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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 37  |  Issue : 4  |  Page : 137-149

Is weight control surgery associated with increased risk of newly onset psychiatric disorders? A population-based, matched cohort study in Taiwan


1 Department of Medical Research, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan; School of Public Health, National Defense Medical Center, Taipei, Taiwan, Republic of China
2 School of Public Health, National Defense Medical Center, Taipei, Taiwan; Taiwanese Injury Prevention and Safety Promotion Association, Taipei, Taiwan, Republic of China
3 School of Public Health, National Defense Medical Center, Taipei, Taiwan, Republic of China
4 Department of Psychiatry, National Defense Medical Center, Tri-Service General Hospital, School of Medicine, Taipei, Taiwan; Student Counseling Center, National Defense Medical Center, Taipei, Taiwan, Republic of China
5 Department of Psychiatry, National Defense Medical Center, Tri-Service General Hospital, School of Medicine, Taipei, Taiwan; Department of Psychiatry, National Defense Medical Center, Tri-Service General Hospital, Songshan Branch, Taipei, Taiwan, Republic of China

Date of Submission07-Sep-2016
Date of Decision29-Mar-2017
Date of Acceptance28-Apr-2017
Date of Web Publication23-Aug-2017

Correspondence Address:
Nian-Sheng Tzeng
Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, No. 325, Section 2, Cheng-Kung Road, Neihu District, Taipei, 11490 Taiwan
Republic of China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmedsci.jmedsci_94_16

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  Abstract 

Background: Morbid obesity is associated with various diseases, and the weight control surgery (WCS) is one of the treatments for morbid obesity. However, the association between the WCS and psychiatric disorders has yet to be elucidated. This study aimed to investigate the association between the WCS and the risk of developing psychiatric disorders. Materials and Methods: A total of 53,052 enrolled participants with 13,263 patients who received WCS and 39,789 controls with matched for sex and age, between January 1 and December 31, 2000, were selected from the National Health Insurance Research Database of Taiwan. After adjusting for confounding factors, Cox proportional hazards analysis was used to compare the risk of developing psychiatric disorders during 10 years of follow-up. Results: Of the study patients, 1170 (8.82%) developed psychiatric disorders when compared to 3490 (8.77%) in the control group. Cox proportional hazards regression analysis revealed that the study patients were more likely to develop psychiatric disorders (hazard ratio [HR]: 2.952, 95% confidence interval [CI] = 2.756–3.163, P < 0.001). After adjusting for gender, age, monthly income, urbanization level, geographic region, and comorbidities, the adjusted HR was 2.901 (95% CI = 2.701–3.115, P < 0.001). Among these psychiatric disorders, depressive disorders, bipolar disorders, and sleep disorders are with significantly increased risk. Conclusions: Patients who received the WCS have a higher risk of developing psychiatric disorders, and the risk was increased in the durations of <1 year and 1–3 years, especially within the duration of 1 year. Regular psychiatric follow-up might be needed for those patients.

Keywords: Weight control surgery, psychiatric disorders, National Health Insurance Research Database, cohort study


How to cite this article:
Chien WC, Chung CH, Lin FH, Chang HA, Kao YC, Tzeng NS. Is weight control surgery associated with increased risk of newly onset psychiatric disorders? A population-based, matched cohort study in Taiwan. J Med Sci 2017;37:137-49

How to cite this URL:
Chien WC, Chung CH, Lin FH, Chang HA, Kao YC, Tzeng NS. Is weight control surgery associated with increased risk of newly onset psychiatric disorders? A population-based, matched cohort study in Taiwan. J Med Sci [serial online] 2017 [cited 2017 Nov 21];37:137-49. Available from: http://www.jmedscindmc.com/text.asp?2017/37/4/137/209986


  Introduction Top


Obesity is a worldwide health problem and might well be associated with significant morbidity, such as diabetes mellitus (DM),[1] hypertension,[2] cardiovascular disease,[3],[4] and increased mortality. For some patients with severe morbid obesity that failed to respond to diet control, medication treatment, or exercise, the weight control surgery (WCS) is a choice to reduce the body weight and consequent obesity-related morbidity or mortality, for example, the WCS could reduce the risk of DM and possibly other metabolic diseases in previous studies.[5],[6]

From a psychiatric aspect, some researches showed psychiatric illness of up to 40%–60% in candidates for the WCS, including depressive disorder, anxiety disorders, substance use disorders, and psychosocial challenges in the perisurgery life adjustments.[7],[8],[9],[10],[11] Studies in regard to the psychosocial effects after the WCS varied. Several studies revealed better psychosocial quality of life and even memory function.[12],[13],[14],[15] Nevertheless, the risk of newly onset psychiatric diagnoses after the WCS was, as yet, to be studied.

