Accepted Manuscript

The Long-Term Effect of Bariatric Surgery on Depression and Anxiety

Hartej Gill , Simratdeep Kang , Yena Lee , Joshua D. Rosenblat ,

Elisa Brietzke , Hannah Zuckerman , Roger S. McIntyre

PII: S0165-0327(18)32146-3
DOI: https://doi.org/10.1016/j.jad.2018.12.113
Reference: JAD 10433

To appear in: Journal of Affective Disorders

Received date: 2 October 2018

Revised date: 13 December 2018
Accepted date: 24 December 2018

Please cite this article as: Hartej Gill , Simratdeep Kang , Yena Lee , Joshua D. Rosenblat ,
Elisa Brietzke , Hannah Zuckerman , Roger S. McIntyre , The Long-Term Effect of
Bariatric Surgery on Depression and Anxiety, Journal of Affective Disorders (2018), doi:
https://doi.org/10.1016/j.jad.2018.12.113

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service
to our customers we are providing this early version of the manuscript. The manuscript will undergo
copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please
note that during the production process errors may be discovered which could affect the content, and
all legal disclaimers that apply to the journal pertain.
 ACCEPTED MANUSCRIPT

Highlights
 Depressive symptoms are lower than baseline beyond 2 years post-surgery.

 The post-surgery course of anxiety symptoms is more variable.

 Pre-surgery anxiety/depressive symptoms do no predict post-surgery BMI.

 Bariatric surgery is associated with long-term psychological improvements.

T
IP
CR
US
AN
M
ED
PT
CE
AC
 ACCEPTED MANUSCRIPT

The Long-Term Effect of Bariatric Surgery on Depression and Anxiety

Hartej Gilla, Simratdeep Kanga, Yena Leea,b,c, Joshua D. Rosenblata,d, Elisa Brietzkea,e, Hannah
Zuckermana, Roger S. McIntyre*,1,a,b,c,d,f

a
Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, Canada
b
Institute of Medical Science, University of Toronto, Toronto, Canada
c
Brain and Cognition Discovery Foundation, Toronto, Canada

T
d
Department of Psychiatry, University of Toronto, Toronto, Canada
e

IP
Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
f
Department of Pharmacology, University of Toronto, Toronto, Canada

CR
Abstract:

US
Background: No previous review has comprehensively assessed long-term changes in anxiety
AN
and depressive symptoms in bariatric surgery patients. This systematic review assessed the

effects of bariatric surgery on long-term reductions (≥24 months) in anxiety and depressive
M

symptom severity in morbidly obese (≥35 BMI kg/m2) participants. Short term effects (<24

months) are briefly reviewed for context.

ED

Methods: PsychINFO, Google Scholar and PubMed databases were systematically searched for
PT

prospective cohort studies published from inception to 14 June 2018 that evaluated long-term

(≥24 months) changes in anxiety and depressive symptom severity in bariatric surgery patients
CE

with a BMI ≥ 35 kg/m2 using a combination of the following search terms: bariatric surgery

(and surgical approaches included under this term), obesity, depression, depressive disorder,
AC

anxiety, anxious, psychiatric disorders, mood disorders.

Results: We reviewed 2058 articles for eligibility; 14 prospective studies were included in the

systematic review. 13 studies (93%) reported significant reductions in depressive symptom

severity 2-3 years after bariatric surgery. However, all studies recorded statistically significant
 ACCEPTED MANUSCRIPT

reductions in depressive symptoms at the conclusion of the study. Similarly, there were

reductions in overall anxiety symptom severity at ≥24 months follow-up (k=8 studies, n=1590

pooled). Pre-operative anxiety or depression scores did not predict outcomes of post-operative

BMI. Similarly, post-surgery weight loss did not predict changes in anxiety symptoms.

Limitations: Very few studies assessed anxiety or depression as a primary outcome. Therefore,

T
we cannot suggest bariatric surgery as a stand-alone therapeutic tool for anxiety and depression

IP
based on our findings.

CR
Conclusion: Currently available evidence suggests that bariatric surgery is associated with long-

term reductions in anxiety and depressive symptoms. This supports existing literature showing

US
that metabolic treatments may be a viable therapeutic intervention for mood disorders.
AN
Key-Words: Bariatric Surgery, Metabolic Syndrome, Obesity, Bipolar Disorder, Major

Depressive Disorder, Generalized Anxiety Disorder

M
ED
PT
CE
AC
 ACCEPTED MANUSCRIPT

1. Introduction

Obesity is a leading cause of morbidity and mortality globally, with significant physical

and psychological repercussions (Alosco et al., 2015). Individuals with obesity have a greater

risk for a number of psychiatric (e.g., depressive disorder) and non-psychiatric medical

conditions (e.g., diabetes mellitus, cardiovascular disease) when compared to non-overweight

T
individuals (McPhee et al., 2015). Clinically significant anxiety and depressive symptoms are

IP
prevalent in populations with obesity and significantly contribute to illness burden. A reciprocal

CR
link has been shown to exist between obesity and depression, wherein obese individuals are at an

elevated risk for depression and likewise, depressed individuals are at an elevated risk for obesity

US
(Luppino et al., 2010). On the other hand, no linear correlation seems to exist between anxiety
AN
and weight, suggesting their relationship is more complex (Haghighi et al., 2015). A moderate

number of studies suggest a positive correlation may exist between anxiety and obesity.
M

However, no study has been able to infer a causal relationship (Gariepy et al., 2010).

Additionally, the presence and severity of anxiety and depressive symptoms confer
ED

cardiovascular risk (Krogh et al., 2015).Thus, both weight and mood symptoms represent

important treatment targets in populations with obesity.

PT

Bariatric surgery (BS) comprises one of the most effective weight reduction
CE

interventions for obesity, particularly among individuals who are unable to lose weight with

exercise and dietary changes (Alosco et al., 2015). The procedure involves either a functional
AC

reduction of stomach size or hindered nutrient absorption (Moore & Kröll, 2017). From 1998 to

2004, the number of BS in the US has increased by 800% (Alosco et al., 2015). In addition to

aiding in weight-loss, BS reduces the risk of various physical comorbidities of obesity including
 ACCEPTED MANUSCRIPT

reductions in risks for diabetes by 92%, cardiovascular disease by 56%, and cancer by 60%

(Adams et al., 2007).

Moreover, mood disorders are common psychiatric comorbidities in candidates for BS.

According to self-reported data on the prevalence of mood disorders, approximately 22.4% to

45% of candidates for BS report the presence of an anxiety or depressive disorder (White et al.,

T
2015). A similar collection of data from BS candidates also illustrated that 20-50% of individuals

IP
that undergo BS in the US are reported to have a history of mood disorders, the most prevalent of

CR
which being depression. Moreover, the prevalence of any mood disorder is greater amongst BS

candidates compared to the general population (Dawes et al., 2016). Namely, depression and

US
anxiety are the most common pre-operative mental health conditions for BS candidates (Dawes
AN
et al., 2016).

Literature has shown significant short-term improvements in mood symptoms following

M

BS. A recent meta-analysis by Dawes and colleagues had investigated changes in mental health

conditions of patients undergoing BS (Dawes et al., 2016). They identified 27 studies that
ED

assessed the association between pre-operative and post-operative mental health conditions in

50,182 BS subjects. Depression was one of the most common pre-operative mental health
PT

conditions in BS participants. Their findings illustrated significant improvements in both the

CE

prevalence and severity of depression after 1 year post-surgery (Dawes et al., 2016).

