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Risk of completed suicide after bariatric surgery: A systematic review

January 2013
Obesity Reviews 14(5)

DOI:10.1111/obr.12014

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PubMed

Authors:

Carolin Peterhänsel

MindDoc by Schön Klinik

David Petroff

University of Leipzig

Grit Klinitzke

University of Leipzig

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Bariatric surgery is one of the most effective treatments for morbid obesity, and a large body of research indicates significant long-term weight loss. While overall mortality decreases in patients who received bariatric surgery, a number of studies have shown that suicide rates are higher in bariatric patients than in control groups. The objective of this study was to present a systematic review of suicide mortality after bariatric surgery and calculate an estimate for the suicide rate. Literature researches of the databases PubMed, Web of Knowledge, PsychInfo, ScienceDirect and Google Scholar were conducted. Thirty studies concerning bariatric surgery and completed suicides met the inclusion criteria. We included 28 studies in the estimation of a suicide rate for the bariatric population. Only one study (Tindle et al.) put a main focus on suicide after bariatric surgery; this was therefore chosen as an adequate reference figure for comparison. The other 27 chosen studies were compared with World Health Organization data and the suicide rate reported by Tindle et al. Twenty-three thousand eight hundred eighty-five people were included in the analysis. In the literature, we found a total of 95 suicides when examining 190,000 person-years of post-bariatric surgery data. Little information was provided describing the reasons for suicide and the time-point of these events after surgery. We estimated a suicide rate of 4.1/10,000 person-years (95% confidence interval [3.2, 5.1]/10,000 person-years). A comparison with Tindle et al. demonstrates that their rate is significantly higher than our estimate (P = 0.03). Bariatric surgery patients show higher suicide rates than the general population. Therefore, there is a great need to identify persons at risk and post-operative psychological monitoring is recommended.

Summary of the included studies in alphabetical order

…

List of papers included for the estimate of the suicide rate in decreasing order of person-years

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Obesity Treatment

Risk of completed suicide after bariatric surgery:

a systematic review

C. Peterhänsel1,2, D. Petroff3,4, G. Klinitzke1,2, A. Kersting1and B. Wagner1,2

1Department of Psychosomatic Medicine and

Psychotherapy, University of Leipzig, Leipzig,

Germany;2Leipzig University Medical Center,

Integrated Research and Treatment Center

(IFB) AdiposityDiseases Germany, Leipzig,

Germany;3Data Centre, IFB

AdiposityDiseases, University of Leipzig,

Leipzig, Germany;4Coordination Centre for

Clinical Trials, University of Leipzig, Leipzig,

Germany

Received 16 October 2012; revised 6

December 2012; accepted 6 December 2012

Address for correspondence: C Peterhänsel,

University of Leipzig, Integrated Research

and Treatment Center (IFB)

AdiposityDiseases, Department of

Psychosomatic Medicine, Semmelweisstraße

10, 04103 Leipzig, Germany.

E-mail:

Carolin.Peterhaensel@medizin.uni-leipzig.de

Summary

Bariatric surgery is one of the most effective treatments for morbid obesity, and a

large body of research indicates signiﬁcant long-term weight loss. While overall

mortality decreases in patients who received bariatric surgery, a number of studies

have shown that suicide rates are higher in bariatric patients than in control

groups. The objective of this study was to present a systematic review of suicide

mortality after bariatric surgery and calculate an estimate for the suicide rate.

Literature researches of the databases PubMed, Web of Knowledge, PsychInfo,

ScienceDirect and Google Scholar were conducted. Thirty studies concerning

bariatric surgery and completed suicides met the inclusion criteria. We included 28

studies in the estimation of a suicide rate for the bariatric population. Only one

study (Tindle et al.) put a main focus on suicide after bariatric surgery; this was

therefore chosen as an adequate reference ﬁgure for comparison. The other 27

chosen studies were compared with World Health Organization data and the

suicide rate reported by Tindle et al. Twenty-three thousand eight hundred eighty-

ﬁve people were included in the analysis. In the literature, we found a total of 95

suicides when examining 190,000 person-years of post-bariatric surgery data.

Little information was provided describing the reasons for suicide and the time-

point of these events after surgery. We estimated a suicide rate of 4.1/10,000

person-years (95% conﬁdence interval [3.2, 5.1]/10,000 person-years). A com-

parison with Tindle et al. demonstrates that their rate is signiﬁcantly higher than

our estimate (P=0.03). Bariatric surgery patients show higher suicide rates than

the general population. Therefore, there is a great need to identify persons at risk

and post-operative psychological monitoring is recommended.

Keywords: Bariatric surgery, depression, suicide.

obesity reviews (2013)

Introduction

The fact that increasing numbers of people are over-

weight (body mass index [BMI] ⱖ25 kg m-2) or obese

(BMI ⱖ30 kg m-2) embodies the lifestyle of the 21st

century both in developed and developing countries, and

represents one of the most challenging tasks for the

world’s healthcare systems. Between 1980 and 2008 the

worldwide prevalence of obesity more than doubled, and

in 2008, 1.4 billion adults aged 20 or older were over-

weight or obese (1). Being overweight or obese increases

the risk of sequelae like diabetes, hyperlipidaemia, hyper-

tension, ischemic or hypertensive heart disease, obstructive

sleep apnoea, osteoarthritis, and depression, (2–5) and

generally decreases life expectancy (6,7). Dietary, pharma-

ceutical and behavioural treatments facilitate modest

reduction in weight (8–10), but fail to establish long-term

effects on weight loss, meaning that bariatric surgery has

obesity reviews doi: 10.1111/obr.12014

become the treatment of choice for obesity and co-existing

medical conditions (11–13). The majority of patients expe-

rience an improvement in their physical health as well as

loss of excess weight after bariatric surgery. Further,

Adams and colleagues showed that bariatric surgery pro-

cedures reduce long-term mortality because of coronary

diseases by 56%, diabetes by 92% and cancer by 60%

compared with a control group (14). However, mortality

rates not caused by disease, such as accidents and suicide,

were found in this study to be 58% higher in the surgery

group than in the control group (11.1 vs. 6.4 per 10,000

person-years).

In their population-based study, Tindle et al. (15)

obtained suicide data from bariatric patients in Pennsylva-

nia over a period of 10 years and compared them with

suicide rates of the U.S. and Pennsylvanian populations.

Their results indicated a substantial excess of suicides in the

surgical group. The overall rate of completed suicides in the

surgical group was 6.6/10,000, a ﬁgure that included a

suicide rate of 5.2 per 10,000 for female participants, and

13.7 per 10,000 for male participants. The reported age-

and sex-matched suicide rates in the general U.S. popula-

tion were 0.7/10,000 for women and 2.4/10,000 among

men. With regard to time frame, it was reported that 30%

of the suicides occurred within the ﬁrst 2 years and 70%

within 3 years of surgery (15). The study of Tindle et al.

(15) has already been commented on by Mirabelli et al.

(16), who have documented a signiﬁcant increase in sui-

cides in their cohort of obese persons. However, they

ascribed this to an association with severe obesity rather

than bariatric surgery.

Two reviews have been recently published addressing the

association between bariatric surgery and suicide (17,18),

concluding that the suicide rate among post-bariatric

surgery patients might be higher in comparison with the

general population (17) or even that the increased risk of

suicide for obese persons cannot be resolved through

bariatric surgical procedures (18). However, these reviews

(17,18) did not provide a systematic review of suicide rates

for bariatric surgery patients speciﬁcally, and included only

a limited number of studies. Furthermore, although the

reviews of Heneghan and colleagues (18) and Hsu et al.

(17) concluded that there is a higher suicide rate in the

bariatric population than in the general population, their

ﬁndings were not statistically signiﬁcant.

As bariatric surgery is an increasingly popular method of

weight-loss management there is an urgent need to provide

clarity on the existing literature. The aim of this review was

to provide an overview of existing literature regarding sui-

cides after bariatric surgery. We will do so by comparing

existing data from studies that report completed suicides

after bariatric surgery with the Tindle et al. (15) study and

suicide data provided by the World Health Organization

(WHO) (19).