The National Health Insurance (NHI) Program was launched in Taiwan in 1995, and as of June 2009, this included contracts with 97% of the medical providers with approximately 23 million beneficiaries or more than 99% of the entire population in Taiwan.[16] The National Health Insurance Research Database (NHIRD) uses the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes to record diagnoses.[17] All diagnoses of psychiatric disorders were made by board-certified psychiatrists. Those diagnoses of morbid obesity that met the criteria are according to the WCS in Taiwan are according to the NHI 1991 consensus, as the following: a body mass index (BMI) (calculated as weight in kilograms divided by the square of height in meters) of 40 kg/m2 or greater (or >35 kg/m2 with obesity-related comorbidities) documented, high probability of failure of nonsurgical weight loss treatments after 6 months, and not related to treatable medical comorbidities or perioperative risks.[18],[19] The Bureau of the NHI randomly reviews the records of 1 in 100 ambulatory care visits and 1 in 20 inpatient claims to verify the accuracy of the diagnoses.[20] Several studies have demonstrated the accuracy and validity of the diagnoses in the NHIRD.[21],[22],[23] Therefore, a nationwide, matched cohort, population-based, is suitable to investigate the association of the WCS and the risk of post-WCS psychiatric disorders.


  Materials and Methods Top


Data sources

In this study, we used data from the NHIRD to investigate the association between patients with morbid obesity who received the WCS and psychiatric disorders over a 10-year period, from the total hospitalization Longitudinal Health Insurance Database in Taiwan (2000–2010).

Study design and sampled participants

This study was a retrospective matched cohort design. Patients who received the WCS were selected from January 1 to December 31, 2000, according to ICD-9-CM codes: including malabsorptive procedures (high gastric bypass: ICD-9-CM OP44.31, “laparoscopic gastroenterostomy:” ICD-9-CM OP44.38, and “other gastroenterostomy without gastrectomy:” ICD-9-CM OP44.39) and restrictive procedures (“laparoscopic sleeve gastrectomy:” ICD-9-CM OP43.82, “open and other partial gastrectomy:” ICD-9-CM OP43.89, “laparoscopic gastroplasty:” ICD-9-CM OP44.68, “other repair of stomach:” ICD-9-CM OP44.69, “laparoscopic gastric restrictive procedure:” ICD-9-CM OP44.95, and “other operations on the stomach:” ICD-9-CM OP44.99). The patients who received the WCS before 2000 were excluded from the study. In addition, the patients diagnosed with psychiatric disorders such as dementia, depressive disorders, bipolar disorders, anxiety disorders, sleep disorders, eating disorders, and psychotic disorders, before 2000 or before the procedures for the WCS, were also excluded from the study. A total of 53,052 patients including the 13,263 subjects who received the WCS, and 39,789 in the age, gender, and index year, matched the control group without a history of receiving the WCS, was enrolled in this study [Figure 1].
Figure 1: The flowchart of study sample selection from the National Health Insurance Research Database in Taiwan

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The covariates included gender, age group (<18, 18–54, ≥55 years), geographical area of residence (North, Center, South, and East of Taiwan), urbanization level of residence (level 1–4), levels of hospitals as medical centers, regional hospitals, and local hospitals, and monthly income (in New Taiwan dollars; <18,000, 18,000–34,999, ≥35,000). The urbanization level of residence was defined according to the population and various indicators of the level of development. Level 1 was defined as a population of >1,250,000 and a specific designation as political, economic, cultural, and metropolitan development. Level 2 was defined as a population between 500,000 and 1,249,999 and as playing an important role in the political system, economy, and culture. Urbanization levels 3 and 4 were defined as a population between 149,999 and 499,999 and <149,999, respectively.[24]

Baseline comorbidities included DM (ICD-9-CM code: 250), hypertension (ICD-9-CM codes: 401.1, 401.9, 402.10, 402.90, 404.10, 404.90, 405.1, and 405.9), hyperlipidemia (ICD-9-CM code: 272.x), coronary artery disease (CAD, ICD-9-CM code: 410-414), and heart failure (HF, ICD-9-CM code: 428).