Notwithstanding the known short-term benefits of BS on mood symptoms in populations

AC

with obesity, it is less clearly understood to what extent BS exerts lasting beneficial effects on

symptoms of anxiety and depression. The primary objective of the present review is to assess

whether BS is associated with a reduction in anxiety and depressive symptoms ≥24 months post-
 ACCEPTED MANUSCRIPT

surgery in morbidly obese patients. This review will additionally evaluate to what extent changes

in anxiety and depressive symptoms are associated with decreases in BMI post-BS.

2. Methods

2.1. Search Methods and Study Selection

We conducted a literature search on PubMed, Google Scholar and PsycINFO for English-

T
language articles published between database inception to June 14th, 2018 using the following

IP
search strings: (bariatric surgery or biliopancreatic diversion or adjustable gastric banding or

CR
sleeve gastrectomy or intragastric balloon or gastric bypass surgery) AND (Depression or Major

Depressive Disorder or Depress* or Anxiety or Anxious or Psychiatric Disorder or Mood

US
Disorder) AND (Obesity or Overweight). The search was limited to human studies written in
AN
English. An additional manual search was conducted in the reference list of identified articles.
M

2.2. Inclusion Criteria

Our inclusion criteria included:

ED

1. A study sample of humans with morbid obesity (i.e., BMI greater than 35 kg/m2)

(Luppino et al., 2010) with no age restrictions.

PT

2. The types of BS procedures included were, biliopancreatic diversion, adjustable gastric

CE

banding, sleeve gastrectomy, intragastric balloon and gastric bypass surgery.

3. Participants with a BMI ≥ 35 kg/m2 that have pre-operative and post-operative

AC

assessments (at ≥24 months) for BMI, anxiety and/or depressive symptoms.

4. Anxiety and depression severity assessments made by a psychiatrist (using a structured

clinical interview) or using standardized and validated scales (i.e the BDI). Assessment
 ACCEPTED MANUSCRIPT

scores were required to be reported both pre- and post-operatively with endpoints (time

of post-operative assessment).

5. Early short-term literature is defined as a follow-up period of < 2 years (Strain et al.,

2014). Consequently, for this study, long-term was defined as longer than 24 months.

Any studies that assessed weight-loss, depression and/or anxiety outcomes shorter than

T
this period were excluded.

IP
2.3. Exclusion Criteria

CR
Our exclusion criteria included:

1. Unpublished data sets, case studies, conference reports, non-refereed abstracts or

observational studies. US
AN
2. Multiple reports from the same data set (only the original investigation was included).
M

2.4. Assessment of Quality

The studies were reported using the Preferred Reporting Items for Systematic Reviews
ED

and Meta-Analyses (PRSIMA) guidelines. The PRISMA checklist helps improve the reliability

of included studies. Quality assessment and bias was assessed using the Newcastle-Ottawa Scale
PT

(NOS) for non-randomized studies (Wells et al., 2018). This scale assessed for quality of
CE

evidence based on selection, comparability and exposure. Stars are awarded based on the NOS

coding manual for case-control and cohort studies (Wells et al., 2018). Selection refers to how
AC

well the included sample represents the given population. Compatibility refers to the use of

cohort-matched controls and whether statistically significant differences exist between the two

groups. Outcome refers to the method of assessment for the variable of interest (Wells et al.,

2018). Greater number of stars awarded indicates higher study quality.

 ACCEPTED MANUSCRIPT

Authors HG and SK independently reviewed all prospective articles. The selected articles

were assessed and data were extracted for sample size, gender distribution, method of

assessment, mean age and mean BMI at the time of operation, diagnosis assessed (depression

and/or anxiety), time of assessment pre- and post-operatively, surgical approach, study design,

outcome of interest, findings (pre- and post-operative anxiety and/or depression severity scores)

T
and control of potential covariates.

IP
3. Results

CR
3.1 Search Results

US
Our database search identified 2058 articles after removal of duplicates (Figure 1). An

additional 24 articles were identified through manual screening of the reference lists. We
AN
screened the titles and abstracts of 2082 articles for eligibility; 2034 articles were excluded after

title and abstract review. The full texts of 48 articles were screened for eligibility.
M

Twenty-four articles were excluded for not reporting post-operative (i.e., ≥24 months)

assessments of BMI, anxiety and/or depression symptom severity. Nine articles were excluded
ED

for not using standardized and validated tools to measure anxiety and/or depression symptom

severity. This included reporting only self-report data without other assessment tools. Three
PT

articles were excluded for duplicate sample data. Twelve articles were excluded for not including
CE

a post-operative follow-up assessment of depression/anxiety following BS.

Fourteen articles were chosen for inclusion. Six of the fourteen articles evaluated changes
AC

in depression symptom severity as the long-term outcome of interest following BS. Eight articles

evaluated both changes in depression and anxiety symptom severity as long-term outcomes.

Twelve studies were classified as being prospective cohorts. Two studies were time-controlled

longitudinal trials.
 ACCEPTED MANUSCRIPT

The patient demographics (table 2), surgical techniques and post-surgical assessment

periods (table 3) and a summary of study outcomes (table 4) are provided in the tables below.

3.2. Quality of Studies

The quality of studies was assessed using the NOS for non-randomized studies. Quality

was assessed for selection, comparability and exposure. Studies were awarded stars for the

T
quality of each category. A maximum of four stars were awarded for selection and exposure. A

IP
maximum of two stars were awarded for comparability. The selection quality was high for the

CR
selected studies. All 14 studies received four stars for selection. Similarly, the quality scores for

outcome were high. All but three studies received three stars for outcome quality. Moreover, the

US
comparability quality was mediocre. Only 4 studies received two stars for comparability
AN
(Karlsson et al., 2007; Jarvholm et al., 2015; Burgmer et al., 2014; Karlsson et al., 1998). The

quality assessment results for each study are provided in Table 3.

M

3.3. Reductions in Depressive Symptoms

The chosen studies evaluated depression by measuring changes in depression severity

ED

from pre-operative baseline through varying time periods post-operatively. Severity of

depression was assessed using standardized scales. Two studies supplemented their scores for
PT

depression with records of antidepressant usage (Mitchell et al., 2014; Booth et al., 2015). The
CE

studies provided reports for antidepressant prescription throughout the study period. No other

study discussed antidepressant usage or supplemented their findings with antidepressant data. A
AC

further breakdown of the method of assessment for depression is provided in table 1.

3.3.1. Reductions in Depressive Symptom severity at 24 months post-surgery

Six studies looked at changes in depression severity up to 24 months post-operatively

(Järvholm et al., 2015; Thoney et al., 2010; Karlsson et al., 1998; Strain et al., 2014; White et al.,
 ACCEPTED MANUSCRIPT

2015; De Zwaan et al., 2011). All six studies concluded that there was a significant decrease in

depression severity at the 24 month follow-up mark. The first study was the only to examine

changes in depression in an adolescent (13-18 years of age) patient population (n=88). They used

a variation in the BDI scale specifically adopted for the adolescent population called the Beck

Youth Inventory (BYI). There was an average decrease of 4.2 in the BYI score after a 2 year

T
follow-up. This was considered statistically significant (P=0.001) (Järvholm et al., 2015). Two

IP
studies (n=193) reported changes in BDI total scores from baseline to 24 months post-surgery.

CR
The mean average pre-operative baseline BDI scores were 11.3 (weighted based on sample size).

