Risk of suicide appears to increase after bariatric surgery

A study of a large group of adults who underwent bariatric surgery finds that the risk for self-harm emergencies increased after the surgery, according to a study published online by JAMA Surgery.

Morbid obesity is an epidemic in affluent countries; approximately 6 percent of Americans are morbidly obese. Mental health problems are prevalent in morbidly obese patients and those undergoing bariatric surgery. Self-harm behaviors, including suicidal ideation and past suicide attempts, are frequent in bariatric surgery candidates. It is unclear, however, whether these behaviors are mitigated or aggravated by surgery, according to background information in the article.

Junaid A. Bhatti, M.B.B.S., M.Sc., Ph.D., of the Sunnybrook Research Institute, Toronto, and colleagues studied 8,815 adults from Ontario, Canada, who underwent bariatric surgery to compare the risk of self-harm behaviors before and after surgery. Follow-up for each patient was 3 years prior to surgery and 3 years after surgery. The researchers categorized 4 distinct mechanisms of self-harm behaviors: medications, alcohol, poisoning by toxic chemicals, and physical trauma.

A total of 111 patients had 158 self-harm emergencies during follow-up. The researchers write that although a few patients had self-harm emergencies, the risk of these emergencies increased significantly (by approximately 50 percent) after surgery. Nearly all events occurred in patients who had a history of a mental health disorder. Intentional self-poisoning by medications was the most common mechanism of attempted suicide.

The authors write that the published literature provides differing reasons for the association between bariatric surgery and the subsequent risk of self-harm, including changes in alcohol metabolism after surgery; surgery might lead to a substitution of substance misuse for food; increased stress and anxiety in postoperative patients; and the effect of surgery on the levels of neurohormones, possible mediators of the likelihood of depression and suicidal behaviors. "Findings from this study advocate a better understanding of these and other theories through future research of potential mechanisms of self-harm in patients undergoing bariatric surgery."

"These adverse events undermine the overall benefits of bariatric surgery. The study findings could be useful for bariatric surgeons and emergency physicians in postoperative follow-up. Additional clinical implications include active postoperative screening for self-harm risk among patients who have undergone bariatric surgery and are presenting for follow up. Patient and surgery factors could help identify vulnerable patients. Overall, these findings imply that more work is needed to understand why self-harm behaviors increase in the postoperative period and how these risks might be reduced."

"The study has 2 important findings. First, the preoperative incidence of self-harm emergencies in patients undergoing bariatric surgery is twice the population average and increases by an additional 50 percent in the postoperative period. The identification of patients with an increased risk of such adverse outcomes remains an elusive goal," write Amir A. Ghaferi, M.D., M.S., and Carol Lindsay-Westphal, Ph.D., of the Ann Arbor Veterans Administration Healthcare System, Ann Arbor, Mich.

"Second, most self-harm emergencies occur in the second and third postoperative years. There is currently no minimum standard for psychological follow-up. Although stringent criteria are in place for insurance and programmatic approval to undergo surgery, the postoperative follow-up rates in general have been poor."

"The study by Bhatti and colleagues underscores the unique vulnerability of patients undergoing bariatric surgery and forces us to look closely at why suicide rates are more than 4 times higher in these patients than the general population. Bariatric surgery is more than just an operation—it is time we recognize and treat it is as such."