ArticlePDF AvailableLiterature Review

Risk of completed suicide after bariatric surgery: A systematic review

  • MindDoc by Schön Klinik

Abstract and Figures

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.
Content may be subject to copyright.
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,
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.
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)
The fact that increasing numbers of people are over-
weight (body mass index [BMI] 25 kg m-2) or obese
(BMI 30 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
1© 2013 The Authors
obesity reviews © 2013 International Association for the Study of Obesity
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
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).
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
© 2013 The Authors
obesity reviews © 2013 International Association for the Study of Obesity
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.
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
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
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
© 2013 The Authors
obesity reviews © 2013 International Association for the Study of Obesity
Table 1 Summary of the included studies in alphabetical order
Study Sample size
(age standard
deviation [range] )
Country Follow-up (range) Surgical procedure Major findings Suicide rate
(% of initial
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
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%
Italy Mean: 5.6 2.9
years and 7.2 1.2
Laparoscopic adjustable
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%
Belgium Median: 35 months
(12–66) for PGB; 34
months (12–66) for
Laparoscopic gastric bypass
(primary 362, secondary 108)
1 suicide two years after the procedure 0.2% 18.4%
Capella and
Capella, 1996
N=328 VBG, 560
VBG-RYGB (mean: 37
82.2% women, 17.8%
USA Up to 5 years VBG or VBG with RYGB
1 suicide, 1 automobile accident (VBG), 2
suicides and 3 automobile accidents
0.3% 28–59%
Carelli et al.,
2010 (53)
N=2,909 patients
(44.63 [18–79] )
68.3% women, 31.7%
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
Gastric bypass (short- and
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
Swedish adjustable gastric
1 suicide 0.3% 3%
Goldfeder et al.,
2006 (23)
N=107 deaths of
patients who had
undergone bariatric
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%
Germany Mean: 22.9 years
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%
USA Laparoscopic RYGB 1 suicide thought to be related to
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%
Belgium Median: 13 years Laparoscopic adjustable
1 suicide for financial reasons 1.2% 45.7%
Kral et al., 1993
N=69 (38 [21–56] ) 81.2% women, 18.8%
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
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
100% men Sweden Mean: 7.3 years
62% restrictive procedures
(VBG, gastric banding), 31,7%
gastric bypass, 6,3% jejunoileal
4 suicides, 9 accidents and intoxications
in the surgical group
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%
Sweden Mean: 9.8 years
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
© 2013 The Authors
obesity reviews © 2013 International Association for the Study of Obesity
Table 1 Continued
Study Sample size
(age standard
deviation [range] )
Country Follow-up (range) Surgical procedure Major findings Suicide rate
(% of initial
Dropout rate
Näslund et al.,
1995 (35)
N=158 (mean: 39.3
74.6% women, 25.4%
Sweden 1 to 7 years VBG 1 suicide 0.5% 20.2%
Nocca et al.,
2008 (34)
N=163 (mean: 41.57
68% women, 32% men France 24 months Laparoscopic sleeve
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%
et al., 1994 (33)
N=27 patients (36
years [22–48] )
70% women, 30% men Finland Mean: 5.4 years
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%
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
at 3-year
Powers et al.,
1997 (55)
(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
[13–69] )
88.9% women, 11.1%
USA 7 years RYGB (primary or in revisional
2 suicides, 1 alcoholic cirrhosis 0.05% 73% did not
respond to
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
0.1% 65% after 1
Suter et al.,
2006 (32)
N=317 patients (38
years [19–69])
86.4% women, 13.6%
Switzerland Mean: 74 months
Laparoscopic gastric banding 1 suicide after 5 years, 1 accident after
5 month
0.3% 18.5% after 7
Suter et al.,
2011 (31)
N=379 (39.4) 74.4% women, 25.6%
Switzerland 5 years Laparoscopic RYGB 3 suicides, 1 drug overdose 0.8% 5.1–10.1%
et al., 1997 (36)
N=91 (age not
79.1% women, 20.9%
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
82.3% women, 17.7%
USA Mixed 31 suicides: mean age: 45 years,
primarily female and white, mean time to
death: 3 years after surgery
Van de Weijgert
et al., 1999 (30)
N=153 (RYGB: 33 8
[18–49], VBG: 35 9
[19–52] )
RYGB: 63 women, 12
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
© 2013 The Authors
obesity reviews © 2013 International Association for the Study of Obesity
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
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
© 2013 The Authors
obesity reviews © 2013 International Association for the Study of Obesity
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).