There were reductions of 11.3 to 5.5 in the BDI total scores (Thonney et al., 2010; Strain et al.,

US
2014). Two studies (n=530) reported changes in Hospital Anxiety and Depression scale (HADS)
AN
total scores from baseline to 24 months post-surgery. The average pre-operative baseline score

was 5.5 (HADS). There were reductions of 5.5 to 3.0 in the HADS total scores (Thonney et al.,
M

2010; Karlsson et al., 1998).

White et al reported that 45% of the study population (n=167) reported clinically
ED

significant depression scores (BDI score ≥15). Depression scores were significantly reduced at

the 1-year follow-up, with only 13.3% of participants reporting clinically significant scores. This
PT

increased to 17.5% at the 24-month follow-up, although there remained a significant overall
CE

reduction (χ2 (N=166, df=1)=5.8, p=.02) (White et al., 2015).

De Zwaan et al reported significant reductions in the prevalence of clinically significant

AC

depressive symptoms 6-12 months following surgery using a SCID-DSM IV. These results were

sustained at a 24-36 month follow-up (n=84, p≤0.001). Prevalence rates were reduced from

32.7% at baseline to 14.3% at the 24-36 month follow-up (de Zwaan et al., 2011).

3.3.2. Reductions in Depressive Symptom Severity beyond 24 months post-surgery

 ACCEPTED MANUSCRIPT

Eight studies evaluated changes in depression severity at follow-up periods longer than

24 months (Karlsson et al., 2007; Schowalter et al., 2008; Dixon et al., 2003; Burgmer et al.,

2014; Nickel et al., 2007; Mitchel et al., 2014; Booth et al., 2015; Rutledge et al., 2012). Most

studies found that decrease in depression severity from baseline continued to be sustained

beyond 2 years. Three studies (n=2450) reported changes in BDI total scores from baseline to

T
beyond 24 months post-surgery. The average pre-operative baseline BDI scores were 9.0

IP
(weighted based on sample size). There were reductions of 9.0 to 5.5 in the total BDI mean

CR
scores (Schowalter et al., 2008; Dixon et al., 2003; Mitchell et al., 2014). Two studies (n=139)

reported changes in HADS total scores from baseline to beyond 24 months post-surgery. The

US
mean average pre-operative baseline scores were 7.4 (HADS). There were reductions of 7.4 to
AN
5.1 in the HADS total scores (Burgmer et al., 2014; Nickel et al., 2007).

Karlsson et al followed BS patients up to 10 years after surgery (n=655) and showed an

M

overall decrease in the prevalence of depression. Based on HADS assessments, 24% of patients

at baseline had possible or probable morbid depression (n=851). This was reduced to 15% at the
ED

10 year follow-up (effect size of change= 0.35; P<0.05) (Karlsson et al., 2007). Similarly,

Rutledge et al found significant reductions in depression treatment during a 5 year follow-up

PT

(n=55). Treatment for depression was reduced from 56.4% pre-operatively to 34.6% post-surgery
CE

(Rutledge et al., 2012).

However, not all studies found overall reductions in depression. Booth et al found that
AC

36% of surgery participants (n=1097) were diagnosed with depression at time of surgery. This

number only decreased to 32% after a 2-year follow-up (clinical depression odds ratio=0.83;

P<0.001). However, the number of participants diagnosed with clinically significant levels of

depression returned to pre-surgery levels at the 7 year follow-up (37%). These findings were
 ACCEPTED MANUSCRIPT

underscored by data showing the number of surgery patients prescribed antidepressants (n=1065)

surpassed pre-surgery levels at 5 years post-surgery (clinical depression odds ratio=0.82;

P<0.001) (Booth et al., 2015).

3.4. Reductions in Anxiety Symptoms

There were 8 studies which evaluated anxiety for periods ≥24 months (n=1590). A

T
detailed breakdown of the method of assessment for anxiety is provided in Table 1.

IP
3.4.1. Reductions in Anxiety Symptom Severity 24 months post-surgery

CR
Four studies recorded anxiety severity scores from baseline to 24 months post-surgery.

US
(Karlsson et al 1998; Thoney et al 2010; Järvholm et al., 2015; De Zwaan et al 2011). Two
AN
studies (n=511) reported changes in HADS total scores from baseline to 24 months post-surgery.

The mean pre-operative baseline HADS scores were 6.4 (weighted based on sample size). There
M

were reductions of 6.4 to 4.7 in the HADS total scores (Karlsson et al 1998; Thonney et al 2010).

The third study evaluated anxiety using the BYI. They found that baseline anxiety scores
ED

decreased from 14.2 at baseline to 10.5 (n= 88) at the 2 year post-surgery mark (Järvholm et al.,

2015). The fourth study assessed anxiety severity pre- and post-bariatric surgery using a SCID-
PT

DSM IV (n= 107). They found no changes in the prevalence of anxiety from baseline (16.8%) to
CE

two years post-surgery (14.3 %) (De Zwaan et al., 2011).

3.4.2. Changes in Anxiety Symptom Severity beyond 24 months post-surgery

AC

Four studies evaluated anxiety symptom severity at follow-up periods longer than 24

months post-surgery (Nickel et al., 2007; Burgmer et al., 2014; Karlsson et al., 2007; Rutledge et

al., 2012). Two studies (n=122) reported changes in HADS total scores from baseline to beyond
 ACCEPTED MANUSCRIPT

24 months post-surgery. The mean average pre-operative baseline scores were 7.4 (HADS).

There were reductions of 7.4 to 6.2 in the HADS total scores (Nickel et al., 2007; Burgmer et al.,

2014).

Karlsson et al (2007) measured anxiety prevalence and revealed an overall reduction in

anxiety prevalence rates at the end of a 10 year follow-up. 34% of the surgical group had a

T
probable anxiety disorder according to HADS assessments at baseline (n=851). At the 10 year

IP
follow-up, 24% were classified as having clinically significant anxiety (n=655; effect size of

CR
change= 0.33; P= NS) (Karlsson et al 2007). Rutledge et al evaluated anxiety by examining

changes in rates of anxiety therapy amongst patients (n=55). Therapeutic tools that were

US
evaluated included anxiolytics and psychotherapies targeting anxiety. This study found the
AN
percentage of patients prescribed anxiolytics and anxiety therapy increased from 23.6% at

baseline to 32.7% at the 5 year follow-up assessment period (n=55) (Rutledge et al., 2012).
M

3.5. Association between BMI changes and Anxiety & Depression Symptom Severity

As a secondary objective this review sought to assess any association between changes in
ED

post-operative BMI with anxiety and depressive symptoms. Six articles reported on associations

between weight change and anxiety and depressive symptoms. Three of the studies found a
PT

negative correlation between changes in BMI and depressive scores, but no correlation was
CE

observed with BMI changes and anxiety (De Zwaan et al., 2011; Burgmer et al 2014 and

Mitchell et al., 2014). The first study found that the presence of a depressive disorder was
AC

significantly associated with a lower degree of weight loss at 24-36 months, but not at 6-12

months (n=107). The presence of an anxiety disorder was not associated with the degree of

weight loss within the same follow-up assessment period (De Zwaan et al., 2011). The second

study found that significant weight loss at year 1 (n=148) and year 2 (n=118) was correlated with
 ACCEPTED MANUSCRIPT

decreased depression scores (HADS). This study found that there was a significant increase in

mean BMI between year 3 (n=102) and 4 (n=101), which correlated with an increase in

depression scores during this same period of assessment (Burgmer et al., 2014). No correlation

was observed between weight loss and anxiety scores (Burgmer et al 2014). Moreover, the third

study found the change in BDI to be significantly associated with changes in BMI (n=2146),

T
although the correlation was weak (r=0.15; p<0.001). However, when analysis was limited to

IP
those with depressive symptoms (BDI ≥ 10) at baseline, the correlation was moderate (Mitchell

CR
et al., 2014).