Methods

We identiﬁed the relevant literature by searching for

English papers within the electronic databases PubMed,

Web of Knowledge, PsychInfo, ScienceDirect and Google

Scholar from 1992 until January 2012. To obtain a

comprehensive list of reports that mention an association

between bariatric surgery, including different surgical pro-

cedures, and completed suicides, the following terms were

used for the literature search:

[obesity surgery OR bariatric surgery OR gastric bypass

OR biliopancreatic diversion OR endoluminal sleeve OR

vertical banded gastroplasty OR gastric band OR sleeve

gastrectomy OR gastric balloon OR gastric plication OR

duodenal switch OR implantable gastric stimulation]

AND suicide

The word combination was used for adults as well as

for adolescents because weight-loss surgery is frequently

applied in practice within these age groups (20,21). Two

authors independently searched for relevant papers and

discussed inclusion and exclusion criteria. Studies based on

the jejunoileal bypass procedure were excluded because this

technique is no longer recommended (22). Also, studies

that reported suicide attempts or suicidal ideation by bari-

atric patients were not included. Papers were excluded if

they were case studies, case series or narrative reviews.

Prospective and retrospective studies were included if

referring to the correct themes and published between 1992

and 2012. If studies provided details of various follow-up

points in the same sample the one with the longest

follow-up period was chosen.

A qualitative analysis of the chosen articles reports on

the number of suicides and, if mentioned, the reason for

committing suicide. Of the 30 studies identiﬁed in the

search, 27 studies were compared with the ﬁndings of

Tindle et al. (15), which is the only study dedicated explic-

itly to the topic. The studies of Goldfeder et al. (23) and

Higa et al. (24) were excluded as they failed to provide

information necessary to estimate the number of person-

years. The 28 remaining papers were then used to come up

with a ﬁnal estimate for a post-bariatric surgery rate.

Statistical analysis

The main goal of the statistical analysis was the estimation

of the suicide rate after bariatric surgery. It was necessary

to ﬁnd the number of person-years considered in each

study. If information regarding the number of person-years

and the mean observation time was not provided in one of

the papers reviewed, then the approximation was made

that it is equal to the number of people included times the

median observation time. The most crucial point in the

analysis was the proper treatment of the selection bias

2Suicide after bariatric surgery C. Peterhänsel et al.obesity reviews

because of the method of ﬁnding papers. We modelled the

data by assuming a binomial distribution for the number

of suicides with a constant probability, where the number

of person-years constitutes the number of ‘draws’ and

where the distribution has been rescaled after taking into

account that the probability of observing no suicides is

zero, the so-called truncated binomial distribution (25).

The probability was found using a maximum likelihood

estimator and conﬁdence intervals (CIs) were determined

with proﬁle likelihood using the package Bhat (26) in the

statistical programme R (27). Comparisons among the

number of suicides was performed with Fisher’s exact test

(28,29). An effective suicide rate based on WHO data was

determined as follows. For a given trial, the most current

rates were taken from the corresponding country for the

age range 35–44. The rates for men and women were

‘averaged’ using the equation a¥rmen +(1 -a)¥rwomen

where ‘a’ is the proportion of women in the study. For

each paper, the effective number of people is given by

anw+(1 -a)nm+2a(1 -a)(nw+nm), where nwand nmare

the number of women and men sampled for the WHO

estimate, respectively. These numbers were also multiplied

by the respective weights and added together. Results were

considered signiﬁcant for P-values <0.05.

Results

Description of studies included

In the literature search, we detected 1,224 publications,

43 of which were duplicates, and therefore immediately

excluded. A further 1,136 papers were eliminated because

they did not meet the selection criteria and ﬁnally 15

studies were removed from the analysis as they only inves-

tigated suicidal ideation or attempt but did not ﬁnd any

suicide (n=3), were based on the same sample (n=4) or

did not mention the topic (n=8). This process left 30

studies for review.

The studies were conducted in the Netherlands (30),

Switzerland (31,32), Finland (33), France (34), Sweden

(35–40), Italy (41), Belgium (42,43), Germany (44),

Canada (45) and Australia (46), but the majority originate

from the United States (14,15,23,24,47–55) (see Table 1).

Twenty-four of the studies were produced by surgical

centres and focused on short- and long-term outcomes

after different surgical procedures to treat obesity (14,

24,30–45,48–51,53,54). The other studies were all reviews

of various weight-loss approaches from a psychiatric

(47,52,55), forensic (23) or epidemiologic perspective

(15,46).

Within the studies included, 12 refer to restrictive

surgery procedures such as gastric banding (32,37,

38,41,43,46,53), vertical banded gastroplasty (VBG)

(33,35,36,52) or sleeve gastrectomy (34), nine studies

were based on gastric bypass (14,24,31,42,47–51), one

study on duodenal switch (45), and eight had mixed

samples (15,23,30,39,40,44,54,55). Follow-up times vary

widely among the chosen studies with a follow-up range

from 5 to 29 months (50) up to 22.9 years (44). Numbers

of participants in the studies differed between 27 (33) and

16,683 (15) and the percentage of female patients lay

between 68% (34) and 90.2% (43), with the exception of

one study, where only outcomes of male patients were

reviewed (39). A list of the publications used and infor-

mation on the number of patients included can be found

in Table 1.

Suicides without further information

Fifteen of the studies did not focus on completed suicides

after bariatric surgery, instead describing the surgical pro-

cedures and their effect on weight-loss and comorbid dis-

eases. Essentially no information was provided about the

suicide, often not even when it occurred.

Marceau et al. (45) reported six suicides in a group of

1,423 patients who had undergone duodenal switch pro-

cedures over a period of 15 years. Pories et al. (49) men-

tioned three suicides in their survey of 608 patients over a

period up to 14 years after surgery. Suter et al. (31) also

observed three suicides, but the cohort consisted only

of 379 patients and had a follow-up time of 5 years.

Two suicides were reported by Näslund et al. (38), who

observed 92 patients over a mean follow-up period of 9.8

years, and also by Christou et al. (48), with a sample of 272

patients and a mean follow-up time of 11.4 years. Smith

et al. (51), who note two suicides, include a large initial

cohort in their study (N=3,855), and their period of obser-

vation was 7 years. Capella and Capella (54) compared two

surgical procedures and found one suicide in the VBG

group (N=328) and two suicides in the VBG–Roux-en-Y

gastric bypass (VBG–RYGB) group (N=560) within a time

period of up to 5 years. Eight other studies (30,34,

35,37,41,44,46,53) reported one suicide in cohort sizes

that varied between 153 and 2,909 patients, and follow-up

times that ranged from 28 months up to 22.9 years. In

summary, the studies described earlier report between one

and six suicides occurring in samples of 92 to 3,855

patients within a follow-up period of 28 months to 22.9

years.

Suicides with further information

In contrast to the papers that did not provide detailed

information about the underlying causes of the suicides, the

date of suicide or a comparison with non-bariatric patients,

several studies gave some information on this or even chose

mortality and suicide rates as their main focus.

obesity reviews Suicide after bariatric surgery C. Peterhänsel et al.3

Table 1 Summary of the included studies in alphabetical order

Study Sample size

(age ⫾standard

deviation [range] )

Gender

distribution

Country Follow-up (range) Surgical procedure Major ﬁndings Suicide rate

(% of initial

population)

Dropout rate

Adams et al.,

2007 (14)

N=7,925 patients

(39.5 ⫾10.5)

84% women, 16% men USA 7.1 years RYGB 63 suicides; deaths not caused by

disease (including suicide, accidents

unrelated to drugs, poisonings, and other

deaths) were 1.58 times as great in the

surgery group as in the control group

0.8%

N=7,925 control

subjects (39.3 ⫾10.6)

Busetto et al.,

2007 (41)

N=821 surgical

patients (mean:

38 ⫾0.7)

75.3% women, 24.7%

men

Italy Mean: 5.6 ⫾2.9

years and 7.2 ⫾1.2

years

Laparoscopic adjustable

banding

1 suicide, 1 car accident 0.1% 2.4%

Cadière et al.,

2011 (42)

N=470 (median

40 ⫾12 [15–74] after

primary gastric bypass

(PGB); 42 ⫾9 [18–66]

after secondary GB)

