Rapid onset of first manic episode after bariatric surgery

To the Editor

To our knowledge, few reports of the onset of first mania following bariatric surgery are available in the literature. Mr A was a 39-year-old man without a history of psychiatric disorders or substance abuse. A review of his medical chart revealed that he had undergone laparoscopic sleeve gastrectomy for morbid obesity (body mass index, 45 kg/m²) 11 days before psychiatric admission. Nine days before, Mr A was discharged from the surgical ward with a clean wound, normal white blood cell count (4790/μL) and normal C-reactive protein level (0.24 mg/dL). However, 5 days before psychiatric admission, Mr A began to experience elevated mood, decreased sleep need, pressured speech and grandiose delusions. When admitted to the psychiatric ward, Mr A was awake and orientated to time, place and person. A serial sevens test revealed no attention deficits. No disturbance of the sleep–wake cycle, such as excessive daytime sleepiness and insomnia at night, was observed.

On the first day of hospitalization, the total Young Mania Rating Scale (YMRS) score was 56. Laboratory examination revealed an elevated white blood cell count (11,590/μL) and C-reactive protein level (1.62 mg/dL). Test results of thyroid function and serum vitamin B12 and folate levels were normal. An electroencephalogram displayed no diffuse slow waves. Valproic acid at 1000 mg/day and risperidone at 3 mg/day were administrated as acute treatment of manic symptoms. Significantly, the severity of manic symptoms rapidly decreased and the white blood cell count and C-reactive protein level returned to their normal range during the first week of psychiatric hospitalization (Figure 1). Mr A was discharged on the seventh day of psychiatric hospitalization, with the total YMRS score of 8.

Figure 1.

Relationship between (A) white blood cell count (WBC) and (B) C-reactive protein (CRP) levels and total Young Mania Rating Scale (YMRS) score during the first week of psychiatric hospitalization.

Several lines of evidence indicate that inflammation plays a key role in bipolar disorder (Goldstein et al., 2009; Modabbernia et al., 2013). Of interest, one reported case demonstrated that a new-onset manic episode occurring after bariatric surgery could be treated using activated charcoal, thus providing evidence for the brain–gut axis of the inflammatory pathway in bipolar disorder (Hamdani et al., 2015). In the present case, we observed that changes in the severity of the first mania were correlated with the levels of inflammatory markers following bariatric surgery. Our observations, together with those of the previous reports, may suggest that the inflammation–mood pathway could be the link between mania onset and bariatric surgery.