Two of the six studies found no association between changes in BMI and depression.

US
White et al demonstrated that clinically significant depressive symptoms at baseline (n=167)
AN
were not related to changes in BMI at any of the post-surgery follow-up periods (White et al.,

2015). Similarly, Dixon et al found no relationship between pre-operative BDI scores (n=487)
M

and percentage of excess weight loss at 1 and 2 years post-surgery (n=262) (Dixon et al., 2003).

In addition, the percentage of excess weight loss was not different from the patients prescribed
ED

antidepressants compared to those that were not (Dixon et al., 2003).

One study did find a relationship between anxiety and weight loss. Karlsson et al
PT

illustrated that reduction in anxiety symptoms were significantly correlated with weight loss up
CE

to 4 years post-surgery. However, prevalence of depressive symptoms increased from 20% to

23% at the 6 to 10 year follow-up periods. At the conclusion of the study, there was an overall
AC

effect change of 0.33 (P=NS) (Karlsson et al., 2007).

4. Discussion

Studies identified in our review found statistically significant reductions in anxiety and

depressive symptoms following the first 24 months after surgery. The largest reductions were
 ACCEPTED MANUSCRIPT

seen in depressive symptoms within the first two years following surgery. Depressive symptoms

did begin to rise after the first two years, however, most studies maintained statistically

significant reductions compared to baseline. Moreover, no correlation was observed between

pre-operative BMI and post-operative anxiety and depression outcomes. A few studies illustrated

a negative correlation between changes in BMI and anxiety and depressive outcomes. However,

T
these results are inconsistent across studies.

IP
Our findings are consistent with previous literature on short-term outcomes. For example,

CR
in a meta-analysis of 58 studies, BS patients observed strong reductions in depressive symptoms

post-operatively. This included reduction in both frequency and severity of depressive conditions

US
(Dawes et al., 2016). All studies saw depression scores increase after the 2-3 year mark post-
AN
operatively. We were unable to find the cause for this increase in depressive symptom severity.

This is of importance because the return of medical comorbidities may result in worsened
M

depressive symptoms and suicide risk post-operatively (Mitchell et al., 2013). While depression

severity did increase after 24 months post-surgery, most studies that evaluated depression
ED

severity were able to find overall reductions in long-term symptoms. Only one study found

depression severity return to pre-surgery levels (Booth et al., 2015). Therefore, BS was able to
PT

provide overall reductions in anxiety and depressive symptoms up to 10 years post-operatively.

CE

We found small reductions in total post-operative anxiety scores compared to baseline.

This finding is in line with existing literature that have reported short-term reductions in anxiety
AC

symptoms following surgery. For example, Tae et al. (2014) had shown anxiety symptoms were

reduced from 87% to 56.5% a year following BS (Tae et al., 2014). However, not all studies

reported improvements in anxiety symptoms. One study found increased levels of treatment for

post-operative anxiety (Rutledge et al., 2012). The authors did not offer an explanation for this
 ACCEPTED MANUSCRIPT

finding. This is similar to findings by Burgmer et al. (2007) that demonstrated significant

improvements in depressive symptoms with non-significant changes in anxiety symptoms

(Burgmer et al., 2007). However, the majority of studies included in this review found overall

reductions in anxiety symptom severity. The number of studies reporting anxiety outcomes were

far fewer than the studies reporting depressive outcomes. While depression and anxiety often co-

T
occur in clinical settings, it remains unclear whether treatment improving one disorder can

IP
improve both when they’re occurring co-morbidly (Hirschfield, 2001). Further trials are required

CR
to assess anxiety symptoms when they’re occurring individually, as well as co-morbidly with

depression. Anxiety outcomes in BS patients are less clearly understood due to the lack of

US
studies reporting on anxiety separate from depression.
AN
Although a few studies were able to show an association between reduced BMI and

improved depression outcomes (De Zwaan et al., 2011, Burgmer et al 2014, and Mitchell et al.,
M

2014), this relationship was not further explored in any of these studies. However, a few previous

studies have proposed possible mediating mechanisms between depression and obesity. A
ED

previous review by Luppino et al. (2010) suggested that HPA-axis dysfunction is prevalent in

depression and it may serve as a potential mediating variable in depression and obesity (Luppino
PT

et al., 2010). Additionally, obesity involves a pro-inflammatory state and adipocytes are involved
CE

in the production of inflammatory mediators. A decrease in adipocytes is able to reverse

inflammation (Santos et al., 2013). Literature shows that elevated levels of pro-inflammatory
AC

cytokines are documented in a number of subtypes of depression, most notably treatment-

resistant depression (Strawbridge et al., 2015). In particular, elevated levels of C-reactive

protein, tumour necrosis factor-α and interleukin-6 are more prevalent in depressed subjects

compared to healthy controls (Strawbridge et al., 2015). Consequently, increased activation of

 ACCEPTED MANUSCRIPT

inflammatory pathways may mediate the link between obesity and psychiatric disorders,

including obesity and depression (Luppino et al., 2010). Thus, weight loss as a result of BS may

lower the levels of pro-inflammatory cytokines, which can be responsible for the improvement in

depressive symptoms. However, further research is needed to investigate this relationship.

Pre-operative anxiety or depressive symptom prevalence was not a predictor of post-

T
operative BMI outcomes. This finding is in line with other systematic reviews and studies that

IP
have assessed changes in post-operative weight-loss and psychiatric disorders. Studies have

CR
suggested that it is not actual weight, but rather perceived weight that mediates the link between

anxiety, depression and obesity. Risk of depression has been shown to increase with perceived

US
weight (Roberts & Duong, 2009; De Zwaan et al., 2011). This is possibly due to changes in self-
AN
esteem. Patients with high self-esteem experience greater weight loss and better psychiatric

outcomes (Van Hout, Verschure & Van Heck, 2005). In contrast, low self-esteem is prevalent in
M

subjects with cognitive decline and anhedonia (Archer et al., 2015). However, no study evaluated

perceived weight or self-esteem of subjects. Future studies should investigate how these
ED

variables interact to influence anxiety and depressive symptom outcomes.

Pre-operative weight is a good predictor of post-operative weight-loss, however, it does

PT

not predict improvements in measures of psychological well-being (Van Hout, Verschure & Van
CE

Heck, 2005). Although heavier obese patients experience the highest absolute weight-loss, they

are more likely to remain obese and experience greater co-morbidities (Van Hout, Verschure &
AC

Van Heck, 2005). In addition, a few studies were able to show changes in post-operative BMI

predicted alterations in depressive symptoms (De Zwaan et al., 2011, Burgmer et al 2014, and

Mitchell et al., 2014). However, no study was able to illustrate that post-surgery BMI predicted

anxiety outcomes post-operatively.