83.4% women, 16.6%

men

Belgium Median: 35 months

(12–66) for PGB; 34

months (12–66) for

SGB

Laparoscopic gastric bypass

(primary 362, secondary 108)

1 suicide two years after the procedure 0.2% 18.4%

Capella and

Capella, 1996

(54)

N=328 VBG, 560

VBG-RYGB (mean: 37

years)

82.2% women, 17.8%

men

USA Up to 5 years VBG or VBG with RYGB

(VBG-RYGB)

1 suicide, 1 automobile accident (VBG), 2

suicides and 3 automobile accidents

(VBG-RYGB)

0.3% 28–59%

0.2%

Carelli et al.,

2010 (53)

N=2,909 patients

(44.63 [18–79] )

68.3% women, 31.7%

men

USA Up to 60 months Laparoscopic adjustable gastric

banding (28 with prior gastric

bypass, 8 with prior VBG)

1 suicide, 1 motor vehicle accident 0.03% 70.55% after

60 months

Christou et al.,

2006 (48)

N=272 (42.0 ⫾3.4) 82% women, 18% men USA Mean: 11.4 years

(4.7–14.9)

Gastric bypass (short- and

long-limb)

2 suicides (after 4.8 and 5.7 years), 1

alcoholic cirrhosis of the liver at 6 years

0.7% 16.2%

Forsell et al.,

1999 (37)

N=326 patients (40

[19–62] )

76% women, 24% men Sweden Mean: 28 months

(6–76)

Swedish adjustable gastric

banding

1 suicide 0.3% 3%

Goldfeder et al.,

2006 (23)

N=107 deaths of

patients who had

undergone bariatric

surgery

Not mentioned USA Not mentioned Not mentioned 1 suicide by toxic ingestion 0.9%

Günther et al.,

2006 (44)

N=195 (32 [16–57] ) 77.4% women, 22.6%

men

Germany Mean: 22.9 years

(16.5–25.4)

Horizontal gastroplasty, stapled

RYGB, transected RYGB

1 suicide 0.5% 30.8%

Higa et al.,

2000 (24)

N=1,040 [13–72] 82.6% women, 17.4%

men

USA Laparoscopic RYGB 1 suicide thought to be related to

depression

0.1% Not mentioned

Himpens et al.,

2011 (43)

N=82 patients (median

50 [28–73] ) of original

151 patients!

90.2% women, 9.8%

men

Belgium Median: 13 years Laparoscopic adjustable

banding

1 suicide for ﬁnancial reasons 1.2% 45.7%

Kral et al., 1993

(40)

N=69 (38 [21–56] ) 81.2% women, 18.8%

men

Sweden Mean: 60 months VBG or VBG +truncal vagotomy 1 suicide 3.5 years after operation 1.4% 6%

Marceau et al.,

2007 (45)

N=1,423 (40.1 ⫾10.5

[15–70] ), 1,356 at last

follow-up!

73% women, 27% men Canada Mean: 7.3 ⫾3.7

years (2–15)

Duodenal switch 6 suicides 0.4% 3%

Marsk et al.,

2010 (39)

N=1,216 patients,

1,492,863 general

population cohort, 5,327

non-surgical cohort

[18–60]

100% men Sweden Mean: 7.3 years

(0–26,8)

62% restrictive procedures

(VBG, gastric banding), 31,7%

gastric bypass, 6,3% jejunoileal

bypass

4 suicides, 9 accidents and intoxications

in the surgical group

0.3%

Mitchell et al.,

2001 (47)

N=78 patients (56.8

[31–77] )

83% women, 17% men USA 13–15 years RYGB 2 deaths of psychiatric-related conditions,

1 death associated with alcoholism

1.3% 22%

Näslund et al.,

1994 (38)

N=92 (mean: 37 years) 81.5% women, 18.5%

men

Sweden Mean: 9.8 years

(7.5–12.3)

Gastric banding – only 25 with

intact band at the end, most

with reoperation or conversion

to other procedure

2 suicides, 1 patient with an

alcohol-related death

2.2% 8%

4Suicide after bariatric surgery C. Peterhänsel et al.obesity reviews

Table 1 Continued

Study Sample size

(age ⫾standard

deviation [range] )

Gender

distribution

Country Follow-up (range) Surgical procedure Major ﬁndings Suicide rate

(% of initial

population)

Dropout rate

Näslund et al.,

1995 (35)

N=158 (mean: 39.3

years)

74.6% women, 25.4%

men

Sweden 1 to 7 years VBG 1 suicide 0.5% 20.2%

Nocca et al.,

2008 (34)

N=163 (mean: 41.57

years)

68% women, 32% men France 24 months Laparoscopic sleeve

gastrectomy

1 suicide 0.6% 39.9%

Peeters et al.,

2007 (46)

N=966 patients

(47.1 ⫾10.9)

Patients: 77% women,

23% men

Australia Median: 4 years Laparoscopic adjustable

gastric banding

1 suicide 0.1% 2.4%

Pekkarinen

et al., 1994 (33)

N=27 patients (36

years [22–48] )

70% women, 30% men Finland Mean: 5.4 years

(2–10)

VBG 1 suicide after 2 years (psychiatric

problems), 1 car accident after 4 years

3.7% 10%

Pories et al.,

1995 (49)

N=608 (37.3 [14–64] ) 83.2% women, 16.8%

men

USA 14 years Greenville gastric bypass 13 emotionally related deaths (3 suicides,

3 cases of cirrhosis because of a return to

drinking, 1 case of bulimia, 1 case of

pernicious anaemia because of a refusal

to take vitamin B12, 1 case of alcoholic

hepatitis, and 4 cases of auto accidents)

0.5% 3.7%

Powers et al.,

1992 (52)

N=100 patients (38.8

[20–59] )

85% women, 15% men USA 5 years VBG 1 suicide 5 years after surgery (chronic

undifferentiated schizophrenia)

1% 75% not

present

at 3-year

follow-up

Powers et al.,

1997 (55)

N=131

(mean: 39.4 years)

85% women, 15% men USA Mean: 5.7 years Not mentioned 1 suicide – multiple previous suicide

attempts and several family members had

committed suicide

0.8% 34%

81 responders to

a questionnaire

Smith et al.,

1995 (51)

N=3,855 (1,039

responders to a

questionnaire! –

[13–69] )

88.9% women, 11.1%

men

USA 7 years RYGB (primary or in revisional

surgery)

2 suicides, 1 alcoholic cirrhosis 0.05% 73% did not

respond to

questionnaire

Smith et al.,

2004 (50)

N=779 (Group A 41

[21–63], Group B 38

[17–67] )

USA 5–29 months Open or laparoscopic RYGB

(328 laparoscopic, 451 open)

1 suicide in a patient with known

long-term depression (1 year after

surgery)

0.1% 65% after 1

year

Suter et al.,

2006 (32)

N=317 patients (38

years [19–69])

86.4% women, 13.6%

men

Switzerland Mean: 74 months

(30–99)

Laparoscopic gastric banding 1 suicide after 5 years, 1 accident after

5 month

0.3% 18.5% after 7

years

Suter et al.,

2011 (31)

N=379 (39.4) 74.4% women, 25.6%

men

Switzerland 5 years Laparoscopic RYGB 3 suicides, 1 drug overdose 0.8% 5.1–10.1%

Svenheden

et al., 1997 (36)

N=91 (age not

mentioned)

79.1% women, 20.9%

men

Sweden 6 to 48 months VBG 1 suicide 18 months post-operatively 1% Not mentioned

Tindle et al.,

2010 (15) bzw.

