There is now a significant body of research confirming that bariatric surgery is the treatment of choice for morbid obesity [1–3]. Many positive psychological benefits are associated with bariatric surgery, such as reduction in depression, improvements in body image and enhancement of various markers of quality of life. These improvements are maintained in some studies for over 5 years [4–9]. However, it has also been reported that up to 15–20 % of surgical patients fail to achieve a significant amount of weight loss [3] and psychological factors are often suggested as a possible contributing factor [10].

While few, if any, published studies suggest an increase in rates of psychopathology such as anxiety or depression as a result of bariatric surgery, this may be due to the fact that most patients with severe psychopathology are excluded from bariatric surgery. Most outcome studies include carefully screened populations of patients largely free of major psychological problems [11, 12]. While the number of patients who report negative psychological outcomes from surgery is small, it is important to make continued efforts to try to understand and predict which variables and which patients might experience such an outcome.

Postoperative bariatric patients often encounter report symptoms of depression, anxiety and other forms of emotional distress following surgery. When one considers the dramatic changes in behavior and functioning that bariatric surgery entails, this should not be surprising. Some reasons that individual patients may experience depression, anxiety or other psychological symptoms include: difficulty adjusting to changes around eating, changes in intimate romantic and social relationships and dissatisfaction with body image [13–19]. Previous authors have suggested that these concerns and others be addressed prior to surgery and that the possibility that such challenges may occur after surgery should be reviewed with patients beforehand [20, 21].

Many studies have documented the prevalence of eating disorders among individuals seeking bariatric surgery. The prevalence of binge eating disorder (BED) in obese patients before bariatric surgery has been reported to be as high as 49 % [12]. The percentage of individuals who meet full criteria for a DSM Eating Disorder at the time of surgery may be lower, in part because many bariatric programs delay or deny patient surgery on the basis of the presence of an eating disorder.

The most common form of disordered eating reported among those seeking bariatric surgery is binge eating. BED has been described as the consumption of an objectively large amount of food within a brief period (generally 2 h or less) combined with a subjective report of a loss of control during the overeating episode [22, 23]. Studies vary as to their methodology for establishing the presence of binge eating and BED, with some studies relying upon on clinical interviews, DSM criteria, or various eating disorder questionnaires or combinations of these assessment methods.

Research on the impact of presurgical eating disorders, including binge eating, on postsurgical weight loss is variable. In a recent article, Livhits et al. [24] reviewed 20 studies that reported on the relationship between preoperative binge eating and postoperative weight loss (n = 2661) with 417 patients identified as binge eaters. Three studies reported that patients with preoperative binge eating lost more weight postoperatively than those without binge eating; 13 studies reported no association and 4 studies reported a negative association. Follow-up time and methods for assessing binge eating varied widely which may account for some of the variability in these results.

A growing body of literature suggests that postoperative disordered eating may have a greater negative impact on surgical outcome [12, 25–27]. It is important to note that the full criteria of BED, as defined by the DSM, are difficult to achieve following bariatric surgery since volume restriction precludes the intake of an “exceedingly large amount of food” in less than a 2-h period. Instead, the diagnosis of “binging” behavior after bariatric surgery must focus less on the absolute quantity of food consumed during an episode and more on subjective feelings of distress and loss of control of eating [26, 28, 29].

In a recent review of eating pathology after bariatric surgery, Marino et al. [30] concluded that while the development of classical eating disorders after bariatric surgery is a rare occurrence, sub-syndromal eating disorders are far more common. The authors recommend that an additional nomenclature to classify such behavior needs to be developed and studied further. Kalarchian et al. observed no binge episodes in patients 4 months status post bariatric surgery [31], however, 46 % of patients have reported either objective or subjective binge eating at longer follow-up [26]. Therefore, one must consider that the presence of binge eating may increase with time and distance from the date of surgery and longer-term monitoring and inquiry about such behavior may be warranted.

Other forms of disordered eating that have received investigation following bariatric surgery include grazing and Night Eating Syndrome (NES). Grazing refers to the consumption of smaller amounts of food over extended periods of time [32]. Grazing, like binging, often involves feeling unable to control one’s behavior and as such can be considered to be quite similar to binge eating but over a more extended period of time. Night Eating Syndrome refers to the consumption of 35 % or more of daily calories after the evening meal, often accompanied by frequent nocturnal awakenings during which patients snack as a means of returning to sleep [33]. Postoperative grazing and “uncontrolled eating” in which patients reported a loss of control during the consumption of a large amount of food has been associated with diminished weight loss following bariatric surgery [34]. The research on NES is inconclusive, in part due to the variability in its definition and measurement, and warrants further study [34, 35].