 ACCEPTED MANUSCRIPT

5. Limitations and Future Directions

There are several limitations to our study. Firstly, the study samples were not controlled

and contained variation between studies. This resulted in the inclusion of studies that contained

entirely women or a specific demographic (e.g., veterans). Subsequently, it resulted in the over-

representation of certain sample populations. This also led to significant variations in the sample

T
size. Some studies had a sample size of 1097, while others had a sample size of 21. This large

IP
disparity results in unequal impact of findings. Secondly, our study included various methods of

CR
assessment for anxiety and depression. For example, studies that used SCID-DSM IV varied in

their methods and criteria for the interview. Moreover, the separate scales used for diagnosis had

US
differing criteria for the diagnosis of anxiety and depressive symptoms. For example, Schowalter
AN
et al. categorized clinically significant depressive symptoms as a BDI score of ≥ 18. Meanwhile,

White et al. defined clinically significant depressive symptoms as a BDI score ≥ 15 (Schowalter
M

et al., 2008; White et al., 2015). Therefore, how the mood disorders were assessed and diagnosed

varied based on the methods of the study, leading to possible inconsistencies between
ED

assessments. This limited our ability to calculate the magnitude of the effect size, as well as the

ways that we can synthesize the reported findings. Third, our review did not stratify results by
PT

including socioeconomic status, age, gender and neighbourhood, which are shown to influence
CE

post-operative outcomes (Sarris et al., 2014). Moreover, the study participants were not assessed

for bipolar disorder. Literature has shown that bipolar disorder is high among individuals
AC

undergoing obesity surgery (Grothe et al., 2014). Thus, assessment for bipolar disorder among

this population is an important consideration when evaluating psychiatric improvements in BS

patients. Also, our review only included English-language studies and the ethnicity of subjects

was not reported in all but one study (White et al., 2015). This may have excluded prospective
 ACCEPTED MANUSCRIPT

studies published in different languages and regions, thus limiting the cross-cultural validity of

our study. Additionally, anxiety and depressive symptoms were not the primary outcome in

majority of included studies. In order to accurately assess the therapeutic efficacy of BS for

anxiety and depressive symptoms, more studies need to be included that assess anxiety and

depression as primary outcomes. Furthermore, only two studies reported antidepressants or

T
anxiolytics data (Mitchell et al., 2014; Booth et al., 2015). It is possible patients were going off

IP
and on medication between follow-up periods. In a study looking at antidepressant usage

CR
following BS, Cunningham et al. (2012) reported 63% of patients had their antidepressant

dosage remain the same or increase (Cunningham et al., 2012). Similarly, Booth et al. (2014)

US
reported increased antidepressant usage after the first year (Booth et al., 2014). There may be
AN
possible variation in antidepressant usage following surgery. Future studies should monitor

changes these changes. Moreover, the issue of clinical versus statistical significance is an
M

important topic to consider. The current studies only evaluated statistical significance. Whether

BS can be a clinically relevant option for anxiety and depression was not investigated in all the
ED

included studies. It may be possible to evaluate clinical relevance using effect size, minimal

important difference and clinical judgment (Armijo-Olivo et al., 2011). Karlsson et al. (2007)
PT

was the only study to report measures of effect size in their results (Karlsson et al., 2007). The
CE

failure to do so limits the clinical relevance of the findings. Therefore, while BS shows potential

as a therapeutic tool capable of improving anxiety and depressive symptoms, further

AC

investigation is required to assess the clinical significance of these results and the likelihood for

BS to serve as a stand-alone treatment for anxiety and depression.

Predicting post-operative outcomes is complex and of primary concern for future work. A

number of factors predict post-operative success and there is a large amount of individual
 ACCEPTED MANUSCRIPT

variability when assessing post-operative weight-loss, including gender, age and mood disorders.

Weight loss following BS is more challenging because some factors that contribute to the ability

to lose weight are not changeable. This includes age, gender and SES (Galioto et al., 2013).

There is significant variability in weight-loss following BS. Melton et al. (2008) reported as

many as 30% of individuals failed to achieve weight loss following BS (Melton et al., 2008). The

T
individuals that are able to achieve initial weight loss are not many times able to maintain it long

IP
term (Galioto et al., 2013). Restraint and inhibition are the most common traits associated with

CR
poor weight loss success. As such, adhering to clinician recommendations following surgery

improves post-operative weight loss. Psychiatric disorders including depression are the most

US
common factors associated with non-adherence (Galioto et al., 2013). Subsequently, patients
AN
with psychological disorders have difficulties sticking to post-operative guidelines to prevent

weight regain. Moreover, they also experience greater dissatisfaction with the results of surgery
M

(Van Hout, Verschure & Van Heck, 2005). It is shown that poor psychological outcomes

correlate with higher attrition rates (Galioto et al., 2013). Meanwhile, patients with high self-
ED

esteem experience greater weight loss (Van Hout, Verschure & Van Heck, 2005). By accounting

for such psychosocial factors and covariates, it may be possible to develop and implement a
PT

standardized method of evaluating mood disorders in obese patients. Consequently, this may
CE

allow future studies to accurately predict post-operative outcomes and provide tailored

therapeutic interventions for BS candidates.

AC

If BS is able to provide long-term mental health benefits, it will change how we assess

obese patients pre- and post-operatively. Currently, it is mandated by the American Society for

Metabolic and BS to offer routine mental health evaluations (Dawe et al., 2006). However,

existing screening processes use a variety of procedures and scales. Most scales, such as the BDI,
 ACCEPTED MANUSCRIPT

focus only on mental health outcomes and do not take into account psychosocial factors.

Literature has shown that a BS outcomes are influenced by a number of factors, including but not

limited to, cognitive function, self-esteem and socioeconomic status (Dawes et al., 2016).

Consequently, future pre- and post-operative monitoring should assess how mental health

outcomes and psychosocial factors influence surgery outcomes.

T
Conflict of Interest

IP
All authors declare that there is no conflict of interest.

CR
6. Conclusion
US
Candidates for BS have a high prevalence of mood disorders, namely depression and
AN
anxiety. It is important to address and account for these disorders as they are important domains

for the quality of life of a patient. Current literature has shown improved long-term depression
M

outcomes among BS patients. Similarly, studies have shown long-term improvements in anxiety
ED

severity, although it is a smaller scale reduction. Moreover, there was no relationship found

between pre-operative BMI scores and post-operative anxiety and depressive symptoms.
PT

Similarly, no relationship was found between post-operative weight-loss and changes in anxiety

severity. A few studies were able to illustrate that a negative correlation exists between post-
CE

surgery BMI and depressive outcomes. However, more work is required to investigate the
AC

mechanistic and causal relationship between obesity and mood disorders, namely anxiety and

depression. Additionally, more studies are needed to evaluate anxiety and depressive symptoms

as the primary outcome before BS can be recommended as a therapeutic tool capable of

independently improving anxiety and depressive symptoms.

7. Disclosure
 ACCEPTED MANUSCRIPT

Authors HG and SK developed the research hypothesis, study design, conducted the

search, data extraction, and wrote the first draft of the manuscript. HG, SK and YL contributed to

data interpretation and writing of the final manuscript. All authors contributed to the final

manuscript proofreading, edits and feedback. This research did not receive any specific grant

T
from funding agencies in the public, commercial, or not-for-profit sectors.

