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Bariatric surgery and suicide

Low absolute risk of bariatric surgery and suicide

The investigators called for post-operative surveillance with particular attention to mental health

Bariatric surgery patients should undergo a thorough pre-operative psychiatric history assessment and be provided with information about increased risk of self-harm following surgery, according to researchers from Sweden who assessed the risk of suicide and self-harm after bariatric surgery compared with non-surgical obesity treatment. The investigators also called for post-operative surveillance with particular attention to mental health.

The paper, ‘Risk of suicide and non-fatal self-harm after bariatric surgery: results from two matched cohort studies’, published in The Lancet Diabetes & Endocrinology, examined suicide and non-fatal self-harm events retrieved from two nationwide Swedish registers: 1) The Swedish Obese Subjects (SOS) study that compared bariatric surgery (n=2,010; 1,369 vertical-banded gastroplasty, 376 gastric banding, and 265 gastric bypass) with usual care (n=2,037; recruitment 1987–2001); and 2) the Scandinavian Obesity Surgery Registry (SOReg; n=20,256 patients who had gastric bypass) matched to individuals treated with intensive lifestyle modification (n=16,162; intervention 2006–13) on baseline BMI, age, sex, education level, diabetes, cardiovascular disease, history of self-harm, substance misuse, antidepressant use, anxiolytics use, and psychiatric health-care contacts.

Outcomes

In total, there were 68,528 person-years (median 18; IQR 14–21) in the SOS study and suicides or non-fatal self-harm events were higher in the surgery group (n=87) than in the control group (n=49; p=0.0021). There were nine and three suicides, respectively (p=0.11).

In analyses by primary procedure type, increased risk of suicide or non-fatal self-harm was identified for gastric bypass (p=0.0010), gastric banding (p=0.011), and vertical-banded gastroplasty (p=0.0015) compared with controls. Out of nine deaths by suicide in the SOS surgery group, five occurred after gastric bypass (two primary and three converted procedures).

In total, there were 149,582 person-years (median 3.9; IQR 2.8–5.2) in SOReg, with more suicides or non-fatal self-harm events were reported in the gastric bypass group (n=341) than in the intensive lifestyle group (n=84; p<0.0001). There were 33 and five were suicides, respectively (p=0.0017). In SOS, substance misuse during follow-up was recorded in 48% (39/81) of patients treated with surgery and 28% (13/47) of controls with non-fatal self-harm events (p=0·023). Substance misuse during follow-up was recorded in 51% (162/316) of participants in the SOReg gastric bypass group and 29% (23/80) of participants in the intensive lifestyle group with non-fatal self-harm events (p=0·0003). The risk of suicide and self-harm was not associated with poor weight loss outcome.

“Bariatric surgery was associated with suicide and non-fatal self-harm. However, the absolute risks were low and do not justify a general discouragement of bariatric surgery,” the authors concluded. “The findings indicate a need for thorough preoperative psychiatric history assessment along with provision of information about increased risk of self-harm following surgery. Moreover, the findings call for postoperative surveillance with particular attention to mental health.”

This study was funded by US National Institutes of Health and Swedish Research Council.

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