N=16,683 patients

(48)

82.3% women, 17.7%

men

USA Mixed 31 suicides: mean age: 45 years,

primarily female and white, mean time to

death: 3 years after surgery

0.2%

Van de Weijgert

et al., 1999 (30)

N=153 (RYGB: 33 ⫾8

[18–49], VBG: 35 ⫾9

[19–52] )

RYGB: 63 women, 12

men;

Netherlands 9.9 ⫾1.6 years for

RYGB and

7.2 ⫾0.8 for VBG

RYGB or VBG 1 suicide, 2 died of alcohol abuse 0.65% 19.5%

VBG: 70 women, 8 men

PGB, primary gastric bypass; RYGB, Roux-en-Y gastric bypass; SGB, secondary gastric bypass; VBG, vertical banded gastroplasty.

obesity reviews Suicide after bariatric surgery C. Peterhänsel et al.5

Time frame

Information about the time after surgery at which suicide

was committed was given in seven studies. One suicide

occurred within 5 years of the operation in the study with

a cohort of 317 patients and mean follow-up time of 74

months (32). Svenheden and colleagues (36) reviewed a

cohort of 95 patients for between 6 and 48 months and

reported one suicide after 18 months. Cadière et al. (42)

focused on outcomes in 470 persons who underwent a

gastric bypass surgery and reported that one patient com-

mitted suicide 2 years after the procedure. In a retrospective

cohort study of 779 patients, one patient committed suicide

1 year after the surgery, but this was thought to be due to

known long-term depression (50). One suicide occurred

after 3.5 years in a study of 69 patients over a follow-up

time of 60 months (40). Pekkarinen et al. (33) reported one

suicide 2 years after gastroplasty within a sample of 27

patients and a mean follow-up period of 5 years. This

person suffered from psychiatric problems and weight

cycling. Five years after the operation, a suicide was

described by Powers et al. in a sample of 100 patients (52).

In summary, suicides in these studies occurred between 18

months and 5 years after surgery.

Reasons for suicide

Only eight studies analysed the reason for suicide.

Himpens et al. (43) indicated one suicide ‘due to ﬁnancial

reasons’ in a sample of 82 patients (54.3% of the original

sample) within a follow-up time of 13 years. A retrospec-

tive cohort study in the New York region analysed the

cause of death of former bariatric patients and found one

suicide by toxic ingestion (23). Other papers proposed

psychiatric problems as an explanation of suicide. Depres-

sion after the unexpected death of a family member was

described as cause of one suicide in a cohort of 1,040

patients in Higa et al. (24) Within the two studies of

Powers et al. (52,55), which may refer to the same sample,

one suicide was seen in a cohort of 100 or 81 people

(follow-up time 5 years and mean 5.7 years, respectively).

In the ﬁrst study, this was attributed to chronic undiffer-

entiated schizophrenia that had been misdiagnosed pre-

surgically as a depression; in the second study, this person

had regained much of his preoperative weight and had a

history of suicide attempts and successful suicides of

family members. Mitchell et al. (47) reported one patient

who died by suicide because of psychiatric-related condi-

tions within a sample of 100 patients in a long-term

follow-up study (13–15 years). And, as already men-

tioned, long-term depression was identiﬁed to be the cause

of the suicide in the study by Smith et al. (50) and psy-

chiatric problems were the reason for suicide in the study

by Pekkarinen et al. (33).

Studies with control groups

In a large retrospective study of Swedish men, Marsk et al.

(39) compared mortality rates and causes of death between

a surgical cohort, an obese non-surgical cohort and a

general population cohort with a mean observation time of

7.3 years. They observed four suicides in the surgical

cohort, which did not differ signiﬁcantly from the number

of suicides in the other two cohorts. The retrospective

cohort study by Adams et al. (14) matched 7,925 gastric

bypass patients with 7,925 severely obese controls in the

USA. At a mean follow-up of 7.1 years, 15 and 5 suicides

occurred within the two groups, respectively (the rate was

2.6 per 10,000 in the surgical group and 0.9 per 10,000 in

the control group). Although a full Cox regression analysis

did not ﬁnd a signiﬁcant difference in deaths not caused by

diseases, a comparison of these death rates is signiﬁcantly

different between the two groups as it would be for the

pure suicide rate as well.

A higher suicide rate was found in the retrospective study

of Tindle et al. (15) who examined suicide rates after

weight-loss surgery on U.S. American residents within a

period of 10 years. Of the 31 suicides, the majority were

Caucasian women, but men had a higher suicide rate

within nearly all age categories (in total 6.6/10,000, for

men 13.7 and for women 5.2 per 10,000). These suicide

rates are considerably higher than those for the United

States (1.1/10,000) (WHO), but the highest suicide rate

was found for men aged 45–54 years, which is in accord-

ance with the reported suicide statistics of the whole United

States.

Estimate of suicide rate and comparison with

previous ﬁgures

Using all 28 studies, we were able to estimate the suicide

rate after bariatric surgery to be 4.1/10,000 (95% CI [3.2,

5.1]/10,000; see Fig. 1). This estimate includes 40,947

people (79.2% of whom were female), a total of 190,433

person-years and 95 suicides. The average age at time of

surgery was 39.7 years.

As the study by Tindle et al. (15) was designed to address

the question of suicide after bariatric surgery, it is therefore

interesting to compare our calculated suicide rate with their

own, which was 6.6/10,000. The rate we ﬁnd is signiﬁ-

cantly lower than that of Tindle and colleagues (P=0.03).

Furthermore, the rate one ﬁnds if one disregards the Tindle

data is 3.2/10,000 (95% CI [2.3, 4.3]/10,000), which is

also signiﬁcantly lower than their value (P=0.0003). To

test the robustness of this estimate, we repeated the analysis

leaving out the largest study (by Adams et al. (14) with

77,600 person-years) and calculated an estimated suicide

rate of 3.9/10,000 with the 95% CI [2.4, 5.8]/10,000. It is

also of interest to compare the estimated suicide rate after

6Suicide after bariatric surgery C. Peterhänsel et al.obesity reviews

bariatric surgery with that of the general population. Using

the latest WHO data, an effective population of around

26.8 million people with a suicide rate of 1.0/10,000 was

found after correcting for country, age and gender as

described in the Statistical Analysis section. When com-

pared with the estimate mentioned earlier, we found an

odds ratio of 0.25 (95% CI [0.20, 0.31] ), meaning that

the probability of a bariatric surgery patient committing

suicide is four times higher compared with the general

population (P<10-15), a difference that is particularly

alarming considering that there is signiﬁcant evidence indi-

cating that obese people tend to have a lower suicide rate

than people of normal weight, as emphasized, for example,

by Klinitzke and colleagues (56).

Drug overdoses, alcoholism and car accidents

Suicide is not the only emotional or psychiatric-related

reason for death after obesity surgery. Although we did not

explicitly search for papers investigating mortality rates not

caused by medical diseases, we found data in the selected

papers regarding car accidents, alcoholism and death fol-

lowing cirrhosis or hepatitis, drug overdoses, bulimia,

intoxications, or lack of motivation resulting in deadly

nutrient deﬁciencies.

The study by Adams et al. (14) indicated deaths that were

not related to medical diseases including 21 accidents unre-

lated to drugs, nine poisonings of undetermined intent, and

18 other deaths. In conjunction with the suicides, this trans-

lated to a 1.58 higher probability for the surgery group of

dying of a cause unrelated to medical diseases in comparison

with the control group. Pories et al. (49) found that in a

cohort of 608 people, 13 patients died because of emotional

causes, including three suicides, four cases of alcoholism

leading to either a cirrhosis (n=3) or alcoholic hepatitis

(n=1), four car accidents, one case of bulimia, and one

patient with a pernicious anaemia who had refused to take

vitamin B12. The study of Marsk et al. (39) found nine

accidents and intoxications in their retrospective study of

Swedish bariatric patients. Van de Weijgert et al. (30) pub-

lished a study of 153 patients with either a VBG or a RYGB

with a mean follow-up time of 9.9 years and reported

two patients who had died of alcohol abuse. Four other

studies mentioned one death secondary to alcohol abuse

(38,47,48,51). Attention was also paid to fatal accidents

because of the possible underlying emotional problems.

Capella and Capella (54) reported one car accident in their

group of 328 VBG patients and three in the group of 560

RYGB patients, whereas Carelli et al. (53), Suter et al. (32),

Pekkarinen et al. (33), and Busetto et al. (41) each men-

tioned one car accident in addition to suicide rates. The

incidence of drug overdoses was provided in only one study

which detailed this as the cause of death for one patient (31).