This review provides an overview of studies examining or
mentioning the relationship between bariatric surgery and
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)
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
© 2013 The Authors
obesity reviews © 2013 International Association for the Study of Obesity
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
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
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
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
© 2013 The Authors
obesity reviews © 2013 International Association for the Study of Obesity
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
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
© 2013 The Authors
obesity reviews © 2013 International Association for the Study of Obesity
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.
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
© 2013 The Authors
obesity reviews © 2013 International Association for the Study of Obesity
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).
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
Conflict of interest statement
No conflict of interest was declared.
This work was supported by the Federal Ministry of Edu-
cation and Research (BMBF), Germany, FKZ: 01EO1001.
1. WHO. Obesity and overweight, Fact sheet No 311. 2012.
[WWW document]. URL
factsheets/fs311/en/index.html (accessed 16 August 2012).
2. National Task Force on the Prevention and Treatment of
Obesity. Overweight, obesity, and health risk. Arch Intern Med
2000; 160: 898–904.
3. Must A, Spadano J, Coakley EH, Field AE, Colditz G, Dietz
WH. The disease burden associated with overweight and obesity.
JAMA 1999; 282: 1523–1529.
4. de Wit L, Luppino F, van Straten A, Penninx B, Zitman F,
Cuijpers P. Depression and obesity: a meta-analysis of community-
based studies. Psychiatry Res 2010; 178: 230–235.
5. Luppino FS, de Wit LM, Bouvy PF et al. Overweight, obesity,
and depression: a systematic review and meta-analysis of longitu-
dinal studies. Arch Gen Psychiatry 2010; 67: 220–229.
6. Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJ.
Selected major risk factors and global and regional burden of
disease. Lancet 2002; 360: 1347–1360.
7. Fontaine KR, Redden DT, Wang C, Westfall AO, Allison
DB. Years of life lost due to obesity. JAMA 2003; 289: 187–
8. McTigue KM, Harris R, Hemphill B et al. Screening and inter-
ventions for obesity in adults: summary of the evidence for the US
Preventive Services Task Force. Ann Intern Med 2003; 139: 933–
9. Wadden TA, Sternberg JA, Letizia KA, Stunkard AJ, Foster GD.
Treatment of obesity by very low calorie diet, behavior therapy,
and their combination: a five-year perspective. Int J Obes 1989;
13(Suppl. 2): 39–46.
10. Glazer G. Long-term pharmacotherapy of obesity 2000: a
review of efficacy and safety. Arch Intern Med 2001; 161: 1814–
11. Maggard MA, Shugarman LR, Suttorp M et al. Meta-analysis:
surgical treatment of obesity. Ann Intern Med 2005; 142: 547–
12. Sjostrom L, Lindroos AK, Peltonen M et al. Lifestyle, diabetes,
and cardiovascular risk factors 10 years after bariatric surgery. N
Engl J Med 2004; 351: 2683–2693.
13. Buchwald H, Avidor Y, Braunwald E et al. Bariatric surgery: a
systematic review and meta-analysis. JAMA 2004; 292: 1724–
14. Adams TD, Gress RE, Smith SC et al. Long-term mortality
after gastric bypass surgery. N Engl J Med 2007; 357: 753–
15. Tindle HA, Omalu B, Courcoulas A, Marcus M, Hammers J,
Kuller LH. Risk of suicide after long-term follow-up from bariatric
surgery. Am J Med 2010; 123: 1036–1042.
16. Mirabelli D, Petroni ML, Ferrante D, Merletti F. Risk of
suicide and bariatric surgery. Am J Med 2011; 124: e17; author
reply e19.
