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Self-harm and surgery

Risk of self-harm increases after bariatric surgery

Overall, self-harm emergencies significantly increased after surgery compared with before surgery

A study of a large group of adults who underwent bariatric surgery finds had an increased risk for self-harm emergencies after the surgery, according to a study, ‘Self-harm Emergencies After Bariatric Surgery. A Population-Based Cohort Study.’, published in JAMA Surgery. 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 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 from Sunnybrook Research Institute, Toronto, Canada. “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 behaviours increase in the postoperative period and how these risks might be reduced."

It is well-known that mental health problems are prevalent in morbidly obese patients and those undergoing bariatric surgery, and self-harm behaviours including suicidal ideation and past suicide attempts, have been reported to be frequent in bariatric surgery candidates. It is unclear, however, whether these behaviours are mitigated or aggravated by surgery, write study authors.

Dr Junaid A Bhatti and colleagues studied 8,815 adults from Ontario, Canada, who underwent bariatric surgery to compare the risk of self-harm behaviours before and after surgery. Follow-up for each patient was three years prior to surgery and three years after surgery. The researchers categorised four distinct mechanisms of self-harm behaviours: medications, alcohol, poisoning by toxic chemicals, and physical trauma.

Overall, self-harm emergencies significantly increased after surgery (3.63 per 1,000 patient-years) compared with before surgery (2.33 per 1000 patient-years), equalling a rate ratio (RR) of 1.54 (95% CI, 1.03-2.30; p=0.007). Self-harm emergencies after surgery were higher than before surgery among patients older than 35 years (RR, 1.76; 95% CI, 1.05-2.94; p=0.03), those with a low-income status (RR, 2.09; 95% CI, 1.20-3.65; p=0.01), and those living in rural areas (RR, 6.49; 95% CI, 1.42-29.63; p=0.02). The most common self-harm mechanism was an intentional overdose (115 [72.8%]). A total of 147 events (93.0%) occurred in patients diagnosed as having a mental health disorder during the five years before the surgery.

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 study has 2 important findings,” write Drs Amir A Ghaferi and Carol Lindsay-Westphal of the Ann Arbor Veterans Administration Healthcare System, Ann Arbor, MI, in an accompanying editorial, ‘Bariatric Surgery - More Than Just an Operation.’. “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. 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 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." 

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