Discussion

This review provides an overview of studies examining or

mentioning the relationship between bariatric surgery and

102103104

Person–years per study

Suicide rate (estimated)

95% condence interval

Result from Tindle et al.

Result from remaining studies

Suicide rate (number per 10 000 person–years)

105

Figure 1 The suicide rate is plotted over the number of person-years. The dots represent the suicide rate observed in each of the studies and the

solid line is the estimate for the suicide rate that results from considering all of the data. A trial with a small number of person-years will still have at

least one suicide because of the inclusion criteria chosen: this is the selection bias. Because the method for estimating the suicide rate takes this

selection bias into account and because such a study will almost always have exactly one suicide, the solid curve at the far left of the plot does not

depend strongly on the precise estimate, passes close to most of the data points and has a very narrow conﬁdence interval. For a large number of

person-years, the effect of the selection bias is negligible and the curve tends to the estimate. Note that the value found by Tindle et al. lies far

outside the conﬁdence interval for the estimate despite the large number of person-years.

obesity reviews Suicide after bariatric surgery C. Peterhänsel et al.7

completed suicides. To our knowledge, it is the ﬁrst that

provides a complete overview over all completed suicides

mentioned in bariatric surgery outcome studies. Our esti-

mate for the suicide rate after bariatric surgery is signiﬁ-

cantly lower than that given by Tindle et al. (15), but

signiﬁcantly higher than the published general population

values from the WHO (19). However, we note that the

numbers published by the WHO for Sweden, for example,

differ signiﬁcantly from those quoted by Marsk et al., (39)

although each source has included a very large number of

subjects. The WHO statistics for men in Sweden are below

3.4/10,000 person-years in all age categories, whereas

the rate in Marsk et al. is 4.9/10,000 person-years. The

numbers in Tindle et al. (15) also point to a potentially

large source of discrepancy in the various statistics,

because 16 of 31 suicides were due to ‘drug overdose’,

which may not always be clear cases of suicide. As most of

the studies did not make suicides after bariatric surgery

their main focus, only a few responsible factors were dis-

cussed. The most frequently mentioned reason was related

to psychiatric abnormality, speciﬁcally depressive symp-

toms (24,50,57). It is a widely accepted fact that mental

disorders, especially depression, have a strong association

with suicide (58,59). The probability of attempted or suc-

cessful suicide in depressive people is much higher than for

the general population. A number of studies indicate a

positive association between mental disorders and extreme

obesity (55,60). Black et al. (60) found a lifetime preva-

lence of 30% for mood disorders, 23% for substance

abuse, and 48% for anxiety disorders in a morbidly obese

bariatric group, which differed signiﬁcantly from the rates

of the age and gender-matched comparison group. In

general, it is evident that obesity has a strong association

to depression, as could be found in the meta-analyses by

Luppino et al. (5) and de Wit et al. (4), who also found

women to be more at risk of developing depression than

men. Scholtz et al. (61) examined a sample of laparoscopic

banding patients and found that nearly 50% of them

developed a psychiatric disorder within 5 years surgery,

also achieving less weight loss than the others. Other

studies indicated that psychological distress in preoperative

assessments correlated with later psychiatric disturbances

(52,62).

Although an improvement of depressive symptoms post-

surgery can be documented for many patients (63), it must

be noted that depression and other psychiatric illnesses still

remain an issue for some patients (64). Pories and col-

leagues attribute this to personal differences in handling

intense changes in lifestyle, especially in terms of altering

eating behaviour and body image (65).

Other important predictors for completed suicide are

suicidal ideation and suicide attempts (66). Windover et al.

(67) found the prevalence of past suicide attempts in bari-

atric patients to be 73 times higher than within the normal

population and Chen et al. (68) observed 30% of their

population reporting suicidal ideation and 5% past suicide

attempts.

Research has also found a link between suicidal behav-

iour and impulsivity (69), even after ruling out aggression

(7). Rydén and colleagues (70) found bariatric patients to

be more impulsive and irritable than a sample of obese

patients with regular treatment and a less obese reference

group. Two years after bariatric surgery there were no

changes in the impulsiveness scale and a decrease in irrita-

bility could only be found within groups with high weight

loss (70). Sansone and colleagues (71) found higher preva-

lence rates of borderline personality disorder among gastric

surgery patients than in the general population. They

assume that as this disorder is associated with inherent

impulsivity, surgical procedures may have worse outcomes

for this group. These patients tend to over-eat and over-

extend the new gastric pouch, resulting in unsatisfying

weight loss and maybe even leading to suicide. Nederkoorn

et al. (72) showed with their results that obese women tend

to be more impulsive in comparison with lean women.

Another reason for increased suicidality could be disap-

pointment about failed weight loss or subsequent weight

regain after bariatric surgery. Regain of weight in was

found in 30% of bariatric surgery patients after 18 months

or 2 years (17), leading to a deterioration in the quality of

life and to increased suicidal ideation. Karlsson et al. (73)

describe an improvement in health-related quality of life

that is related to the magnitude of weight loss. Groups with

low levels of weight loss (<20 kg) showed a tendency to

return to baseline levels 24 month after surgery despite

their initial improvement. In the study by Valley and Grace

(74) they emphasize that psychopathology could lead to

increased food intake as a way of dealing with emotional

stress. After the surgical procedure, this strategy cannot

be used anymore, leading to more distress and medical

complications.

Many researchers have investigated for a history of

sexual abuse and maltreatment in their bariatric surgery

candidates and documented the impact of these factors on

the outcome of the surgery. Steinig and colleagues give an

overview to this topic (75), showing that 15.5% (76) to

32% (77) of the bariatric population report experience of

sexual abuse at some point in their lives and 37% report

some form of non-sexual abuse (77). They concluded that

having experienced sexual abuse has an impact on weight

loss shortly after the operation, but that this effect seems to

disappear after some time (75). It was reported, however,

that these people tend to have an increased risk of psychi-

atric comorbid diseases after surgery (77,78), and this may

also have an inﬂuence on suicide risk.

It is evident that patients become more physically active

after bariatric surgery (79) but average activity levels still

remain lower than those of people of normal weight (80).

8Suicide after bariatric surgery C. Peterhänsel et al.obesity reviews

Elkins and colleagues found that bariatric patients tend to

have problems putting post-operative recommendations

into practice and exercise is an area particularly neglected

(81). As physical activity has an important effect on

mental health (82) and weight loss (83), less exercise may

lead to further problems and therefore to increased risk of

suicide.

Another possible reason for later suicide is the recurrence

of obesity-related diseases. Patients mostly experience a

remission of diabetes and obstructive sleep apnoea after the

surgical intervention (13). But several studies have pointed

out that bariatric patients often suffer from a relapse of

these illnesses (84–86). Diabetes mellitus has been found

to re-emerge or worsen by 24% after 3 years (84) or by

43% after 5 years (85), and prevalence of obstructive

sleep apnoea also signiﬁcant increases over 7.5 years after

surgery (86). As the most reported reason for opting for

obesity surgery is the improvement of co-existing diseases

(87), it can be disappointing to experience a relapse and

this may lead to suicidal tendencies.

It is further important to mention that alcohol metabo-

lism is modiﬁed after gastric bypass and sleeve gastrectomy,

resulting in a higher blood alcohol concentration and a

longer period to decline the level to zero than before the

operation or in comparison with control subjects (88–90).

Despite this, Hagedorn and colleagues (91) found that

bariatric patients do not tend to perceive more effects of

alcohol when compared with a reference group. As bariat-

ric patients reported increases in their substance use (92),

and alcoholism is a risk factor for suicide attempts (93), it

should be observed carefully in these patients.

Further, aspects of metabolic changes associated with

obesity surgery could play an important role in the

increased suicide risk.