17. Hsu LK, Benotti PN, Dwyer J et al. Nonsurgical factors that
influence the outcome of bariatric surgery: a review. Psychosom
Med 1998; 60: 338–346.
18. Heneghan HM, Heinberg L, Windover A, Rogula T, Schauer
PR. Weighing the evidence for an association between obesity and
suicide risk. Surg Obes Relat Dis 2012; 8: 98–107.
19. WHO. Country reports and charts available. 2012. [WWW
document]. URL
suicide/country_reports/en/index.html (accessed 18 August 2012).
20. Inge TH, Krebs NF, Garcia VF et al. Bariatric surgery for
severely overweight adolescents: concerns and recommendations.
Pediatrics 2004; 114: 217–223.
21. Tsai WS, Inge TH, Burd RS. Bariatric surgery in adolescents:
recent national trends in use and in-hospital outcome. Arch Pediatr
Adolesc Med 2007; 161: 217–221.
22. Halverson JD, Wise L, Wazna MF, Ballinger WF. Jejunoileal
bypass for morbid obesity critical appraisal. Am J Med 1978; 64:
23. Goldfeder LB, Ren CJ, Gill JR. Fatal complications of bariat-
ric surgery. Obes Surg 2006; 16: 1050–1056.
24. Higa KD, Boone KB, Ho T. Complications of the laparoscopic
Roux-en-Y gastric bypass: 1,040 patients what have we learned?
Obes Surg 2000; 10: 509–513.
25. Selvin S. Maximum likelihood estimation in the truncated,
single parameter, discrete exponential family. Am Stat 1971; 25:
obesity reviews Suicide after bariatric surgery C. Peterhänsel et al.11
© 2013 The Authors
obesity reviews © 2013 International Association for the Study of Obesity
26. Venzon DJ, Moolgavkar SH. A method for computing profile-
likelihood-based confidence-intervals. Appl Stat 1988; 37: 87–94.
27. Team RDC. R: A language and environment for statistical
computing. Vienna, Austria: R Foundation for Statistical Comput-
ing, 2011.
28. Fisher RA. The logic of inductive inference. J R Stat Soc 1935;
98: 39–82.
29. Fisher RA. Confidence-limits for a cross-product ratio. Aust J
Stat 1962; 4: 41.
30. van de Weijgert EJHM, Ruseler CH, Elte JWF. Long-term
follow-up after gastric surgery for morbid obesity: preoperative
weight loss improves the long-term control of morbid obesity after
vertical banded gastroplasty. Obes Surg 1999; 9: 426–432.
31. Suter M, Donadini A, Romy S, Demartines N, Giusti V.
Laparoscopic Roux-en-Y gastric bypass: significant long-term
weight loss, improvement of obesity-related comorbidities and
quality of life. Ann Surg 2011; 254: 267–273.
32. Suter M, Calmes JM, Paroz A, Giusti V. A 10-year experience
with laparoscopic gastric banding for morbid obesity: high
long-term complication and failure rates. Obes Surg 2006; 16:
33. Pekkarinen T, Koskela K, Huikuri K, Mustajoki P. Long-term
results of gastroplasty for morbid obesity: binge-eating as a pre-
dictor of poor outcome. Obes Surg 1994; 4: 248–255.
34. Nocca D, Krawczykowsky D, Bomans B et al. A prospective
multicenter study of 163 sleeve gastrectomies: results at 1 and 2
years. Obes Surg 2008; 18: 560–565.
35. Näslund E, Backman L, Granstrom L, Stockeld B. Does the
size of the upper pouch affect weight-loss after vertical banded
gastroplasty. Obes Surg 1995; 5: 378–381.
36. Svenheden KE, Akesson LA, Holmdahl C, Naslund I. Staple
disruption in vertical banded gastroplasty. Obes Surg 1997; 7:
136–138; discussion 139–141.
37. Forsell P, Hallerback B, Glise H, Hellers G. Complications
following Swedish adjustable gastric banding: a long-term follow-
up. Obes Surg 1999; 9: 11–16.