Outcome measures

All of the study participants were followed from the index date until the onset of dementia (ICD-9-CM codes: 290.0, 290.10, 290.11, 290.12, 290.13, 290.20, 290.21, 290.3, 290.41, 290.42, 290.43, 290.8, 290.9, and 331.0), anxiety disorders (ICD-9-CM codes: 300.X), eating disorders (307.1 anorexia nervosa; 307.51 bulimia nervosa; and 307.59 other disorders of eating), depressive disorders (ICD-9-CM codes: 296.2, 296.3, 300.4, and 311), bipolar disorders (ICD-9-CM codes: 296.0X, 296.4X, 296.5X, 296.6X, 296.7X, and 296.8X), sleep disorders (ICD-9-CM codes: 307.4x and 780.5x), and psychotic disorders (ICD-9-CM codes: 295.xx, 297.xx, and 298.xx), withdrawal from the NHI program, or the end of 2010.

Statistical analysis

All analyses were performed using SPSS software version 22 (SPSS Inc., Chicago, Illinois, USA). Chi-square and t-tests were used to evaluate the distributions of categorical and continuous variables, respectively. Fisher's exact test for categorical variables was used to statistically examine the differences between the two cohorts. Multivariate Cox proportional hazards regression analysis was used to determine the risk of psychiatric disorders, and the results were presented as a hazard ratio (HR) with a 95% confidence interval (CI). The difference in the risk of psychiatric disorders, between the study and control groups, was estimated using the Kaplan–Meier method with the log-rank test. A two-tailed P < 0.05 was considered to indicate statistical significance.

Ethics approvals

This study was conducted in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki). The Institutional Review Board (IRB) of the Tri-Service General Hospital approved this study (IRB No. 2-104-05-126 and IRB No. 1-104-05-145).


  Results Top


[Table 1] shows the gender, age, comorbidities, urbanization and area of residence, and income of the study patients and controls. Compared to the controls, the study patients tended to have higher rates of DM and hyperlipidemia (P < 0.001) in medical centers or regional hospitals and more lived in higher urbanized regions and in the northern areas of Taiwan (P < 0.001).
Table 1: Characteristics of study in the baseline

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[Figure 2] shows the Kaplan–Meier analysis for the cumulative incidence of psychiatric disorders in the study and control groups, and the differences between the two groups were significant (log-rank test <0.001). In addition, at the 1st year of follow-up, the difference between the two groups became significant.
Figure 2: Kaplan–Meier for cumulative risk of psychiatric disorders stratified by weight control surgery injury with log-rank test

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[Table 2] shows that at the end of the follow-up, 1170 out of 13,263 in the study group (8.82%) and 3490 out of 39,789 (8.77%) in the control group developed psychiatric morbidity. Among these psychiatric disorders, depressive disorders and sleep disorders were higher in the patient group than the non-WCS control group (2.71% vs. 1.69%, P < 0.001 and 2.70% vs. 2.36%, P = 0.015, respectively). Conversely, dementia and anxiety disorders were lower than the non-WCS control group (2.01% vs. 2.96%, P < 0.001 and 0.89% vs. 1.16%, P = 0.006, respectively). In the patient group, hyperlipidemia was higher than the non-WCS control group, but DM and hypertension were lower than the control group. The patient group was more likely to be hospitalized during the summer or autumn seasons in medical centers or regional hospitals and lived in higher urbanized regions and in the northern areas of Taiwan (P < 0.001).
Table 2: Characteristics of study in the end of follow-up