The presence of postoperative eating disorders and their effect on long-term outcome from bariatric surgery highlights the need for ongoing follow-up with these patients to continually assess for the presence of such problems and to provide counseling and interventions when necessary. As in the nonsurgical weight loss population, cognitive behavior therapy (CBT) interventions have been found helpful in modifying eating disorders and disordered eating in the bariatric population.

Depression is common in candidates for bariatric surgery with rates as high as 25–35 % [9, 36, 37]. Bariatric surgery results in significant positive effects on mood and quality of life in the initial years following surgery [9, 12, 15, 38, 39]. Less clear are the longer-term effects of bariatric surgery on mood. Given that the majority of weight lost from surgery occurs during the first 2 years, it makes sense that improvements in mood would occur during this early period. Further, there is evidence that the amount of weight loss is proportional to improvement in mood [40, 41], but it is difficult to determine which factor is the cause and which is the effect.

There are mixed data regarding the impact of a previous history of psychiatric disorders on surgical outcome. Some researchers have found that the presence of mood and anxiety disorders prior to surgery is not a contraindication for surgery, and could in fact be prognostic of a positive outcome [40, 42, 43]. However, other studies suggest it may [44–48] adversely affect outcomes.

As is the case with disordered eating, the reoccurrence of anxiety and depressive disorders following surgery might have a stronger impact on weight loss than presurgery diagnoses [47]. De Zwaan et al. recently studied the course of preoperative and postoperative anxiety and depressive disorders using face-to-face interviews with 107 obese bariatric patients. They found that the point prevalence of depressive disorders decreased significantly after surgery whereas the point prevalence of anxiety disorders did not [48]. Additionally, as with other studies, the presence of a postoperative depressive disorder was associated with lower weight loss at 24–36 months [47]. Postoperative anxiety disorder was not associated with the amount of weight loss at any time. The Swedish Obese Subjects (SOS) study [49] also showed that the depressive subscale scores on the HADS worsened over time after significant initial improvement. There is also the suggestion that the severity of the disorder rather than the type of disorder may be more relevant for outcome following bariatric surgery [12].

It could be suggested that after the bulk of the weight is lost, the novelty of weight loss begins to fade and patients are now faced with life after dramatic weight loss leading to the recurrence of depressive symptoms. Many patients describe this immediate post-op time period as the “honeymoon phase,” where weight loss is rapid and continuous. Once again, this speaks to the urgent need to discuss patient expectations prior to surgery [20] so they are prepared for the eventual slow-down of weight loss and the resumption of life after surgery.

Attention should be paid to recent research suggesting a relationship between bariatric surgery and increased rates of suicide [50–56]. These findings are troubling as the reasons for an excess of suicides among bariatric surgery patients remain unknown. While the absolute suicide rate among bariatric patients is still quite low, it remains higher than in the general population. Factors responsible for this increase may include the emotional burden of severe obesity as well as a history of major depression. An excellent summary of these factors can be found in Wadden’s 2007 review [33]. As suggested by Tindle et al., it may be possible that presurgical psychological distress is exacerbated by suboptimal results of surgery or inadequate improvement in quality of life [56]. Addressing patient expectations and definitions of success from surgery are thus quite important [20, 57]. Tindle’s group further suggests that the influence of body image [58], and recurrence of psychiatric disorders and susceptibility to substance abuse [59] may also be related to these higher suicide rates. While more research in this area is needed, it is clear that the need for identifying higher-risk patients prior to surgery and monitoring their progress, mood and functioning after surgery is important.

Some researchers have suggested a connection between medical and surgical outcomes and a previous history of sexual abuse [60–62]. Kral stated that in his experience, “the most critical ‘psychological/psychiatric’ predictor of negative outcome has been a history of abuse, whether sexual or other.” [63].

Steinig’s extensive review on the impact of sexual abuse on weight loss following bariatric surgery yielded mixed results [64]. In this review, the authors report on 13 studies that examined rates of sexual abuse among bariatric patients and 8 studies that investigated the effects of sexual abuse on surgery outcome. In all studies, patients initially lost weight following surgery. However, three studies demonstrated significantly reduced weight loss among sexually abused patients. The authors note that significant methodological differences among these studies make it difficult to draw conclusions. For example, almost none of the 13 studies provided a detailed definition of sexual abuse. Additionally, the studies varied considerably in their choice of tools to measure sexual abuse. Interestingly, the 3 studies documenting the highest prevalence rates of sexual abuse used the Childhood Trauma Questionnaire (CTQ) [65, 66], which the authors indicate provides a more detailed interrogation of sexual abuse as compared to a standard clinical interview.