Ghrelin, an enteric peptide hormone, is often discussed

to have a possible impact on suicide risk. Ghrelin is pro-

duced by the areas that are affected by Roux-en-Y bypass

operation, more precisely the stomach and the duodenum

(94). Many studies show a decrease of ghrelin levels in

bariatric surgery patients, which contrasts with the ﬁnding

that normal modes of weight loss are accompanied by an

increase in ghrelin levels (95–97). Therefore, ghrelin levels

in these patients are lower than those of lean and matched-

obese controls, leading to a loss of hunger and subsequent

weight loss (95). Rimonabant, an anti-obesity drug, works

by blocking the CB1receptor, but also by decreasing ghrelin

levels, resulting in a rapid decrease of food intake (98). It

was taken off the market as it produced psychiatric distur-

bances, especially depressive symptoms, a side effect that

may be attributable to the impact of lower ghrelin levels

(99). As Kluge and colleagues point out, ghrelin may have

an antidepressant effect, implicating that the absence of

enough ghrelin may lead to depression and therefore sui-

cidal tendencies (100).

It is noteworthy that anti-obesity drugs must undergo

extensive examination regarding their effectiveness and

safety and will only be placed on the market if they meet

special quality criteria (101). Doses can also be altered, or

drug delivery tailored, to prevent unwanted reactions. Such

rigorous examination is not given for surgical procedures

although they cannot be reversed at a later point.

Another issue that could be interesting within this dis-

cussion is the ﬁnding of an increased suicide rate in patients

who have undergone a partial gastrectomy to cure ulcer

diseases (102,103). In these studies, this is mostly attrib-

uted to the personality of the patients rather than the

surgical procedure itself. It must be noted that, as sleeve

gastrectomy is the same procedure, the surgical technique

seems to have an inﬂuence on suicidal tendencies, especially

when the inﬂuence on ghrelin is considered.

The gastric bypass also often leads to the dissection of

the vagus nerve (104), which has an impact on the distri-

bution of ghrelin (105). Vagus nerve stimulation is also

used as an antidepressant therapy (106). The disruption of

signalling from this nerve again leads to lower ghrelin levels

and to a possible increase in depressive symptoms (107).

Mitchell and colleagues also mention the peptides GLP-1,

PYY and NPY as factors that have to be addressed by

future studies in their review of possible inﬂuential factors

on suicide risk (108). It must therefore be stated that the

surgical procedure itself produces effects that could lead to

increased suicidal behaviour.

Methodological limitations of the described studies

Despite the fact that a number of important conclusions

can be drawn concerning increased suicide rates after bari-

atric surgery, a number of methodological limitations must

be pointed out. First, the deﬁnition of suicides ranges

widely. The deﬁnition ranges from completed suicide to

forms such as accidents or drug overdoses, and this should

be standardized in further studies. Further, many studies do

not mention reasons for suicide or just speculate about a

possible cause without a psychological autopsy to prove

this assumption. There is also often minimal information

regarding the timing of suicide, meaning that the conclu-

sions we make about main causes of suicide and time frame

between operation and suicide are often based on presump-

tions. Additionally, most studies do not give a detailed

description regarding gender or age, despite the fact that

these are highly confounding variables regarding the risk of

completed suicide. We are therefore lacking some of the

essential information for the calculation of a suicide/per

year ratio, which is necessary for comparisons with

national suicide prevalence. Another limitation is the high

dropout rate in most long-term follow-up studies of bari-

atric surgery procedures (see Table 2). Shen and colleagues

pointed out that bariatric procedure patients who returned

obesity reviews Suicide after bariatric surgery C. Peterhänsel et al.9

more frequently for follow-up visits achieved more excess

weight loss (109). This was also conﬁrmed in the study by

Harper et al. who underlined the importance of regular

follow-up visits to monitor for weight loss, possible com-

plications and co-existing diseases (110). Possible reasons

for non-attendance could be that patients are unsatisﬁed

with their weight loss or even embarrassed about weight

regain, discouraging them from searching for assistance.

Also, failure to lose weight could lead to reduced conﬁ-

dence in the skills of the surgeon or the medical team (110).

Furthermore, most studies did not evaluate their dropout

patients by searching death registers, which would give

more accurate fatality results. Therefore, it remains unclear

whether patients lost to follow-up may have a poorer

outcome, possibly even leading to increased suicidal ten-

dencies, meaning that the total suicide rate calculated by

many studies could be underestimated. Generally, only a

very low percentage of eligible obese patients choose a

surgical treatment option. Very little is known about

whether this group might have higher levels of affective

disorders or impulsivity when compared with non-surgical

patients. Future research should focus on comparison

studies focusing on preoperative mental disorders.

Implications

Within the chosen papers we found suicides occurring after

18 months post-surgery, and Tindle et al. (15) observed

that 70% of patients who committed suicide did so within

the 3 years of the operation. Multi-professional teams

working with bariatric patients should keep this in mind

and offer a continuous follow-up programme to attend

and support patients in case of problematic situations. To

establish and maintain well-elaborated post-operative care

routines, sufﬁcient resources should be provided and

administrators should be informed about this topic. The

time frame of suicide risk should be taken into considera-

tion and it would be best if post-operative treatment did

not end after 1 year, instead being a continued option for

the rest of the patient’s life (111).

Furthermore, professional assistance has to start even

before surgery. More focus should be placed upon provid-

ing patients with detailed information about the conse-

quences of such an operation, with emphasis upon

advantages, disadvantages and possible complications.

Further, it has also been recommended that psychological

evaluation should be undertaken for every patient to

Table 2 List of papers included for the estimate of the suicide rate in decreasing order of person-years

Person-years Weight # of patients # of women # of suicides Country

Adams 77,602 0.5397 9,949 8,556 21 USA

Marceau 10,388 0.0722 1,423 1,025 6 Canada

Marsk 8,877 0.0617 1,216 0 4 Sweden

Pories 8,316 0.0578 594 494 3 USA

Carelli 6,057 0.0421 2,909 1,989 1 USA

Busetto 4,598 0.0320 821 618 1 Italy

Smith 1995 (51) 3,882 0.0270 1,762 1,567 2 USA

Peeters 3,478 0.0242 966 744 1 Australia

Christou 2,599 0.0181 228 187 2 Canada

Günther 2,244 0.0156 98 82 1 Germany

Capella 2,237 0.0156 888 730 3 USA

Suter 2011 (31) 2,152 0.0150 379 282 3 Switzerland

Suter 2006 (32) 1,639 0.0114 311 269 1 Switzerland

Van de Weijgert 1,634 0.0114 200 174 1 Netherlands

Cadière 1,362 0.0095 470 392 1 Belgium

Mitchell 1,121 0.0078 85 72 1 USA

Himpens 1,066 0.0074 82 74 1 Belgium

Näslund 1994 (38) 799 0.0056 85 69 2 Sweden

Forsell 761 0.0053 326 248 1 Sweden

Powers 1997 (55) 747 0.0052 131 111 1 USA

Kral 477 0.0033 69 56 1 USA/Sweden

Näslund 1995 (35) 457 0.0032 142 84 1 Sweden

Powers 1992 (52) 395 0.0027 100 85 1 USA

Smith 2004 (50) 354 0.0025 779 1 USA

Nocca 228 0.0016 133 90 1 France

Svenheden 166 0.0012 91 72 1 Sweden

Pekkarinen 146 0.0010 27 19 1 Finland

The column entitled ‘weight’ is the fraction of the total number of person-years and is used in the analysis for comparing the estimated suicide rate

for patients after a bariatric operation with the rate for an equivalent general population.

10 Suicide after bariatric surgery C. Peterhänsel et al.obesity reviews

examine for psychopathology, their motivation for the

operation, their understanding of the chosen procedure,

and their awareness of the need to restructure their diet

and exercise after the procedure. Evidence from previous

studies imply that patients with severe psychopathology

should be excluded, as should patients with lacking moti-

vation to change their lifestyle (112). Surgery should also

be removed from consideration as a treatment option if a

candidate is unwilling to agree to lifelong follow-up care.

That said, no consensus regarding psychological evaluation

currently exists, and clear contraindication protocols for

the exclusion of patients could be useful (112,113).

Summary

In conclusion, this review shows that bariatric surgery

patients suffer from an increased risk of suicide, compared

with the general population, although the rate we describe

is lower than that reported by Tindle et al. in a trial exam-

ining precisely this topic (15). Only a few studies described

reasons for suicide. Among those listed were pre-surgical

psychiatric disorders, mood disorders and ﬁnancial prob-

lems. Only three studies used a control group without

bariatric surgery; therefore, future research should focus

on long-term follow-up study designs involving a control

group without bariatric surgery to evaluate more precisely

the effect that surgical procedures have on patients. It is

recommended that psychological assessment and monitor-

ing is carried out on patients after bariatric surgery to

identify those who suffer from mood disorders or suicidal

ideation.