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[Table 3] shows the results of Cox regression analysis of the factors associated with the risk of developing psychiatric disorders. The crude HR was 2.952 (95% CI = 2.756–3.163, P < 0.001). After adjusting for age, gender, comorbidities, geographical area of residence, urbanization level of residence, and monthly income, the adjusted HR was 2.901 (95% CI = 2.70–3.115, P < 0.001). For the patients aged >55, the risk of developing psychiatric disorders was 2.086 times more than the patients aged <18. The patients of DM and HF tended to have a lower risk for developing psychiatric disorders. Patients with a residence in higher urbanization regions, who received the WCS in medical centers or regional hospitals and had higher monthly incomes, tended to have a lower risk for developing psychiatric disorders.
Table 3: Factors of psychiatric disorders in the end of follow-up using Cox regression

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In the subgroups stratified by their gender, age, comorbidities, urbanization and region of residence, and monthly income, we found that the male study patients were 2.684 times (P < 0.001), female 3.188 times (P < 0.001), higher than the control group, respectively. For the study patients aged 18–55 and > 55 years, we found that the risk of developing psychiatric disorders was 4.250 times (P < 0.001) and 2.421 times (P < 0.001) than the control group. Despite the comorbidity of DM, hypertension, hyperlipidemia, CAD, or HF, the urbanization or area of residence, or the levels of hospitals of the WCS, the number of patients was higher than the control group in their risk of developing psychiatric disorders [Table 4].
Table 4: Factors of psychiatric disorders in the end of follow-up stratified by variables listed in the table using Cox regression

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In the 13,263 patients who received the WCS, 8155 received malabsorptive procedures, 6721 received restrictive procedures, and 1613 received both malabsorptive and restrictive procedures. No matter whether single or combined WCS the patients received, the overall risk of psychiatric disorders was higher than the non-WCS control group [Table 5].
Table 5: Factors of psychiatric disorders in the end of follow-up stratified by type of bariatric surgery using Cox regression

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[Table 6] shows that the study patients had an increased risk of developing depressive disorders, bipolar disorders, and sleep disorders than the control groups (adjusted HR 4.240, 2.724, and 3.386, P < 0.001, respectively).
Table 6: Factors of subgroups of psychiatric disorders in the end of follow-up using Cox regression

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The study patients were at increased risk of psychiatric disorders within 3 years after enrollment as adjusted HR 2.230 (%95 CI: 1.937–2.568, P < 0.001) in the duration <1 year after enrollment and 1.117 (%95 CI: 1.005–1.312, P = 0.003) in 1–3 years after enrollment. After 3 years, the adjusted HR was 1.105 (%95 CI: 0.951–1.284, P = 0.190). For depressive disorders, bipolar disorders, and sleep disorders, the individual adjusted HRs were significant in the durations of <1 year and 1–3 years [Table 6].


  Discussion Top


In our study, the WCS was associated with an increased risk in newly onset psychiatric disorders. Even after adjusting for comorbidities and other covariates, the overall adjusted HR was 2.901 (95% CI = 2.701–3.115, P < 0.001). In other words, the study patient group had an almost 2.9-fold increased risk of developing psychiatric disorders. The Kaplan–Meier analysis revealed that the study patients had a significantly lower 10-year psychiatric disorder-free survival rate than the controls. In addition, it took 1 year to achieve a significantly adjusted HR, and therefore, 10 years appears to be a reasonable period to follow-up on patients who received the WCS. Among the psychiatric disorders, depressive disorders, bipolar disorders, and sleep disorders were associated with the WCS. Most of the previous studies for the psychiatric morbidity related to patients who had received WCS were to compare the prevalence or incidence of the patients before and after their surgery.[7],[8],[9],[11] This is the first population-based study for newly onset psychiatric disorders after the WCS.

