image.
Many people who lose weight will regain it, even with bariatric surgery,17 making it important for providers to have those conversations with their patients.
How can providers specifically address depression and other mental health concerns in patients receiving bariatric surgery?
Dr Millner: The main issue to address is weight stigma. If that was addressed, it could mean fewer people would have bariatric surgery, which can potentially impact those who profit from the surgery. Patients having bariatric surgery may have depression or other mental health concerns before surgery, but providers can address concerns with a better sense of underlying causes rather than assuming it is about body image and that surgery will “fix” these mental health concerns.
Editor’s note: The Association for Weight and Size Inclusive Medicine is an additional resource for clinicians. This interview was edited for clarity and accuracy.