BARIATRIC SURGERY IS currently the only effective long-term treatment for severely obese patients.1 The prevalence of at least one current axis I disorder in this population is high (55.5%),2 although the mediators of this association are poorly understood.

Here we report a case of a 43-year-old woman with bipolar disorder (BD) type 2 with onset during adolescence. The patient had previously taken lithium with intolerance and had a documented good response and tolerance to oxcarbazepine and risperidone in combination. She also presented morbid obesity (Body Mass Index = 46.0), which, at the age of 38, was treated with Roux-en-Y gastric bypass surgery. After the surgery, she developed severe gastrointestinal symptoms, especially postprandial nausea and vomiting. Due to severe and frequent nausea and vomiting, since the surgery, the patient could not tolerate anymore mood stabilizers or atypical anti-psychotics, including oxcarbazepine, lamotrigine, valproate, aripiprazole, quetiapine, ziprasidone and oral risperidone. During 1 year, these medications were tried but their irregular administration was associated with three episodes of hypomania and with persistent subsyndromal depressive symptoms.

As a strategy to maintain the psychiatric treatment despite the gastrointestinal symptoms, long-acting injectable risperidone was started, and a maintenance dose of 25 mg every 2 weeks was established. This treatment has produced a satisfactory control of the acute hypomanic symptoms and prevented new episodes until now, for a period of 1 year.

The impact of bariatric surgery on psychiatric pharmacotherapy has not received much attention, and few specific recommendations exist to optimize medication regimens for this population. Although long-action injectable risperidone was classically considered an option for bipolar 1 patients3 with difficulties in adherence,4,5 in other situations, such as those described in this case, this medication may be useful. During the treatment, patients need to be monitored for manic/hypomanic and depressive symptoms as well as for adverse effects of long-action risperidone, which include sedation, extrapyramidal effects, hyperprolactinemia and weight gain.6 The patient provided written informed consent for publication of this case.


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  • 1
    Ochner CN, Gibson C, Shanik M, Goel V, Geliebter A. Changes in neurohormonal gut peptides following bariatric surgery. Int. J. Obes. 2010; doi:10.1038/ijo.2010.132.
  • 2
    Mühlhans B, Horbach T, de Zwaan M. Psychiatric disorders in bariatric surgery candidates: a review of the literature and results of a German prebariatric surgery sample. Gen. Hosp. Psychiatry. 2009; 3: 414421.
  • 3
    Yatham LN, Kennedy SH, Schaffer A et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: update 2009. Bipolar Disord. 2009; 11: 225255.
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    Quiroz JA, Yatham LN, Palumbo JM, Karcher K, Kushner S, Kusumakar V. Risperidone long-acting injectable monotherapy in the maintenance treatment of bipolar I disorder. Biol. Psychiatry. 2010; 68: 156162.
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    Fagiolini A, Casamassima F, Mostacciuolo W, Forgione R, Goracci A, Goldstein BI. Risperidone long-acting injection as monotherapy and adjunctive therapy in the maintenance treatment of bipolar I disorder. Expert. Opin. Pharmacother. 2010; 11: 17271740.
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    Cañas F, Möller HJ. Long-acting atypical injectable antipsychotics in the treatment of schizophrenia: safety and tolerability review. Expert. Opin. Drug Saf. 2010; 9: 683697.