Wednesday, January 23, 2008

Why are so many weight loss surgery patients on antidepressants?

A friend sent me an article today from one of the large medical sites. The article was authored by Drs Roizen and Mehmet Oz (of "You On A Diet" and Oprah show fame). Although they are two of my favorite health authors, they sometimes do not distinguish between when they are giving facts and when they are expounding on their theories.

This article talked about gut hormones and how they can affect the moods and my friend, a gastric bypass patient, asked if this was the reason why so many longer term gastric bypass patients require anti-depressant medication.

A logical question which I began to think about.

Truth is, no one knows why, although several studies done by psychologists have suggested that gastric bypass surgery seems to cause more psychological problems and relationship problems than it cures (despite what the TV ads tell us).

However, in pondering this, I came up with a few of my own theories. For what they are worth (probably not much) - I am not a psychologist and I don't even play one on TV.

I think so many gastric bypass patients are on anti depressants for the following reasons (and this is -my- opinion, not scientific fact - how's that for a disclaimer?):

1. Many people including those who become severely overweight are handling some of their stressful situations with food (it's a well known fact that a goodly portion of the population can medicate with food without becoming severely overweight although this is something the diet industry works earnestly to keep secret). For some, the consumption of food causes the production of endorphins (our body's natural -feel good- pain killer which actually has a similar structure to the opioid drugs). This, in some folks, can actually function as an anti depressant. When the person is severely calorie restricting in dieting or gastric bypass surgery and not able to use food as a comfort, they miss that "anti depressant". And of course, foods which are low calories are generally not the ones which produce endorphins (like broccoli).

2. Gastric bypass pre ops are never warned that in order to keep some weight off (in some people) the doctors will be giving them a disability of the digestive tract. Gastric bypass is sold as a fix rather than the introduction of one illness which hopefully causes less pain than the one it's supposed to cure.

"By doing this surgery, you're creating a medical disease in the body. Before you expose someone to that risk, you have to be absolutely sure that you are treating an illness which is equal to or greater than the one you are creating."
(Dr Edward Livingston, bariatric surgeon in Self Magazine, 4-2001)

So when they wake up with a disability, they are totally unprepared... never expecting they would be coping with new illness. And to make things worse, there is no help for them. No one takes them through the four stages of getting used to a disability (similar to the four stages of mourning) because no one wants to admit that gastric bypass -is- a disability.

Generally speaking, disabilities you cannot see, tend to cause problems with doctors and friends alike. People are often, overly considerate at the sight of a wheelchair but not considerate at all to someone who is struggling to walk on their feet (who may need the help much more than someone who has become mobile via a wheelchair). Likewise for a doctor confronted by a gastric bypass patient with gut pain or stomach pain which likely has a real underlying physical cause. It's so less troublesome to say "it's in your head" and prescribe anti depressants which only are a bandaid, than it is to try and unravel the complexities of illness which drastically cutting up and rearranging your stomach and gut can cause.

3. The high number of marriages which break up after WLS is similar to the high number of marriages which break up after a person gets, for example, multiple sclerosis or a spinal cord injury. The spouse sometimes, can not handle the disability and what goes along with it... visits to the ER, illness and/or inconvenience plus the pain and suffering which accompanies this. Many marriages may be more based on the fact that they like to have fun together rather than the "better or worse" principle and so when the "worse" comes along, it can do damage to the well being of the couple. Additionally, the couple was never expecting anything but an almost magical "cure" to obesity when the patient got WLS and so, both are shocked and unprepared at the reality.

4. As mentioned before, people tend to lack sympathy for disabilities which are not obvious to the casual observer, as is true of those in the digestive tract. To make things worse, the person might "look good" and be "the picture of health" according to what we are told - slim - so what on earth is their problem, people wonder. That the patient is often sick a lot, losing efficiency at work, depressed, suffering pain and more must be in their head because they are slim, right? The gastric bypass patient who has regained a lot of weight, fares even worse. One often hears horror stories of patients with serious physical problems, having their medical providers tell them that all their problems would be solved if they -only- could lay down their fork, the provider totally ignoring a potentially serious problem the patient is complaining about!

5. Somehow, a disability which seems a result of a decision one has made, is worse than one which happens by luck of the draw. But, truth is, that many patients were -not- aware that they were, in fact, chosing a disability because the media sells the gastric bypass as a medical cure for diabetes, and whatever illness people have, as well as a fix for being socially unacceptable i.e. fat. So when illness and repercussions occur, the patient has an easy time agreeing with the medical providers and the rest of the WLS community in saying that somehow -they- caused the problems they are having. This is depressing to think about and may explain the reactive depression which many patients suffer. That is, they blame themselves but somehow can not -do- anything to help the situation.

6. Ok, perhaps Dr Oz and Roizen's theory of gut hormones being disarranged might play into the equation too. I wouldn't doubt it. The drastic rearrangement of digestive organs is bound to cause severe repercussions. That seems a no brainer.

7. And last but not least, many people were depressed before surgery and those providers who promised that being slim or losing weight would solve all problems were simply not even close to the reality.

Whatever the case, people who decide on gastric bypass surgery should be totally aware of all the repercussions which can occur by making sure they have informed consent, and that they understand that this is the type of medical procedure which "breaks" one thing (the digestive system) to hopefully fix another thing "obesity" and that they will be dealing with new disabilities and co-morbidities even if their procedures go well for them.

I feel that medical providers who tend to not give us lay folk informed consent (one medical provider told me "if we gave informed consent, no one would ever have anything done") need to consider distinguishing between those surgeries which are essential for survival, and those which are elective. I think they also need to trust us more - that we can do research and that we can know what will work best for us even if our answer to their proposed medical procedure is negative.

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