Bariatric Surgery Linked to Suicide Attempts

Pam Harrison

October 14, 2015

Suicide attempts increase substantially in morbidly obese patients in the years following bariatric surgery, when the "honeymoon" period of substantial weight loss comes to an end, new research shows.

Junaid Bhatti, PhD, evaluative clinical sciences, Sunnybrook Research Institute, Toronto, Ontario, and colleagues found that overall, self-harm risk increased from 2.33 events per 1000 patients a year prior to the surgery to 3.63 per 1000 patients after bariatric surgery ― a mean increase of approximately 50%.

Notably, 93% of the self-harm events occurred in patients diagnosed as having a mental health disorder during the 5 years preceding the surgery.

"Patients with morbid obesity are more likely to have mental health problems than the general population anyway, so we see a higher prevalence of mental illness diagnoses prior to bariatric surgery," Dr Bhatti told Medscape Medical News.

"And while most patients do benefit from the surgery, a small proportion of patients may experience self-harm issues, and what we are suggesting is that they be referred back to the appropriate mental health professional after surgery so that any potential for self-harm can be dealt with."

The study was published online October 7 in JAMA Surgery.

Most Events in Women

Investigators carried out a population-based, self-matched longitudinal cohort analysis of patients living in the province of Ontario who underwent bariatric surgery.

A total of 8815 patients underwent bariatric surgery during the 5-year enrollment period, almost all of whom underwent the Roux-en-Y gastric bypass procedure.

Approximately 64% of patients had received a diagnosis of anxiety prior to surgery, about 8% had been diagnosed with depression, and 0.6% had been diagnosed with alcohol dependence.

A total of 111 patients (1.3%) of the cohort had at least one self-harm emergency before or after surgery, including 11 patients who had emergencies in both periods ― 37 in the preoperative period, and 63 in the postoperative period.

"A total of 62 separate self-harm events occurred in the preoperative interval and 96 in the postoperative interval," the investigators report.

Most events were reported in women, in patients aged 35 years or older, and in those living in urban areas.

Intentional self-poisoning by medication was the most common means of attempted suicide, accounting for 73% of all suicide attempts. Physical trauma accounted for about 21% of the events.

"Almost all events were considered of high triage urgency and resulted in hospitalization," the authors write.

Mental Health Consultations

Dr Bhatti noted that most bariatric surgery programs offer mental health consultations prior to the surgery to ensure that candidates are suited to undergo the procedure.

However, as they found in the current study, the period for mental health support may need to be considerably longer for some patients.

Suicide attempt rates were distinctly accentuated in patients living in lower-income and rural areas ― a pattern that is potentially relevant to screening patients preoperatively and to counseling them as to postoperative expectations, the authors add.

The authors note that "patients with a history of major depression similarly accounted for almost all events, suggesting that such patients also merit a comprehensive risk assessment."

Investigators also suggested that any postoperative emergency visit by patients who have undergone bariatric surgery could be used as an opportunity to look for any problems in mental health that patients may be facing.

Two Important Findings

In an accompanying editorial, Amir Ghaferi, MD, and Carol Lindsay-Westphal, PhD, Veterans Administration Healthcare System, Ann Arbor, Michigan, note "the study has two important findings."

First, the preoperative incidence of self-harm emergencies in patients undergoing bariatric surgery is twice that of the population in general and increases by an additional 50% in the postoperative period.

Clearly there is significant room for improvement to identify ideal screening tools, protocols, and follow-up, they suggest.

"Secondly, most self-harm emergencies occur in the second and third postoperative years," they point out.

Most bariatric surgery programs focus on the first postoperative year, when most weight loss occurs.

Given the findings of the current study, "data support the call for long-term follow-up in bariatric surgery, especially for patients with a history of major depressive disorder and/or self- harm."

Mandatory Long-term Follow-up

Commenting on the study for Medscape Medical News, Sanjeev Sockalingam, MD, associate professor of psychiatry, University of Toronto, in Ontario, noted that most patients who come for bariatric surgery have a lifetime history of a formal psychiatric illness. Dr Sockalingam is also director of psychiatric assessment in a large-volume bariatric surgery program at the Toronto Western Hospital.

"What I think this signals is that obesity and mental health have a really close bidirectional relationship," Dr Sockalingam said.

One thing the current study did not do is look at what happens to severely obese people who do not undergo bariatric surgery, which would have made for an interesting comparison, he added.

In a broader context, Dr Sockalingam believes the study clearly shows how important it is to screen patients not just before they undergo bariatric surgery but over the long term.

"Having a history of psychiatric illness is not a reason not to undergo surgery," Dr Sockalingam said.

"But it's really about making sure that people have appropriate support, that their mental health condition is appropriately managed and stable, and most importantly, that they have appropriate access and follow-up for their mental health as they go through their postoperative journey."

Since 2009, there has been a mandated 5-year follow-up period in bariatric centers in the province of Ontario.

Dr Ghaferi reports receiving salary support from Blue Cross Blue Shield of Michigan as director of the Michigan Bariatric Surgery Collaborative. None of the other study authors nor Dr Sockalingam have disclosed any relevant financial relationships.

JAMA Surg. Published online October 7, 2015. Abstract, Editorial

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