Eric Wang, Senior Photographer

For many patients, the consequences of obesity are more than just physical. Patients with obesity face a slew of mental health challenges, including elevated rates of depression and anxiety.

As a result, doctors treating obesity combat the chronic condition on the physiological and mental fronts. Their most effective tool is bariatric surgery, a procedure that stimulates weight loss by making modifications to the body’s digestive system.

And though the surgery is effective at reducing weight and weight-related comorbidities, some patients suffer from mental health complications — even after the procedure wraps up, doctors say.

“What we see with bariatric surgery is that it’s safe, effective and for the vast majority of people, they do well,” said John Morton, division chief for bariatric and minimally invasive surgery in Yale-New Haven Health. “But there is a subset, just like there is in any field of medicine, that can have issues … around depression, suicidal ideation and alcohol abuse. The biggest predictor for those issues is having those same issues before.”

The operation

Inside the operating room, the most commonly performed type of bariatric surgery is the sleeve gastrectomy. 

The procedure takes roughly 45 minutes, Morton said. A surgeon makes four incisions, each less than three-quarters of an inch. Then, the surgeon uses a surgical stapler to remove two-thirds of the stomach, shrinking it from the size of a football to the size of a banana. 

The portion of the stomach removed is not essential for digestion, Morton said. Removing it leaves patients feeling more full, more quickly. The procedure also treats the comorbidities of obesity, like type 2 diabetes and high blood pressure.

The surgery’s capacity to reduce mental health challenges, however, is less certain. 

“We’re able to improve, or put into remission diabetes about 80 percent of the time and high blood pressure about 70 percent of the time,” Morton told the News. “ For depression, it’s a mixed bag, it’s probably maybe 50 percent. Some people get better, but some might get worse.”

That’s because the success of bariatric surgery isn’t just about modifying the digestive process. For sustained weight loss, patients need to commit to several behavioral and dietary changes to help keep weight off in the long run. 

Two weeks before bariatric surgery, for instance, patients switch to a liquid diet, which helps shrink the patient’s liver and kick-starts weight loss in the patient, Morton said.

After the surgery, patients begin a process of diet escalation, Morton said, shifting from a liquid to a puréed diet over several weeks. Once patients return to regular eating, he said, they need to exercise, consume more protein and eat fewer carbohydrates and sugars.

But if a patient’s mental health challenges limit their ability to follow those post-operative guidelines, the prospect of sustainably losing weight might be in jeopardy.

Mental health screenings

At Yale, mental health is embedded into standard patient care for obesity. Before the surgery, Morton said, patients meet twice with the surgeons, twice with nurses and six times with nutritionists and psychiatrists, allowing his team to establish rapport with his patients.

And to screen patients for mental health challenges, individuals seeking bariatric surgery also undergo a psychological evaluation, he said.

Mary Motwani, a psychologist at Yale-New Haven Hospital who performs mental health evaluations, describes the process as looking for “red flags” like untreated or undertreated mental health issues that could interfere with a patient’s ability to follow strict surgical guidelines.

Most mental health challenges that patients face after bariatric surgery also exist prior to the surgery, Motwani said. The bariatric population suffers from depression, body image shame, social anxiety, body dysmorphia, eating disorders and general impulse control disorders — a tendency of addictions to substances or other compulsive habits such as shopping or gambling, she said.

And according to Joshua Hrabosky, a psychologist who helps lead Morton’s bariatric mental health care, it is especially common to encounter patients with bipolar disorder and schizophrenia in the New Haven area.

But mental health challenges do not preclude patients from undergoing bariatric surgery.

“I don’t want to be a gatekeeper,” Hrabosky said. “Our role as psychologists, psychiatrists and clinical social workers is not to prevent a person from having surgery.”

Instead, Morton and Hrabosky’s goal is to catch patients who could be at-risk for mental health challenges before the bariatric surgery and ensure that they have resources in place to avoid issues stemming from untreated conditions.

By identifying these red flags, the team hopes to identify obstacles that patients may need to overcome to have positive outcomes after surgery. If a patient’s mental health condition makes it difficult for them to observe the doctor’s patient-care instructions, then patients may receive a referral to therapy as part of their postoperative care recommendations, Hrabosky said.

“What we would like to do within Yale-New Haven Health System is for the pre-bariatric psych eval[uation] to be educational,” said Hrabosky. “[It’s] an opportunity for patients to be aware of how some of these risk factors can impact their post-surgical outcomes because we want them to have the best outcome possible.”

Sometimes, Hrabosky said, red flags during the psychological evaluation might mean that bariatric surgery may not be the best outcome or a patient struggling with mental health challenges. In these cases, Hrabosky works with the hospital’s medical weight loss program if a patient is a better fit for weight-loss medication — like Wegovy or Zepbound — instead of surgery. 

“Our goal is never to discharge … or dismiss patients from the program,” Hrabosky told the News. “We really want to support them in any way possible, whether it’s through surgery or medical avenues.” 

Emotional aftermath

For many patients, the improved health and weight loss resulting from the surgery can help alleviate symptoms of depression and anxiety, Motwani said. 

For others, however, lifestyle changes after the surgery can exacerbate mental health struggles. Large changes to an individual’s body weight and shape can make them feel self-conscious — making existing anxiety symptoms, for example, worse.

It’s the reason that, after the surgery, patients have access to a bariatric treatment support group led by Gregory Berlin, a clinical psychologist and the YNHH Center for Behavioral and Nutritional Health. 

“Oftentimes people will lose a significant amount of weight, and then folks will comment on their body and say that they look underweight, and then people can feel really self-conscious about both their pre- and post-operative body,” Berlin said. “So if anxiety and depression are there preoperatively, and you’re undergoing all the postoperative changes, there’s definitely a chance that you can struggle after surgery.”

To combat emotional complications after the surgery, Berlin teaches bariatric patients techniques to be more emotionally aware. Those lessons include methods for patients to better identify locations of physical tension in their body, how their thinking patterns change depending on their stress level and how to accurately label their emotions at any given moment.

Berlin also teaches patients how to take control of aspects of their physical wellbeing: promoting better sleep, maintaining treatment goals and eating mindfully.

For Berlin, postoperative care is as transformative psychologically as it is physically. He emphasized that patients going through bariatric treatment are not alone: staying in contact with medical providers can help patients navigate the emotional aftermath of bariatric surgery.

“You’re not alone in feeling that and the very best thing you can do postoperatively is stay in close connection with your medical team,” Berlin told the News. “They’re there to help, and it’s not unexpected to have issues after surgery.”

The first weight loss surgery was conducted in 1954.

Carlos Salcerio covers the Yale School of Medicine and the Yale School of Nursing for the SciTech desk. Originally from Cuba, he is a prospective pre-medical student majoring in Molecular Biophysics and Biochemistry in Jonathan Edwards College.