Conﬂict of interest statement

No conﬂict of interest was declared.

Acknowledgements

This work was supported by the Federal Ministry of Edu-

cation and Research (BMBF), Germany, FKZ: 01EO1001.

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Zero-Truncated Modelling Meta-Analysis for When Studies with No Events Are Systematically Excluded: Estimating Completed Suicide After Bariatric Surgery

Preprint

Full-text available

May 2023

Meta-analysis is a well-established method for integrating results from several independent studies to estimate a common quantity of interest. However, meta-analysis is prone to selection bias, notably when particular studies are systematically excluded. This can lead to bias in estimating the quantity of interest. Motivated by a meta-analysis to estimate the rate of completed suicide after bariatric surgery, where studies which reported no suicides were excluded, a novel zero-truncated count modelling approach was developed. This approach addresses heterogeneity, both observed and unobserved, through covariate and overdispersion modelling, respectively. Additionally, through the Horvitz-Thompson estimator, an approach was developed to estimate the number of excluded studies, a quantity of potential interest for researchers. Uncertainty quantification for both estimation of suicide rates and number of excluded studies was achieved through a parametric bootstrapping approach.

Bariatric surgery and mental health outcomes: an umbrella review

Article

Full-text available

Nov 2023

Aims To evaluate the breadth, depth and effectiveness of the evidence quality of all existing studies on bariatric surgery and mental health outcomes. Design Umbrella review of existing Systematic review and meta-analyses. Data sources PubMed, Embase, Web of Science, and the Cochrane Liberally databases of Systematic review and meta-analyses, and hand searching the reference lists of eligible publications. Results The search identified nine studies and 20 mental health outcomes from 1251 studies. Evidence shows that bariatric surgery is associated with significant improvement in areas such as anxiety, depression and eating disorders (including binge-eating disorder), and there is a significant harmful association with suicide, self-harm and alcohol use disorder (AUD). Among them, the most studied outcome is depression (4 articles). High-quality evidence proves that the score of depressive symptoms can be significantly improved after bariatric surgery within a two-year follow-up period and is not affected by the follow-up time. Low-quality evidence shows that bariatric surgery can significantly reduce depressive symptoms regardless of age and BMI, with an odds ratio (OR) of 0.49. Regardless of the postoperative BMI, the anxiety symptoms of women over 40 still decreased significantly, with an OR of 0.58. Regardless of the type of surgery, surgery can significantly reduce the incidence of eating disorders and symptoms. However, there is no obvious change in the follow-up time of AUD in the first two years after bariatric surgery, and the risk increases obviously in the third year, with an OR of 1.825. The evidence of moderate research shows that the risk of suicide and self-harm increases after bariatric surgery. The odds ratios in the same population and the control group were 1.9 and 3.8 times, respectively. Conclusion Bariatric surgery is beneficial for improving most mental health-related outcomes. However, we should be cautious about the increased risk of adverse mental health after surgery, such as suicide, self-harm, and AUD.

Prävention und Management von postinterventioneller GewichtszunahmePrevention and management of postinterventional weight regain

Article

Full-text available

Oct 2023

Zusammenfassung Die Ursachen der postinterventionellen Gewichtszunahme nach Lebensstiländerung, psychologischer Therapie, Pharmakotherapie oder chirurgischen Maßnahmen gehen weit über einen Motivations- oder Compliance-Verlust der Betroffenen hinaus. Der Gewichtszunahme liegen komplexe periphere und zentrale Mechanismen zugrunde, deren Ausmaß individuell unterschiedlich zu sein scheint und die darauf ausgerichtet sind, die Nahrungszufuhr durch reduziertes Sättigungs- und vermehrtes Hungergefühl zu erhöhen (gastrointestinale Hormone) und den Energieverbrauch zu reduzieren (metabolische Adaptierung). Diese Mechanismen erschweren das Abnehmen und Gewichthalten in einem „adipogenen“ Lebensraum, wie wir in weltweit immer häufiger vorfinden, ungemein. Das Verständnis dieser molekularen Mechanismen sollte in die Planung von Therapieprogrammen zur langfristigen Gewichtsreduktion, welche eine entsprechende Nachsorge zur Prävention und individualisierten Therapie einer postinterventionellen Gewichtszunahme beinhalten sollten, miteinbezogen werden. Dabei empfiehlt es sich, die therapeutischen Maßnahmen und Kontrollintervalle nach dem Ausmaß der Gewichtszunahme pro Zeitintervall auszurichten.

Pre-Operative Substance Use Disorder is Associated with Higher Risk of Long-Term Mortality Following Bariatric Surgery

Article

Full-text available

Apr 2023
OBES SURG

Purpose Metabolic and bariatric surgery (MBS) has been associated with reduced all-cause mortality. While the number of subjects with substance use disorders (SUD) before MBS has been documented, the impact of pre-operative SUD on long-term mortality following MBS is unknown. This study assessed long-term mortality of patients with and without pre-operative SUD who underwent MBS. Materials and Methods Two statewide databases were used for this study: Utah Bariatric Surgery Registry (UBSR) and the Utah Population Database. Subjects who underwent MBS between 1997 and 2018 were linked to death records (1997–2021) to identify any death and cause for death following MBS. All deaths (internal, external, and unknown reasons), internal deaths, and external deaths were the primary outcomes of the study. External causes of death included death from injury, poisoning, and suicide. Internal causes of death included deaths that were associated with natural causes such as heart disease, cancer, and infections. A total of 17,215 patients were included in the analysis. Cox regression was used to estimate hazard ratios (HR) of controlled covariates, including the pre-operative SUD. Results The subjects with pre-operative SUD had a 2.47 times higher risk of death as compared to those without SUD (HR = 2.47, p < 0.01). Those with pre-operative SUD had a higher internal cause of death than those without SUD by 129% (HR = 2.29, p < 0.01) and 216% higher external mortality risk than those without pre-operative SUD (HR = 3.16, p < 0.01). Conclusion Pre-operative SUD was associated with higher hazards of all-cause, internal cause, and external cause mortality in patients who undergo bariatric surgery. Graphical Abstract

Identification of Risk Factors for Suicide and Insights for Developing Suicide Prevention Technologies: A Systematic Review and Meta-Analysis

Article

Full-text available

Mar 2023

Suicide is a termite that engulfs close to seven hundred thousand people worldwide each year. Existing work on risk factors that predict suicide lacks statistical associations, does not consider most countries, and has a wide range of risk factor domains. The goal of this systematic review and meta-analysis is to enhance our current understanding of suicidality by identifying risk factors that are most strongly associated with suicide and their impact on developing technological interventions for suicide prevention. A search strategy was carried out on four databases: (1) PsycINFO, (2) IEEE Xplore, (3) the ACM Digital Library, and (4) PubMed, and twenty-five studies were included based on the inclusion criteria. Factors statistically associated with suicide are any diagnosed mental disorder, adverse life events, past suicide attempts, low education level, loneliness or high levels of isolation, bipolar disorder, depression, multiple chronic health conditions, family history of suicide, sexual trauma, and being female. Domain-wise, comorbid disorders, and behavior-related risk factors are most strongly associated with suicide. We present a new hierarchical model of risk factors for suicide that advances our understanding of suicide and its causes. Finally, we present open research directions and considerations for developing suicide prevention technologies.