A crucial question is that whether the increased risk of the newly onset psychiatric disorders after the WCS is related to morbid obesity or the WCS. One meta-analysis study found a reciprocal association between obesity and depression.[25] The stigma of overweight or obesity might create negative impacts on the social, psychological, and physical health[26],[27] or even increase the risk of major depressive disorders[28] for those targeted. However, the latter study also found that obesity might show some protective effects on alcohol abuse and drug dependence.[28] On the other hand, several other studies found the higher risk of suicide rates, self-harm emergencies, anxiety, mood, or substance use disorders, after the WCS then before the surgery.[29],[30],[31] In our study, we have excluded the patients and controls with psychiatric disorders before the follow-up period; the patients who received the WCS are associated with higher risk in overall psychiatric disorders than the control group, especially in depressive disorders, bipolar disorders, and sleep disorders. Even though we could not evaluate the body weight loss or the BMI decrease in this claim database study, a 5-year follow-up study found that the patients who received the WCS had weight loss at 5 years being 28.3% + 8.9% kgw, and the decrease of the mean BMI was 37.5 ± 6.1–27.1 + 4.3 kgw/m2.[32] This may suggest that the WCS plays an important role in increasing the risk of developing psychiatric disorders even though these patients might have significant body weight loss after the surgery.

Psychological stressors, somatic concerns, depressive and anxious moods, and even emotional eating might contribute to the increased risk of overall psychiatric disorders, especially mood and sleep disorder after bariatric surgery.[33],[34],[35],[36],[37],[38] In our study, the patients with a residence in higher urbanization regions, who received the WCS in medical centers or regional hospitals and had higher monthly incomes, tended to have a lower risk for developing psychiatric disorders. Socioeconomic disadvantages might be another reason for the increase in newly onset psychiatric disorders in patients who received the WCS.

Some previous studies found that postsurgical eating disorders were associated with less weight loss after surgery, adding to the literature suggesting that disordered eating after surgery is related to suboptimal weight loss.[39],[40] In our study, no postsurgical eating disorders were found. A possible reason is that the presurgery psychiatric screening might have excluded the patients with potential risk of eating disorders.[41]

A regular psychiatric follow-up might be important for the patients who received the WCS, with the finding as an increased risk of overall psychiatric disorders, especially mood and sleep disorders in this group. It should be noted that a preliminary study suggests that adherence to postoperative psychiatric follow-up is associated with greater postoperative weight loss.[42]

The risk of psychiatric disorders after WCS was increased in the durations of <1 year and 1–3 years, especially within the duration of 1 year. This might imply that clinicians should pay attention to mental health in patients who have had received WCS, especially within 3 years, and especially within the duration of 1 year, after the surgery. Furthermore, these findings also hint that the risk of obesity-related psychiatric disorders could decrease with the time passed, after ≥3 years of follow-up. Besides, most trials followed participants for only 1 or 2 years, the long-term effects such as recurrence of obesity after the surgery were unknown,[43] and therefore, a long-term follow-up study, for at least ≥3 years of study period, is needed to clarify the potential association between risk of psychiatric disorders and recurrent obesity after WCS.[25],[26],[27],[28]

Study limitations

There are several limitations to this study. First, insurance claims data have been used in studies for patients who received the WCS; however, data on actual body weights and the BMI of individual patients were not available in the NHIRD. Second, the role of other nonsurgical obesity treatments, which were not covered by the NHI reimbursements, was not able to be clarified in this study. Third, patients with higher socioeconomic levels might well have more access to medical resources and better psychosocial care to prevent them from developing psychiatric disorders.


  Conclusions Top


Patients who received the WCS have a higher risk of developing psychiatric disorders, and the risk was increased in the durations of <1 year and 1–3 years, especially within the duration of 1 year. Regular psychiatric follow-up might be needed for those patients.

Acknowledgments

The authors would like to extend their appreciation to Ms. Hui-Wen Yeh, RN, MSc, for her proofreading and contributions to this paperwork. The authors would also like to thank Chin-Bin Yeh, MD, PhD, San-Yuan Huang, MD, PhD, Ru-Band Lu, MD, Wei-Shan Chiang, MSc, Yu-Ching Chou, PhD, Chang-Huei Tsao, PhD, and Yung-Fu Wu, PhD, for their help and inspiration in this study. We also want to thank Professor Lu Pai, PhD for her professional assistance in confirming the statistical analysis used in this study.

Financial support and sponsorship

This study was funded by the Tri-Service General Hospital Research Foundation (TSGH-C105-003, TSGH-C105-130 and TSGH-C106-002).

Conflicts of interest

There are no conflicts of interest.

 
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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