It is possible that the more detailed the inquiry regarding sexual abuse, the greater the rate of abuse discovered. Additionally, actual rates of sexual abuse among bariatric patients could be far higher as patients might conceal experiences of sexual abuse during the preoperative psychological evaluation for fear that it may jeopardize their candidacy for surgery. It is known that posttraumatic stress disorder (PTSD) secondary to childhood sexual abuse is common in the morbidly obese population and may be underreported during the preoperative psychological evaluation to evaluators unknown to the patient. In one study of 340 weight loss surgery candidates assessed for childhood maltreatment, 32 % reported sexual abuse [67]. One study noted a sudden onset of PTSD symptoms after major weight loss in patients with a history of sexual abuse [68].

Steinig and colleagues note in their review a tendency for slower weight loss after bariatric surgery in subjects who have been sexually abused. However, there is no evidence that sexually abused patients do worse over the long term. The authors suggest that this speaks against the widely held assumption that sexually abused patients might fight against weight loss (sabotage) as a mechanism of self-protection against further attention although this may vary among individuals.

Based upon these findings, there is little evidence to support the exclusion of individuals with a history of sexual abuse from having bariatric surgery. The authors suggest the advice of Grothe [20] that patients should be questioned for their views on possible positive aspects of being obese to predict and prevent any negative psychological implication of the results of the bariatric procedure. Further research on the complex relationship between sexual abuse and outcome from bariatric surgery is clearly needed.

The literature on postoperative substance abuse largely focuses on the effects of alcohol. This author did not identify any studies demonstrating an increased use of other substances following bariatric surgery. While early articles hypothesized a mechanism of “addiction transfer,” whereby patients replaced the consumption of food with the consumption of alcohol, this concept has been largely dismissed in favor of research demonstrating the changes in the body’s absorption of alcohol particularly in the case of the Roux-en-Y gastric bypass (RYGB) procedure [69].

Specifically, serum ethanol levels reach their peak much sooner and take longer to return to zero than compared to nonsurgical controls [59, 70]. In addition, individuals have reported more rapid onset of the intoxicating effects of ethanol after surgery and that these effects are experienced after consuming fewer drinks [71]. Ethanol is metabolized partially in the stomach by the gastric ADH enzyme, which is reduced during gastrectomy, thus increasing serum ethanol levels [72]. Similar alterations in the ethanol pharmacokinetics are demonstrated with Vertical Sleeve Gastrectomy (VSG) [73]. No studies have been conducted to demonstrate similar changes following laparoscopic adjustable gastric banding (LAGB).

In a study of 51 patients, Suzuki and colleagues found no association between weight loss following surgery and the development of an alcohol use disorder (AUD) or other Axis I diagnoses [74]. However, significantly more current AUDs were reported by individuals with a lifetime history of AUD compared to those without a lifetime AUD, and by individuals undergoing Roux-en-Y gastric bypass (RYGB) compared to those undergoing LAGB. The authors concluded that individuals with a lifetime history of AUD may be at increased risk for relapsing after surgery. While none of the study participants met criteria for an AUD at the time of surgery, about 10 % met criteria for a current AUD 2–5 years after surgery, which is comparable to the prevalence found in the general population. Since the majority (83.3 %) of those meeting criteria for an AUD after surgery had a lifetime history of AUD, these cases represent relapses rather than the novel development of an AUD after surgery.

There is the suggestion of a connection between binge eating disorder (BED) and AUD among individuals seeking bariatric surgery. Some morbidly obese individuals with higher lifetime prevalence of AUD and BED may reduce their consumption of alcohol because eating or binging provides sufficient rewards that were previously provided by alcohol [75]. This is consistent with reports that highly palatable foods produce effects in the brain and brain chemistry that are similar to that produced by substances of abuse [76–78]. These results suggest that patients with a history of AUD should be informed of their potentially greater risk of relapse given the significant changes in alcohol metabolism particularly in the case of RYGB and VSG.