IP
CR
US
AN
M
ED
PT
CE
AC
 ACCEPTED MANUSCRIPT

References

Aarts, F., Hinnen, C., Gerdes, V., Acherman, Y., & Brandjes, D. (2014). Psychologists’

Evaluation of Bariatric Surgery Candidates Influenced by Patients’ Attachment

T
Representations and Symptoms of Depression and Anxiety. Journal Of Clinical Psychology

IP
In Medical Settings, 21(1), 116-123. doi: 10.1007/s10880-014-9385-4

CR
Adams, T. D., Gress, R. E., Smith, S. C., Halverson, R. C., Simper, S. C., Rosamond, W.

US
D.,Hunt, S. C. (2007). Long-Term Mortality after Gastric Bypass Surgery. New England

Journal of Medicine,357(8), 753-761. doi:10.1056/nejmoa066603

AN
Alosco, M., Spitznagel, M., Strain, G., Devlin, M., Cohen, R., & Crosby, R. et al. (2015). Pre-

operative history of depression and cognitive changes in bariatric surgery patients.

M

Psychology, Health & Medicine, 20(7), 802-813. doi: 10.1080/13548506.2014.959531

ED

Archer, T., Josefsson, T., & Lindwall, M. (2015). Effects of Physical Exercise on Depressive

Symptoms and Biomarkers in Depression. CNS & Neurological Disorders - Drug

PT

Targets,13(10), 1640-1653. doi:10.2174/1871527313666141130203245

CE

Armijo-Olivo, S., Warren, S., Fuentes, J., & Magee, D. J. (2011). Clinical relevance vs.

statistical significance: Using neck outcomes in patients with temporomandibular disorders

AC

as an example. Manual Therapy,16(6), 563-572. doi:10.1016/j.math.2011.05.006

*Booth, H., Khan, O., Prevost, A., Reddy, M., Charlton, J., & Gulliford, M. (2015). Impact of

bariatric surgery on clinical depression. Interrupted time series study with matched controls.

Journal Of Affective Disorders, 174, 644-649. doi: 10.1016/j.jad.2014.12.050

 ACCEPTED MANUSCRIPT

*Burgmer, R., Legenbauer, T., Müller, A., Zwaan, M. D., Fischer, C., & Herpertz, S. (2014).

Psychological Outcome Four Years after Restrictive Bariatric Surgery. Obesity

Surgery,24(10), 1670-1678. doi:10.1007/s11695-014-1226

*Dawes, A. J., Maggard-Gibbons, M., Maher, A. R., Booth, M. J., Miake-Lye, I., Beroes, J. M.,

T
& Shekelle, P. G. (2016). Mental Health Conditions Among Patients Seeking and

IP
Undergoing Bariatric Surgery. Jama,315(2), 150. doi:10.1001/jama.2015.18118

CR
*De Zwaan, M., Enderle, J., Wagner, S., Mühlhans, B., Ditzen, B., & Gefeller, O. et al. (2011).

Anxiety and depression in bariatric surgery patients: A prospective, follow-up study using

US
structured clinical interviews. Journal Of Affective Disorders, 133(1-2), 61-68. doi:

10.1016/j.jad.2011.03.025
AN

*Dixon, J. B., Dixon, M. E., & Obrien, P. E. (2003). Depression in Association With Severe
M

Obesity. Archives of Internal Medicine,163(17), 2058. doi:10.1001/archinte.163.17.2058

Galioto, R., Gunstad, J., Heinberg, L. J., & Spitznagel, M. B. (2013). Adherence and Weight
ED

Loss Outcomes in Bariatric Surgery: Does Cognitive Function Play a Role? Obesity
PT

Surgery,23(10), 1703-1710. doi:10.1007/s11695-013-1060-6

Gariepy, G., Nitka, D., & Schmitz, N. (2009). The association between obesity and anxiety
CE

disorders in the population: A systematic review and meta-analysis. International Journal of

AC

Obesity,34(3), 407-419. doi:10.1038/ijo.2009.252

Grothe, K. B., Mundi, M. S., Himes, S. M., Sarr, M. G., Clark, M. M., Geske, J. R., . . . Frye, M.

A. (2014). Bipolar Disorder Symptoms in Patients Seeking Bariatric Surgery. Obesity

Surgery,24(11), 1909-1914. doi:10.1007/s11695-014-1262-6

 ACCEPTED MANUSCRIPT

Haghighi, M., Jahangard, L., Ahmadpanah, M., Bajoghli, H., Holsboer-Trachsler, E., & Brand,

S. (2016). The relation between anxiety and BMI – is it all in our curves? Psychiatry

Research,235, 49-54. doi:10.1016/j.psychres.2015.12.002

Hirschfield, R. M. (2001). The Comorbidity of Major Depression and Anxiety Disorders. The

T
Primary Care Companion to The Journal of Clinical Psychiatry,03(06), 244-254.

IP
doi:10.4088/pcc.v03n0609

CR
Hout, G. V., Boekestein, P., Fortuin, F., Pelle, A., & Heck, G. V. (2006). Psychosocial

Functioning following Bariatric Surgery. Obesity Surgery,16(6), 787-794.

doi:10.1381/096089206777346808
US
AN
*Järvholm, K., Karlsson, J., Olbers, T., Peltonen, M., Marcus, C., Dahlgren, J., Flodmark, C.

(2015). Two-year trends in psychological outcomes after gastric bypass in adolescents with
M

severe obesity. Obesity,23(10), 1966-1972. doi:10.1002/oby.21188

*Karlsson, J., Sjöström, L., & Sullivan, M. (1998). Swedish obese subjects (SOS) – an
ED

intervention study of obesity. Two-year follow-up of health-related quality of life (HRQL)

PT

and eating behavior after gastric surgery for severe obesity. International Journal of

Obesity,22(2), 113-126. doi:10.1038/sj.ijo.0800553

CE

*Karlsson, J., Taft, C., Rydén, A., Sjöström, L., & Sullivan, M. (2007). Ten-year trends in
AC

health-related quality of life after surgical and conventional treatment for severe obesity:

The SOS intervention study. International Journal of Obesity,31(8), 1248-1261.

doi:10.1038/sj.ijo.0803573
 ACCEPTED MANUSCRIPT

Krogh, J., Speyer, H., Gluud, C., & Nordentoft, M. (2015). Exercise for patients with major

depression: A protocol for a systematic review with meta-analysis and trial sequential

analysis. Systematic Reviews,4(1). doi:10.1186/s13643-015-0030-6

Luppino, F., de Wit, L., Bouvy, P., Stijnen, T., Cuijpers, P., Penninx, B., & Zitman, F. (2010).

T
Overweight, Obesity, and Depression. Archives Of General Psychiatry, 67(3), 220. doi:

IP
10.1001/archgenpsychiatry.2010.2

CR
Mcphee, J., Freidl, E. K., Eicher, J., Zitsman, J. L., Devlin, M. J., Hildebrandt, T., & Sysko, R.

(2015). Suicidal Ideation and Behaviours Among Adolescents Receiving Bariatric Surgery:

US
A Case-Control Study. European Eating Disorders Review,23(6), 517-523.

doi:10.1002/erv.2406
AN

Melton, G. B., Steele, K. E., Schweitzer, M. A., Lidor, A. O., & Magnuson, T. H. (2008).
M

Suboptimal Weight Loss after Gastric Bypass Surgery: Correlation of Demographics,

Comorbidities, and Insurance Status with Outcomes. Journal of Gastrointestinal

ED

Surgery,12(2), 250-255. doi:10.1007/s11605-007-0427-1

PT

Mitchell, J. E., Crosby, R., Zwaan, M. D., Engel, S., Roerig, J., Steffen, K.,Wonderlich, S.

