Can gastric bypass surgery cause psychosis?

Gastric Bypass and Risk of Psychosis

While gastric bypass surgery is not directly associated with causing psychosis, it can increase the risk of various psychiatric disorders including worsening or new-onset depression, anxiety disorders, and suicidal ideation. 1

Psychiatric Risks Associated with Gastric Bypass

Mental Health Complications

• Gastric bypass surgery patients face increased risk for:

  • Substance abuse disorders
  • Worsening of pre-existing depression
  • New-onset depression and anxiety disorders
  • Suicidal ideation 1

• Recent evidence shows a significant increase in psychiatric disorders following bariatric surgery:

  • 27 percentage point differential increase in psychiatric disorders (135% relative increase) within one year post-surgery compared to non-surgical obese controls 2
  • Higher 5-year rates of suicidal ideation (adjusted hazard ratio=1.21) and suicide attempts (adjusted hazard ratio=1.62) compared to matched non-surgical controls 3

Physiological Mechanisms That May Contribute

• Rapid weight loss and nutritional changes can affect neurotransmitter function
• Post-bariatric hypoglycemia (PBH) can cause neuropsychiatric symptoms including:
  • Impaired cognition
  • Confusion
  • Seizures 1
• Altered medication absorption affecting psychiatric medication efficacy 4
  • Therapeutic drug monitoring of antipsychotics has shown significantly reduced blood levels post-surgery

Pre-Surgical Assessment and Risk Mitigation

Mental Health Screening

• All candidates for metabolic surgery should be assessed by a mental health professional with expertise in obesity management prior to consideration for surgery 1
• Surgery should be postponed in individuals with:
  • Alcohol or substance use disorders
  • Severe depression
  • Suicidal ideation
  • Other significant mental health conditions until these conditions have been sufficiently addressed 1

Post-Surgical Monitoring

• Individuals with preoperative or new-onset psychopathology should be assessed regularly following surgery 1
• Monitoring should include:
  • Screening for psychiatric symptoms
  • Assessment of medication efficacy (particularly for patients on psychotropic medications)
  • Evaluation for nutritional deficiencies that could impact mental health

Management Approach for Post-Surgical Psychiatric Symptoms

For Neuropsychiatric Symptoms Related to Hypoglycemia

1. Rule out post-bariatric hypoglycemia through:

   • Detailed food intake records
   • Physical activity patterns
   • Symptom timing (typically 1-3 hours after high-carbohydrate meals)
   • Continuous glucose monitoring 1

2. If hypoglycemia is confirmed:

   • Dietary modification to reduce rapidly digested carbohydrates
   • Ensure adequate protein and healthy fats
   • Consider medications like acarbose, diazoxide, or octreotide 1

For New-Onset Psychiatric Symptoms

• Prompt psychiatric evaluation
• Consider medication adjustment as absorption may be altered post-surgery 4
• Extended-release oral formulations may be particularly problematic post-RYGB
• Non-oral antipsychotic formulations may be preferred in some patients 4

Important Caveats and Pitfalls

• While psychosis specifically is not commonly reported as a direct complication of gastric bypass in guidelines, the overall risk of psychiatric disorders increases significantly post-surgery 2
• Medication absorption changes can lead to subtherapeutic levels of psychiatric medications, potentially worsening pre-existing conditions 4
• Nutritional deficiencies post-surgery require lifelong monitoring and supplementation to prevent neuropsychiatric complications 1
• The psychological impact of body image changes and lifestyle adjustments should not be underestimated

Recognizing the increased risk of psychiatric disorders following gastric bypass surgery highlights the importance of comprehensive pre-surgical mental health assessment and ongoing post-surgical monitoring to optimize outcomes and quality of life.