Suicide risk increases after bariatric surgery, indicating need for screening

The risk of self-harm emergencies increased after bariatric surgery, underscoring the need for suicide risk screening and prevention during follow-up, says a new study from the Institute for Clinical Evaluative Sciences (ICES).

The study, published today in the journal JAMA Surgery, examined the records of close to 9,000 patients undergoing gastric bypass surgery, most of whom were women over the age of 35. A total of 111 patients had 158 self-harm emergencies during the follow-up period, three times the population average. 

Overall, the relative risk of self-harm emergencies increased by approximately 54 per cent after bariatric surgery compared to the same patients before surgery. The relative risk increased by about 75 per cent for patients over the age of 35 and the risk doubled for patients living at a low income.  For people living in rural areas, the relative risk of a self-harm emergency grew more than six-fold.

Intentional self-poisoning by medications was the commonest mechanism of self-harm. These events led to significant consequences for the patient, with about half requiring hospital admission.

“The vast majority of these self-harm emergencies happened for people diagnosed with a mental health disorder during the years prior to the surgery,” says the study’s lead author Junaid Bhatti, an ICES fellow and a scientist at the Sunnybrook Research Institute. “Our study demonstrates a clear need for screening for self-harm behaviours as well as other factors such as excessive alcohol or drug use when treating patients with bariatric surgery.”

The study found that:

• Overall, self-harm emergencies significantly increased after surgery (3.63/1,000 patient-years) compared to before surgery (2.33/1,000 patient-years), equaling an incidence rate ratio (RR) of 1.54 (95% confidence interval [95% CI]=1.03-2.30; P=0.007).
• Self-harm emergencies after surgery were especially high following surgery among patients older than 35 years (RR=1.76; 95% CI=1.05-2.94), those with a low-income status (RR=2.09, 95%CI=1.20-3.65), and those living in rural settings (RR=6.49; 95% CI=1.42-29.63).
• The most common self-harm mechanism was an intentional overdose (73%).
• About 93% of events occurred in patients diagnosed with a mental health disorder during the five years prior to the surgery.

The study notes that bariatric surgery is an effective treatment for morbid obesity, with an estimated 60 to 80 per cent reduction in excess weight within a year after surgery for the average patient. Bariatric surgery is also regarded as a safe procedure, with surgical mortality rates averaging less than one per cent.

However, the authors say that the success of the surgery can be compromised by mental health problems that are prevalent in morbidly obese and bariatric surgery patients, including substance misuse, depression and eating disorders. These issues can also be factors in self-harm behaviours.

Says Bhatti, “Our hope is that this study will be useful for planning postoperative care in bariatric patients, who may need a longer period of follow-up for mental health issues than previously thought. Additionally, emergency room physicians should be aware of the mental health issues that make self-harm more likely in the bariatric patient population.”

“Self-harm emergencies following bariatric surgery: a population-based cohort study,” was published today in the journal JAMA Surgery.
 
Author block: Junaid A. Bhatti, Avery B. Nathens, Deva Thiruchelvam, Teodor Grantcharov, Benjamin I. Goldstein, Donald A. Redelmeier.

ICES is an independent, non-profit organization that uses population-based health information to produce knowledge on a broad range of healthcare issues. Our unbiased evidence provides measures of health system performance, a clearer understanding of the shifting healthcare needs of Ontarians, and a stimulus for discussion of practical solutions to optimize scarce resources. ICES knowledge is highly regarded in Canada and abroad, and is widely used by government, hospitals, planners, and practitioners to make decisions about care delivery and to develop policy. For the latest ICES news, follow us on Twitter: @ICESOntario

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