38. Näslund E, Granstrom L, Stockeld D, Backman L. Marlex
mesh gastric banding a 7–12 year follow-up. Obes Surg 1994; 4:
39. Marsk R, Naslund E, Freedman J, Tynelius P, Rasmussen F.
Bariatric surgery reduces mortality in Swedish men. Br J Surg
2010; 97: 877–883.
40. Kral JG, Gortz L, Hermansson G, Wallin GS. Gastroplasty for
obesity: long-term weight loss improved by vagotomy. World J
Surg 1993; 17: 75–78; discussion 79.
41. Busetto L, Mirabelli D, Petroni ML et al. Comparative long-
term mortality after laparoscopic adjustable gastric banding versus
nonsurgical controls. Surg Obes Relat Dis 2007; 3: 496–502;
discussion 502.
42. Cadière GB, Himpens J, Bazi M et al. Are laparoscopic gastric
bypass after gastroplasty and primary laparoscopic gastric bypass
similar in terms of results? Obes Surg 2011; 21: 692–698.
43. Himpens J, Cadiere GB, Bazi M, Vouche M, Cadiere B, Dapri
G. Long-term outcomes of laparoscopic adjustable gastric
banding. Arch Surg 2011; 146: 802–807.
44. Günther K, Vollmuth J, Weissbach R, Hohenberger W, Huse-
mann B, Horbach T. Weight reduction after an early version of the
open gastric bypass for morbid obesity: results after 23 years. Obes
Surg 2006; 16: 288–296.
45. Marceau P, Biron S, Hould FS et al. Duodenal switch: long-
term results. Obes Surg 2007; 17: 1421–1430.
46. Peeters A, O’Brien PE, Laurie C et al. Substantial intentional
weight loss and mortality in the severely obese. Ann Surg 2007;
246: 1028–1033.
47. Mitchell JE, Lancaster KL, Burgard MA et al. Long-term
follow-up of patients’ status after gastric bypass. Obes Surg 2001;
11: 464–468.
48. Christou NV, Look D, Maclean LD. Weight gain after short-
and long-limb gastric bypass in patients followed for longer than
10 years. Ann Surg 2006; 244: 734–740.
49. Pories WJ, Swanson MS, Macdonald KG et al. Who would
have thought it an operation proves to be the most effective
therapy for adult-onset diabetes-mellitus. Ann Surg 1995; 222:
50. Smith SC, Edwards CB, Goodman GN, Halversen RC, Simper
SC. Open versus laparoscopic Roux-en-Y gastric bypass: compari-
son of operative morbidity and mortality. Obes Surg 2004; 14:
51. Smith SC, Goodman GN, Edwards CB. Roux-en-Y gastric
bypass: a 7-year retrospective review of 3,855 patients. Obes Surg
1995; 5: 314–318.
52. Powers PS, Boyd F, Blair CR, Stevens B, Rosemurgy A.
Psychiatric issues in bariatric surgery. Obes Surg 1992; 2: 315–
53. Carelli AM, Youn HA, Kurian MS, Ren CJ, Fielding GA.
Safety of the laparoscopic adjustable gastric band: 7-year data
from a U.S. center of excellence. Surg Endosc 2010; 24: 1819–
54. Capella JF, Capella RF. The weight reduction operation of
choice: vertical banded gastroplasty or gastric bypass? Am J Surg
1996; 171: 74–79.
55. Powers PS, Rosemurgy A, Boyd F, Perez A. Outcome of gastric
restriction procedures: weight, psychiatric diagnoses, and satisfac-
tion. Obes Surg 1997; 7: 471–477.
56. Klinitzke G, Steinig J, Bluher M, Kersting A, Wagner B.
Obesity and suicide risk in adults a systematic review. J Affect
Disord 2012. doi: 10.1016/j.jad.2012.07.010.
57. Vagenas K, Panagiotopoulos S, Kehagias I, Karamanakos SN,
Mead N, Kalfarentzos F. Prospective evaluation of laparoscopic
Roux en Y gastric bypass in patients with clinically severe obesity.
World J Gastroenterol 2008; 14: 6024–6029.