(2013). Possible risk factors for increased suicide following bariatric surgery. Obesity,21(4),
CE

665-672. doi:10.1002/oby.20066
AC

*Mitchell, J. E., King, W. C., Chen, J., Devlin, M. J., Flum, D., Garcia, L., Yanovski, S. (2014).

Course of depressive symptoms and treatment in the longitudinal assessment of bariatric

surgery (LABS-2) study. Obesity,22(8), 1799-1806. doi:10.1002/oby.20738

 ACCEPTED MANUSCRIPT

Moore, K. T., & Kröll, D. (2017). Influences of Obesity and Bariatric Surgery on the Clinical

and Pharmacologic Profile of Rivaroxaban. The American Journal of Medicine,130(9),

1024-1032. doi:10.1016/j.amjmed.2017.05.011

*Nickel, M. K., Loew, T. H., & Bachler, E. (2007). Change in Mental Symptoms in Extreme

T
Obesity Patients after Gastric Banding, Part II: Six-Year Follow up. The International

IP
Journal of Psychiatry in Medicine,37(1), 69-79. doi:10.2190/x40r-712p-8j44-0l3h

CR
Roberts, R., & Duong, H. (2015). Does major depression affect risk for adolescent obesity?.

Journal Of Affective Disorders, 186, 162-167. doi: 10.1016/j.jad.2015.06.030

US
*Rutledge, T., Braden, A. L., Woods, G., Herbst, K. L., Groesz, L. M., & Savu, M. (2012). Five-
AN
Year Changes in Psychiatric Treatment Status and Weight-Related Comorbidities Following

Bariatric Surgery in a Veteran Population. Obesity Surgery,22(11), 1734-1741.

M

doi:10.1007/s11695-012-0722-0

Santos, J., Salgado, P., Santos, C., Mendes, P., Saavedra, J., Baldaque, P., Costa, E. (2013).
ED

Effect of bariatric surgery on weight loss, inflammation, iron metabolism, and lipid profile.
PT

Scandinavian Journal of Surgery,103(1), 21-25. doi:10.1177/1457496913490467

Sarris, J., O’Neil, A., Coulson, C. E., Schweitzer, I., & Berk, M. (2014). Lifestyle medicine for
CE

depression. BMC Psychiatry,14(1). doi:10.1186/1471-244x-14-107

AC

*Schowalter, M., Benecke, A., Lager, C., Heimbucher, J., Bueter, M., Thalheimer, A., Faller, H.

(2008). Changes in Depression Following Gastric Banding: A 5- to 7-year Prospective

Study. Obesity Surgery,18(3), 314-320. doi:10.1007/s11695-007-9316-7

 ACCEPTED MANUSCRIPT

*Strain, G. W., Kolotkin, R. L., Dakin, G. F., Gagner, M., Inabnet, W. B., Christos, P., Pomp, A.

(2014). The effects of weight loss after bariatric surgery on health-related quality of life and

depression. Nutrition & Diabetes,4(9). doi:10.1038/nutd.2014.29

Strawbridge, R., Arnone, D., Danese, A., Papadopoulos, A., Vives, A. H., & Cleare, A. (2015).

Inflammation and clinical response to treatment in depression: A meta-analysis. European

T
Neuropsychopharmacology,25(10), 1532-1543. doi:10.1016/j.euroneuro.2015.06.007

IP
Tae, B., Pelaggi, E. R., Moreira, J. G., Waisberg, J., Matos, L. L., & Delia, G. (2014). Impact of

CR
bariatric surgery on depression and anxiety symptons, bulimic behaviors and quality of life.

Revista Do Colégio Brasileiro De Cirurgiões,41(3), 155-160. doi:10.1590/s0100-

69912014000300004 US
AN
*Thonney, B., Pataky, Z., Badel, S., Bobbioni-Harsch, E., & Golay, A. (2010). The relationship

between weight loss and psychosocial functioning among bariatric surgery patients. The
M

American Journal of Surgery,199(2), 183-188. doi:10.1016/j.amjsurg.2008.12.028

ED

Wells GASB, O'Connell D, Peterson J, Welch V, Losos M, Tugwell P. [Accessed July 13,

2018];Newcastle-Ottawa Quality Assessment Scale Cohort Studies. Available from

PT

http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp
CE

*White, M. A., Kalarchian, M. A., Levine, M. D., Masheb, R. M., Marcus, M. D., & Grilo, C.

M. (2015). Prognostic Significance of Depressive Symptoms on Weight Loss and

AC

Psychosocial Outcomes Following Gastric Bypass Surgery: A Prospective 24-Month

Follow-Up Study. Obesity Surgery,25(10), 1909-1916. doi:10.1007/s11695-015-1631-9

 ACCEPTED MANUSCRIPT

Appendix

T
IP
CR
US
AN
M
ED

Fig 1. Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) study
PT

selection flow diagram.

CE
AC
 ACCEPTED MANUSCRIPT

Source Sample Gender Method Of Mean Mean BMI Control of Confounding

Size (No. %) Assessment Age (baseline) Variables

de Zwaan et al., 2011 107 M=30; Structured Clinical 37.5 49 Weight and height (linear regression
F=70 Interview (DSM IV analysis)
criteria)

Booth et al., 2015 1097 M=21; Diagnosis through 45.9 44 Gender, age and type of BS
F= 79 Medical Record review (Matched Controls)

T
Strain et al., 2014 150 M=27.6; BDI 43.5 50.7 EWL and HRQoL adjusted for

IP
F=72.4 covariance (ANCOVA)

CR
White et al., 2015 167 M=14; BDI 43.7 51.2 Height, weight, eating disorder
F=86 psychopathology (binary regression
analysis)

Rutledge et al., 2012 55 M=69.1;

F= 30.9
US
Medical Record Review
and Structured Clinical
Interview (DSM IV)
52.5 44.1 Age, substance use, dementia
diagnosis, English as primary
language, psychiatric admissions
(ANOVA)
AN
Karlsson et al., 2007 1276 HADS 47 41.9 Age and BMI (Matched Controls)
(ANOVA)
M

Schowalter et al., 248 M= 67.3; BDI 38.5 46.4 Age, gender, BMI and weight,
2008 F=32.7 depression and
self- acceptance (Matched controls)
ED

Järvholm et al., 2015 88 M=35; BDI; Beck Youth 16.8 45.6 Age and BMI (Matched Controls)
F=65 Inventory (ANOVA)
PT

Thonney et al., 2010 43 F=100 BDI; HADS 39.3 44.7 Age and BMI (ANOVA)
CE

Dixon et al., 2003 487 M=15; BDI 41.2 44.1 Age, sex, BMI, anthropometric
F= 85 measures, insulin resistance, history
AC

of medical illness

Burgmer et al., 2014 118 M=31.8; HADS 38.8 50.7 Gender, age, BMI and index year
F=68.2 (Matched controls)

Karlsson et al., 1998 487 M=33; HADS 46.6 M=40.8, F Matched control for each case (based
F=67 =42.3 on 18 variables, 6 psychosocial)
 ACCEPTED MANUSCRIPT

Source Sample Gender Method Of Mean Mean BMI Control of Confounding

Size (No. %) Assessment Age (baseline) Variables

Nickel et al., 2007 21 F=100 HADS N/A N/A BMI (Non-surgical group matched
controls)

