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Bariatric surgery linked to increased suicide risk

Risk increased by around 50% after procedure, underscoring need for monitoring of mental health, say researchers

Caroline White

Thursday, 08 October 2015

Bariatric surgery may be linked to an increased risk of suicide, indicates a large study* of adults who underwent the procedure, published in JAMA Surgery.

Mental health issues are relatively common in morbidly obese patients and those undergoing bariatric surgery. Self-harm behaviours, including suicidal ideation and previous suicide attempts, are common in patients opting for bariatric surgery. But it is unclear whether these behaviours are lessened or made worse by surgery.

Junaid Bhatti of the Sunnybrook Research Institute, Toronto, and colleagues, tracked 8,815 adults from Ontario, Canada, who underwent bariatric surgery to compare the risk of self-harm behaviours in the three years before the procedure and in the three years afterwards.

Most (80%) of the patients were women, and most were above the age of 35.

The researchers focused on four distinct methods of self-harm: drug overdose, alcohol, poisoning, and physical trauma.

In all, 111 patients required emergency treatment for 158 incidents of self-harm during the monitoring period. This number is comparatively small, say the researchers, but the risk of these emergencies increased significantly by around 50% after surgery.

Nearly all events occurred in patients with a history of a mental health issues. They were also more common among those living in rural areas. Intentional overdose was the most common method used to attempt suicide.

Previous studies offer various explanations for the association between bariatric surgery and the subsequent risk of self-harm.

These include changes in alcohol metabolism after surgery; substitution of substance misuse for food; increased postoperative stress and anxiety; and the effect of surgery on the levels of neurotransmitters, which may affect the likelihood of depression and suicidal behaviours.

“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,” write the authors.

They add: “These adverse events undermine the overall benefits of bariatric surgery,” and suggest that patients who have had the procedure should be proactively screened for mental health issues.

“Overall, these findings imply that more work is needed to understand why self-harm behaviours increase in the postoperative period and how these risks might be reduced,” they conclude.

In a linked commentary,** Dr Amir and Dr Carol Lindsay-Westphal, of the Ann Arbor Veterans Administration Healthcare System, Ann Arbor, Michigan, write that identifying those who might be vulnerable to suicide “remains an elusive goal.”

Furthermore, they point out that most of these emergencies occur two to three years after the procedure.

“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,” they point out.

“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 four times higher in these patients than the general population. Bariatric surgery is more than just an operation—it is time we recognise and treat it is as such.”

* Junaid A. Bhatti, et al. Self-harm emergencies after bariatric surgery. A Population-Based Cohort Study. JAMA Surg. Published online October 07, 2015. doi:10.1001/jamasurg.2015.3414

** Amir A. Ghaferi, Carol Lindsay-Westphal, et al. Bariatric Surgery—More Than Just an Operation. JAMA Surg. Published online October 07, 2015. doi:10.1001/jamasurg.2015.3396

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