Psychiatric, psychological and addiction management in obesity surgery: Early identification for better support

Article

Jan 2023

Although bariatric surgery results in a significant weight reduction and an improvement in the quality of life in most people who undergo surgery, there are inter-individual differences in terms of postoperative results. Psychological, psychiatric and addictive disorders contribute substantially to these difficulties. Between 20% and 50% of bariatric surgery candidates have a current psychiatric/addictive disorder and approximately 30-75% have a history of a psychiatric/addictive disorder within their lifetime. Surgery is accompanied in the short-term by an improvement in depressive symptoms and binge eating, but these symptoms tend to increase again beyond the 3rd postoperative year. Over the long-term, only the improvement in depression remains durable, whilepostoperative anxiety and disordered eating symptoms do not differ significantly from the preoperative levels. There is a two to four fold increased risk of post-surgical suicide and suicide attempts (from the 1st postoperative year onward), as well as an increased risk of alcohol-abuse (beyond two years after surgery). Psychological support must therefore continue long-term. Several psychotherapeutic and pharmacological treatments have demonstrated their effectiveness in improving the postoperative prognosis of patients with psychological/psychiatric disorders. The early integration of psychological/psychiatric/addiction evaluation and support into multidisciplinary management makes it easier to identify these difficulties and to optimize the postoperative prognosis, both in terms of weight and quality of life. Prior to surgery, patients should be systematically evaluated by a psychologist or psychiatrist in order to identify and to manage disorders that could negatively impact the postoperative prognosis. After surgery, this assessment and support can be carried out in a programmed and systematic way for those patients who were identified preoperatively as the most vulnerable, but support can also be offered during follow-up in the event of specific symptoms (i.e., loss of control over food intake, failure in terms of weight or quality of life, suicidal ideation, loss of control over alcohol use, significant depression or anxiety symptoms).

Suicide Attempts after Bariatric Surgery: Comparison to a Non-surgical Cohort of Individuals with Severe Obesity

Article

Sep 2023
SURG OBES RELAT DIS

Pre‐Operative Management: Psychological Aspects

Chapter

Nov 2022

Chris Gillespie

Psychological Assessment of the Bariatric Surgery Patient

Chapter

Feb 2023

Denise Ratcliffe

Psychological assessments are an integral part of the bariatric surgery process, and it is important to be clear about the purpose and function of these assessments. The purpose of the psychological assessment has shifted from identifying contraindications for surgery and evolved toward assessing psychological and behavioral readiness and adjustment challenges which may arise. While there are higher rates of psychological morbidity among bariatric candidates, no single preoperative psychological predictor of outcome has been identified. It is important to assess for psychological readiness for bariatric surgery as the weight loss outcomes are highly dependent on the individual implementing and maintaining significant behavior changes. While there is significant variability in the methods and outcomes of these assessments, there is a general consensus about the domains that should be covered. The chapter will provide an outline of the key areas that should be included in a preoperative bariatric psychological assessment. The psychologist undertaking the assessment needs specific experience and knowledge of bariatric surgery as well as the preoperative and postoperative issues that may arise. The assessment should lead to individualized recommendations and possible psychological interventions in order to minimize the impact of psychological risk factors on weight loss and psychosocial outcomes. The psychological assessment may generate useful clinical information for other members of the multidisciplinary team. The assessment is an opportunity to help individuals make informed decisions about bariatric surgery. It also helps to raise their awareness of the preoperative preparatory behavioral changes they are recommended to make to optimize their postoperative outcomes.

Psychological Issues Before and After Bariatric Surgery

Chapter

Feb 2023

Vanessa Snowdon-Carr

Bariatric surgery is an extremely effective treatment for severe and complex obesity. However, changes are dramatic and rapid and therefore, it is a psychologically demanding intervention even for patients who experience very positive outcomes. A person’s weight and eating history, past attempts to lose weight, and self-efficacy will influence the decision to have weight loss surgery. Past dieting “failure” can result in desperation and the belief that weight loss is not possible by any other means. The complex relationship between mental health and obesity also impacts on a person’s ability to make lifestyle changes. There is a wide range of adjustments to be made postoperatively as a result of the significant changes to eating, weight, identity, and coping. Difficulties can occur with each of these issues and therefore, appropriate detection and provision of psychological support is required. Better understanding of factors which previously led to, and maintained, obesity and postoperative issues may help to improve outcome for the significant minority of patients who either regain weight or have other adjustment difficulties. Health professionals need to have a greater understanding of the range of psychological and social factors influencing outcome.

Meta-analysis: Surgical treatment of obesity (vol 142, pg 547, 2005)

Article

Sep 2005

Selected major risk factors and global regional burden of disease

Article

Jan 2002

The weight reduction operation of choice, vertical banded gastroplasty or gastric bypass?

Article

Apr 1995
GASTROENTEROLOGY

Equation of State Calculations by Fast Computing Machines

Article

Jan 1935

R.A. Fisher

Bariatric surgery: A systematic review and meta-analysis

Article

Jan 2004

Psychiatric Issues in Bariatric Surgery

Conference Paper

Nov 1992

In this study, 100 patients were evaluated prior to surgery to assess psychiatric status. The demographic anthropometric and psychological characteristics are described. Seventeen patients developed severe psychiatric complications and required hospitalization; the diagnoses which precipitated hospital admission were most commonly affective disorders (especially major depression with suicidal ideation). The only deaths in the sample of 100 occurred among the patients who required post-surgical psychiatric hospitalization. The hospitalized group was compared to a matched group drawn from the original 100 patients. Factors associated with post-surgical psychiatric hospitalization were: pre-surgical psychiatric hospitalization, presence of multiple pre-surgical Axis I psychiatric diagnoses, and untreated Axis I diagnosis at the time of pre-surgical assessment. Psychiatric screening criteria were revised and 31 subsequent patients were evaluated; less than half of this group were found suitable for surgery at the time of preliminary assessment.

Overweight, Obesity, and Health Risk

Article

Apr 2000
ARCH INTERN MED

More than half of adult Americans are overweight or obese, and public health recommendations call for weight loss in those who are overweight with associated medical conditions or who are obese. However, some controversy exists in the lay press and in the medical literature about the health risks of obesity. We review briefly the large body of evidence indicating that higher levels of body weight and body fat are associated with an increased risk for the development of numerous adverse health consequences. Efforts to prevent further weight gain in adults at risk for overweight and obesity are essential. For those whose present or future health is at risk because of their obesity and who are motivated to make lifestyle changes, a recommendation for weight loss is appropriate.

Stomach Is a Major Source of Circulating Ghrelin, and Feeding State Determines Plasma Ghrelin-Like Immunoreactivity Levels in Humans

Article

Oct 2001

H. Ariyasu

Team RDC.R: A Language And Environment For Statistical Computing. R Foundation for Statistical Computing: Vienna, Austria

Technical Report

Jan 2012

Core R Team

Screening and Interventions for Obesity in Adults: Summary of the Evidence for the U.S. Preventive Services Task Force

Article

Dec 2003

Kathleen M Mctigue

Background: Obesity poses a considerable and growing health burden. This review examines evidence for screening and treating obesity in adults. Data Sources: MEDLINE and Cochrane Library (January 1994 through February 2003). Study Selection: Systematic reviews; randomized, controlled trials; and observational studies of obesity's health outcomes or efficacy of obesity treatment. Data Extraction: Two reviewers independently abstracted data on study design, sample, sample size, treatment, outcomes, and quality. Data Synthesis: No trials evaluated mass screening for obesity, so the authors evaluated indirect evidence for efficacy. Pharmacotherapy or counseling interventions produced modest (generally 3 to 5 kg) weight loss over at least 6 or 12 months, respectively. Counseling was most effective when intensive and combined with behavioral therapy. Maintenance strategies helped retain weight loss. Selected surgical patients lost substantial weight (10 to 159 kg over 1 to 5 years). Weight reduction improved blood pressure, lipid levels, and glucose metabolism and decreased diabetes incidence. The internal validity of the treatment trials was fair to good, and external validity was limited by the minimal ethnic or gender diversity of volunteer participants. No data evaluated counseling harms. Primary adverse drug effects included hypertension with sibutramine (mean increase, 0 mm Hg to 3.5 mm Hg) and gastrointestinal distress with orlistat (1% to 37% of patients). Fewer than 1% (pooled samples) of surgical patients died; up to 25% needed surgery again over 5 years. Conclusions: Counseling and pharmacotherapy can promote modest sustained weight loss, improving clinical outcomes. Pharmacotherapy appears safe in the short term; long-term safety has not been as strongly established. In selected patients, surgery promotes large amounts of weight loss with rare but sometimes severe complications.