Mitchell et al., 2014 2148 N/A BDI, Antidepressant N/A N/A Depressive symptoms,

T
medication hospitalization for depression &
treatment for depression over time

IP
CR
Table 1. The table illustrates sample size, gender (given as a percentage), method of assessment

for diagnoses of depression and anxiety, mean age and BMI of participants, and the control

US
confounding variables for each included study. (Abbreviations: M=male, F=female, ANOVA=

analysis of variance, BDI= Beck Depression Inventory, HADS= Hospital Anxiety and
AN
Depression Scale, EWL= excess weight loss, HRQoL= Health-related quality of life, BMI= body

mass index given in kg/m2)

M
ED
PT
CE
AC
 ACCEPTED MANUSCRIPT

Source Study Design Surgical Diagnosis Timing of Timing of Assessment

Approach Assessed Assessment (Post-Operative)
(Pre-Operative)

de Zwaan et al., Prospective Cohort GBS, GB Depression and 26.9 weeks 6-12 months and 24-36
2011 Anxiety months

Booth et al., Controlled Interrupted LAGB (1297), GB Depression Up to 3 years prior 7 years
2014 Time Series Design (1265), SG (477), surgery

T
IP
Strain et al., Prospective cohort RYGB, LAGB, SG Depression At time of surgery 25 months
2014 GB, BPD (baseline)

CR
White et al., Prospective cohort GB Depression At time of surgery 6, 12, and 24 months
2015 (baseline)

Rutledge et al., Longitudinal GB, LAGB Depression and At time of surgery 1 and 5 year
2012 Examination
(Retrospective and
Prospective) US
Anxiety (baseline)
AN
Karlsson et al., Prospective Not Specified Depression and At time of surgery 0.5, 1,2,3,4,6,8 and 10 years
2007 longitudinal Anxiety (baseline)

Schowalter et Prospective cohort GB Depression At time of surgery 5.6 year (average follow up)
al., 2008 (baseline)
M

Järvholm et al., Prospective cohort LAGB Depression and At time of surgery 1 and 2 years
2015 Anxiety (baseline)
ED

Thoney et al., Prospective cohort GB Depression and At time of surgery 1 and 2 years
2010 Anxiety (baseline)
PT

Dixon et al., Prospective cohort LAGB Depression At time of surgery 1,2,3 and 4 years
2003 (baseline)

Burgmer et al., Prospective cohort Vertical Depression and At time of surgery 1,2,3 and 4 years
CE

2014 Gastroplasty, GB Anxiety (baseline)

Karlsson et al., Prospective cohort Vertical Banded Depression and At time of surgery 6,12 and 24 months
1998 Gastroplasty, Anxiety (baseline)
AC

GBS, GB

Nickel et al., Prospective cohort Gastric Banding Depression and At time of surgery 48, 60, 72 months
2007 Anxiety (baseline)

Mitchell et al., Longitudinal Cohort RYGB, LAGB, Depression At time of surgery Between 1-3 years
2014 SG, GB, BDP (baseline)
 ACCEPTED MANUSCRIPT

Table 2. The table illustrates diagnoses assessed, surgical approach, diagnosis assessed, time of

assessment (both pre-operative and post-operative follow-ups) (Abbreviations: GB= Gastric

bypass, GBS= Gastric Banding Surgery, LAGB= Laparoscopic Adjustable Gastric Banding,

SG= sleeve gastrectomy, RYGB= Roux-en-Y Gastric Banding, BPD= biliopancreatic division)

T
IP
CR
US
AN
M
ED
PT
CE
AC
 ACCEPTED MANUSCRIPT

Source NOS Score Outcome of Interest Observed Outcomes

de Zwaan et al., Selection: **** Anxiety and Depression Point prevalence of depression decreased at 6-12 and
2011 Comparability: * from pre-op. to post-op. (6- 24-36 month.
Outcome: *** 12 and 24-36 months) Anxiety did not change from baseline.

Booth et al., 2014 Selection: **** Is clinical depression Diagnosis of depression and/or antidepressant therapy

T
Comparability: * following reduced after BS decreased.
Outcome: *** 1st year post-surgery, before rising to or surpassing

IP
pre-surgery levels in years 5-7.

Strain et al., 2014 Selection: **** Evaluated HRQOL and Depression reported with less frequency and is less

CR
Comparability: * depression before and 25 impairing; not directly associated with EWL
Outcome: *** months after BS

White et al., 2015 Selection: ****

Comparability: *
Outcome: ***
US
Pronostic significance of
depressive symptoms in BS
patients up to 24 months
post-operatively.
Depression improved after surgery. Increased at 24
months, although still lower than baseline
AN
Rutledge et al., 2012 Selection: **** Psychiatric treatment status Antidepressant treatment reduced pre-surgery to 5
Comparability: * and weight loss related years post-operatively.
Outcome: ** comorbidities in a series of Anxiety treatment increased from pre- to post-surgery.
M

follow-ups over 5 years

Karlsson et al., 2007 Selection: **** Trends and effects of weight- Depression improved after surgery, although effects
ED

Comparability: ** loss treatment diminished over time. Anxiety improved

Outcome: *** on health related quality of post surgery, however, started to increase again
life in the severely obese beyond 6 years. Both below baseline.
PT

Schowalter et al., Selection: **** Long-term changes in Significantly improved depression scores. Greater
2008 Comparability: * depression and self- reductions in those with greater weight-loss and higher
Outcome: *** acceptance pre-surgery depression scores.
CE

following gastric banding

Järvholm et al., 2015 Selection: **** Generic and obesity specific Symptoms of anxiety and depression significantly
Comparability: ** psychological health in reduced at 2 years post surgery.
AC

Outcome: *** adolescents undergoing

gastric bypass surgery

Thoney et al., 2010 Selection: **** If psychological profile
Comparability: * before gastric bypass has
Outcome: ** influence on weight loss, or if
weightloss modifies
psychological factors
Decrease in BMI was associated with improvements in
anxiety and depression scores
1 year after surgery with maintenance in year 2 post-
surgery.
 ACCEPTED MANUSCRIPT

Source NOS Score Outcome of Interest Observed Outcomes

Burgmer et al., 2014 Selection: **** The course of weight-loss Depression lower at each time point post-op. compared
Comparability: ** with changes in depression, to baseline. Anxiety decreased
Outcome: *** anxiety and HRQOL of BS between baseline and t2. No significant changes
patients between baseline and t3, t4

Karlsson et al., 1998 Selection: **** Effects of weight loss on Depression scores significantly lower 2 years post-op.

T
Comparability: ** HRQOL in BS patients Non-significantly reduced for anxiety.
Outcome: ***

IP
Nickel et al., 2007 Selection: **** BMI reduction and changes Found significant long-term reduction in both anxiety

CR
Comparability: * in anxiety, depression, and depression.
Outcome: ** employment, quality of life Most significant changes observed first year post-
surgery

Mitchell et al., 2014 Selection: ****

Comparability: *
Outcome: ***
US
Changes in depressive
symptoms 3 years following
BS
Significant improvements in depressive symptoms, and
modest reduction in antidepressant meds in 1st year
post surgery.
There is a small deterioration in years 1-3.
AN

Table 3. The table illustrates the study design, Newcastle-Ottawa Quality Assessment Score
M

(awarded as stars), outcome of interest and observed outcomes (findings) for each reviewed
ED

study (Abbreviations: NOS= Newcastle-Ottawa Quality Assessment Scale, BS=bariatric surgery,

HRQoL= Health-related quality of life, BMI= body mass index)

PT
CE
AC