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.
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