Similarly, in a recent prospective cohort study of 2458 participants across 10 US hospitals, King et al. found that the prevalence of AUD was greater in the second postoperative year than the year prior to surgery or in the first postoperative year. Additionally, it was associated with male sex, younger age and numerous preoperative variables including a history of AUD and choice of RYGB procedure [79]. The authors suggest that since the significant increase in postoperative AUD was observed in those undergoing RYGB primarily during the second postoperative year, an increase in alcohol sensitivity combined with resumption of higher level of alcohol consumption during the second year is likely responsible. The authors did not find a significant association between preoperative mental health, depressive symptoms, binge eating or past-year treatment of psychological or emotional problems and postoperative AUD. However, they did note that worse postoperative mental health and postoperative treatment for psychiatric or emotional problems were significantly associated with AUD. This again suggests the need for close monitoring and provision of mental health services following surgery, especially among those with a history of AUD who undergo RYGB and possibly VSG.

Currently, there is little empiric evidence that bariatric surgery increases the risk of substance use or other addictive behaviors, but additional research is certainly warranted [80]. Many surgical practices either deny or postpone surgery for candidates with active substance abuse at the time of the presurgical psychological evaluation, likely for fear that such behavior impacts judgment or is a predictor of poor impulse control or other factors that will adversely affect compliance and outcome. A significant number of individuals with a past history of substance abuse present for surgery and there is little evidence to suggest that these individuals do worse than other candidates in terms of weight loss. However, these results must be interpreted with caution as most such individuals are eliminated from candidacy from surgery.

What is clear is that patients with a history of substance use or abuse need to be counseled prior to surgery about the potential for relapse after surgery, perhaps especially for those having RYGB or VSG. This psychologist has noted that during the presurgical evaluation, many patients with a history of substance use and abuse believe that their eating behavior changed following their termination from using substances, specifically that eating took the place of the use of their former drug. This phenomenon of increased eating is commonly described by individuals following their termination from cigarette smoking, but is also acknowledged in the case of alcohol and other substances. While biochemical causes of this behavior are being explored, behavioral causes must be considered as well. It has been this author’s experience that many patients reported that twelve-step programs they have attended actually encouraged attendees to substitute sugar and other food-items in favor of alcohol if necessary to maintain their sobriety, thereby training such behavior.

Because of the prevalence of this behavior and many patients’ belief that food has taken the place of previous substances, this issue should be addressed prior to surgery. While it remains uncertain if patients with histories of substance abuse are at greater risk of relapse following bariatric surgery, it is prudent to make patients aware of the possibility that relapse could occur and, if so, to immediately bring it to the attention of the bariatric team and/or other health professionals.

Modern Western culture denigrates excess weight and stigmatizes obese individuals [81]. Among the severely obese, impaired body image is commonly observed [82, 83]. Risk factors for poor body image among the obese include the severity of obesity and female gender [84]. Most studies demonstrate improved body image following weight loss surgery [58, 85–87], however there are some inconsistencies that may be due to combining surgery types within studies as well as with the various methods used to assess body image. Improvements in body image following massive weight loss occur may be due to reductions in depression rather than to the percentage of weight lost [8, 88].

More than half of post-bariatric patients report that excess skin is a negative consequence of surgery [89]. Studies from other cosmetic procedures suggest that body image improves postoperatively [90–93]. Kinzl and colleagues noted that patients who achieved minor weight loss were more content with their appearance than patients who achieved more substantial weight loss [94]. Some authors have found that excess skin could interfere with additional weight loss or actually lead to weight regain [95].

In a study of 252 patients who underwent gastric bypass between 2003 and 2009, Kitzinger and colleagues found that that 90 % of women and 88 % of men felt their appearance was at least satisfactory or better after the massive weight loss [96]. However, 96 % reported loose and hanging skin, 27 % reported recurring itching beneath the excess skin, 70 % reported occasional itching and only 3 % reported no itching. Intertriginous dermatitis was described as recurring in 54 %, intermittent in 41 % and absent in only 4.7 %. A third of patients reported difficulty doing sports as a result of the excess skin, with only 4.2 % reporting no discomfort during physical activity. A majority (65 %) of patients reported some difficulty finding appropriately fitting clothing. As might be expected, women were more critical in their evaluations of individual body parts. Most patients (89 %) were informed about the possibility of needing body-contouring surgery either by their surgeon, other physicians or the Internet. The reported discontent with body image was associated with a desire for body contouring surgery in 75 % of women and 68 % of men in this study. Sarwer and colleagues [97] showed that very overweight women are still not content with their body image even after massive weight loss.

