Suicide Risk Increases In Bariatric Surgery Patients

Using the search terms “suicide among bariatric surgery patients,” I found several articles on studies about the suicide risk increase in patients having bariatric surgery.

This study, published online October 7 in JAMA Surgery says - 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.

Mental health has been discovered to be the main culprit 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,"

Many patients do benefit from the surgery; a small proportion of patients may experience self-harm issues. 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.

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.

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. 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.

Most bariatric surgery programs do offer mental health consultations before the surgery to ensure that candidates are suited to undergo the procedure. 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.

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

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."

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.

"It is 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.

'Obamacare' and Mental Health Promoted

We have all heard about the can of worms. Fishermen love them and most people shrink from them. This article in WebMD is another can of worms. It is time that mental health came back and became part of medicine. We even understand and appreciate the coverage of pre-existing conditions as a benefit.

One of the factors is not mentioned and this is the lack of trained doctors to treat people needing treatment. This may the reason behind the new guideline manual the Diagnostic and Statistical Manual (DSM5). In the manual they have a medication for every conceivable mental health issue and almost say to forget counseling from a positive perspective to enable their patients to take charge of a mental health problem and overcome it. Medications are now the only answer. This may have been anticipated that other doctors will need to help fill the shortage in an as needed basis.

The psychiatrists and psychologists are in short supply in most states and this is one reason many governors discouraged mental health exams for gun owners and this confirms the continuing shortage. See my blog here about the medications being encouraged for most mental conditions.

According to the WebMD article, an estimated 32 million people will gain mental health or substance use disorder benefits, or both, as a result of the Affordable Care Act (ACA). This results from the requirement that small group and individual insurance plans offer coverage for mental health issues and substance abuse services. The author claims most large insurance plans already include such coverage; however, my blog here shows how large insurance companies side step their obligations. Maybe under ACA they will not do this as much.

The author quotes Susan Lindau, a licensed clinical social worker and associate adjunct professor at the University of Southern California School of Social Work in Los Angeles, as saying, "parity has been written into the law so mental health coverage ostensibly should be much easier to access."

Andrew Sperling, director of legislative advocacy for the National Alliance on Mental Illness (NAMI), is quoted as saying, "We're still waiting for the final regulations. And, because of the Supreme Court decision, the Medicaid expansion is optional, and a large number of states are talking about not participating. There are a high percentage of people that have a diagnosable mental illness living below the poverty line."

There are two sides to this issue and for the most part, more people will have more mental health care than before, but a large number may still be unserved. This is a loophole that needs to be eliminated, but with the current congressional climate, may not be for several years.

With the current DSM5 guidelines, many other doctors may see the shortage as a way of using prescription medications recommended under DSM5 as a way to treat more patients. Mental health care will fail under this treatment and more serious mental health problems may become worse.

With the problems people with diabetes have, this may not be good for people with diabetes needing treatment for depression.

Insurers Still Skirting Mental Health Parity Law

Hopefully this problem will come to an end. It is disturbing that our medical insurance industry continues to sidestep the law and continues to discriminate against patients with mental illnesses. Some companies will cover some conditions with no problems, but for the majority of mental health illnesses, they will drop the coverage as soon as they can and many drop all coverage after a patient is diagnosed with a mental illness.

I am not saying this is the case, but it may go a long ways to explain why doctors are prescribing antidepressants without a diagnosis. I had not considered this when I wrote my blog here. The Mental Health Parity and Addiction Equity Act passed into law in 2008, but not taking effect until 2010 requires insurance to cover mental health illnesses.

Unfortunately, the guidance from parity regulators has so far not been specific or clear enough, allowing some insurers to hide behind a level of vagueness. Until enforcement of the parity law, and until there is an effective definition of what parity protections there are, it's possible that even under Medicaid insurers are free to delete some of these essential treatment services.

Many in the American Psychiatric Association say that there is too much not spelled out in the law and until the APA and Parity regulators determine a clear definition, some insurance groups will continue to interpret the law to their benefit. Are they right? Yes, as there are legitimate differences of opinion even among the APA and parity regulators that need to be resolved.

Until the federal agencies responsible for regulations of the parity law finalize clear definitions for the scope of services, insurance groups will continue down the path of their choice. At present there is no one that can definitively say that an issue in your health plan is clearly out of compliance, and that another issue may be in compliance. At present there is confusion at all levels.

So at present, the medical insurance companies will continue doing their thing and patients may suffer the consequences. Read the article here. There are some real problems to be resolved.