In a study of 62 consecutive patients undergoing sleeve gastrectomy using the body image questionnaire (BIQ-20) to assess body image and the Patient Health Questionnaire (PHQ-9) to assess depression, there was an overall improvement in body image at 1-year follow-up [98]. However, there was no relationship found between body image and postoperative weight. The authors note that there are likely a number of variables that increase obese individuals’ susceptibility to body image problems, many of which have yet to be identified. Some possible risk factors that have been identified include gender and physical appearance [84], traits like perfectionism or self-esteem [99]. The possibility exists that alterations in lower gut hormones after bariatric surgery may modulate body image, but we are far from knowing how. The authors comment that: “the most important improvement in body image seems to be due to the initial bariatric procedure, which may be enhanced by body contouring .” It is important to note that body contouring leads to dissatisfaction with other parts of the body, suggesting that as patients become closer to their ideal, their ideal may shift [100].

In a study of 160 patients who underwent gastric bypass surgery , Steffen and colleagues found that the greater the patients’ BMI at the time completing the postoperative questionnaire, the more likely they were to be dissatisfied with excess skin [101]. Additionally, their findings were consistent with previous findings in noting an inverse relationship between the time elapsed since surgery and the desire for contouring surgery [102], suggesting that patients may come to accept the excess skin over time. Of the 160 patients in this study, 32 had contouring surgery since their weight loss surgery. Most, but not all, reported greater satisfaction after contouring surgery. The authors suggest that this dissatisfaction may be due to perioperative complications or to scarring and other esthetic consequences from contouring surgery. No specific predictors of interest in body contouring surgery could be identified. The authors importantly comment that in the same way that bariatric surgery programs encourage patients to have realistic weight loss expectations, so too should they discuss the likely body image changes patients might experience with massive weight loss and the potential role of contouring surgery to address the excess skin after bariatric surgery.

In their study of 98 patients having body-contouring surgery after gastric bypass surgery as compared to a matched control-group of 102 patients without body contouring, Modaressi and colleagues demonstrated that gastric bypass surgery improves health related quality of life (HRQoL), HRQoL improvement is directly related to weight loss, and that body contouring surgery further improves HRQoL in comparison to gastric bypass surgery alone.

Self-esteem is the most affected aspect of HRQoL, especially in women between 35 and 64 [103]. Despite improvement in self-esteem after bariatric surgery, it still remained low after the weight loss. However self-esteem was further enhanced with body contouring. Interestingly, sexual activity is the only domain where the majority of patients experienced no change after gastric bypass and only minimal improvement after body contouring. The authors suggest the explanation offered by Herpetz [39] that partners have some difficulty adapting to their new image following weight loss. The authors conclude that given the significant additional improvements in HRQoL and satisfaction with their post-body contouring surgery despite major scars, that patients be informed about the potential benefits of undergoing body contouring surgery. They further suggested that body contouring may represent an intervention that improves psychosocial functioning that could serve to further strengthen the weight loss produced by bariatric surgery, an idea previously discussed by Kalarchian and colleagues [104].

Much of the research on psychological outcomes after bariatric surgery focuses on symptoms that are measured by clinical questionnaires or that have established criteria such as DSM psychiatric disorders. For example, investigations of “depression” generally rely upon instruments such as the BDI-II and related self-report measures or the definition of Major Depressive Disorder as defined by the DSM ascertained either by clinical interview or structured interviews such as the SCID. Similarly, the impact of surgery on quality of life is measured by any one of tens of instruments which may or may not comprehensively assess quality of life. However, this psychologist and many others are certainly familiar with numerous psychological struggles that bariatric patients encounter that either do not have formal names or do not reach a level of significance that presently warrants a DSM diagnoses [13, 57, 105]. Consider the following vignettes:

Sogg and Gorman describes an extensive array of the many interpersonal, social, work-related, and other challenges faced by patients following bariatric surgery like those described above [13]. This remains a relatively new area of study and there is little research on this topic [15].

Many patients struggle with increased attention following dramatic weight loss and it may take considerable time for their self-concept to become consistent with their actual appearance [106]. Following surgery , the patient’s body often changes faster than their self-perception. Patients often experience feelings of awkwardness in navigating social situations that would be simple for others, such as accepting compliments. Social skills are learned by experience and many formerly obese people have avoided social situations or engaged in a limited number of situations so that they have never developed such skills. This often leads to social discomfort or social anxiety.