58. Beskow J. Depression and suicide. Pharmacopsychiatry 1990;
23(Suppl. 1): 3–8.
59. Harris EC, Barraclough B. Suicide as an outcome for mental
disorders a meta-analysis. Br J Psychiatry 1997; 170: 205–228.
60. Black DW, Goldstein RB, Mason EE. Prevalence of mental
disorder in 88 morbidly obese bariatric clinic patients. Am J Psy-
chiatry 1992; 149: 227–234.
61. Scholtz S, Bidlake L, Morgan J et al. Long-term outcomes
following laparoscopic adjustable gastric banding: postoperative
psychological sequelae predict outcome at 5-year follow-up. Obes
Surg 2007; 17: 1220–1225.
62. Davidson T, Rohde P, Wastell C. Psychological profile and
outcome in patients undergoing gastroplasty for morbid obesity.
Obes Surg 1991; 1: 177–180.
63. Herpertz S, Kielmann R, Wolf AM, Langkafel M, Senf W,
Hebebrand J. Does obesity surgery improve psychosocial function-
ing? A systematic review. Int J Obes 2003; 27: 1300–1314.
64. Pories WJ, MacDonald KG Jr, Flickinger EG et al. Is type II
diabetes mellitus (NIDDM) a surgical disease? Ann Surg 1992;
215: 633–642; discussion 643.
65. Pories WJ, Caro JF, Flickinger EG, Meelheim HD, Swanson
MS. The control of diabetes mellitus (NIDDM) in the morbidly
obese with the Greenville Gastric Bypass. Ann Surg 1987; 206:
66. Owens D, Horrocks J, House A. Fatal and non-fatal repetition
of self-harm. Systematic review. Br J Psychiatry 2002; 181: 193–
12 Suicide after bariatric surgery C. Peterhänsel et al.obesity reviews
© 2013 The Authors
obesity reviews © 2013 International Association for the Study of Obesity
67. Windover AK, Merrell J, Ashton K, Heinberg LJ. Prevalence
and psychosocial correlates of self-reported past suicide attempts
among bariatric surgery candidates. Surg Obes Relat Dis 2010; 6:
68. Chen EY, Fettich KC, McCloskey MS. Correlates of suicidal
ideation and/or behavior in bariatric-surgery-seeking individuals
with severe obesity. Crisis 2012; 33: 137–143.
69. Dougherty DM, Mathias CW, Marsh DM, Moeller FG,
Swann AC. Suicidal behaviors and drug abuse: impulsivity and its
assessment. Drug Alcohol Depend 2004; 76(Suppl.): S93–S105.
70. Ryden A, Sullivan M, Torgerson JS, Karlsson J, Lindroos AK,
Taft C. Severe obesity and personality: a comparative controlled
study of personality traits. Int J Obes Relat Metab Disord 2003;
27: 1534–1540.
71. Sansone RA, Schumacher D, Wiederman MW, Routsong-
Weichers L. The prevalence of binge eating disorder and borderline
personality symptomatology among gastric surgery patients. Eat
Behav 2008; 9: 197–202.
72. Nederkoorn C, Smulders FT, Havermans RC, Roefs A, Jansen
A. Impulsivity in obese women. Appetite 2006; 47: 253–256.
73. Karlsson J, Sjostrom L, Sullivan M. Swedish obese subjects
(SOS) an intervention study of obesity. Two-year follow-up of
health-related quality of life (HRQL) and eating behavior after
gastric surgery for severe obesity. Int J Obes Relat Metab Disord
1998; 22: 113–126.
74. Valley V, Grace DM. Psychosocial risk factors in gastric
surgery for obesity: identifying guidelines for screening. Int J Obes
1987; 11: 105–113.
75. Steinig J, Wagner B, Shang E, Dölemeyer R, Kersting A. Sexual
abuse in bariatric surgery candidates impact on weight loss after
surgery: a systematic review. Obes Rev 2012; 13: 892–901.
76. Mahony D. Assessing sexual abuse/attack histories with bari-
atric surgery patients. J Child Sex Abus 2010; 19: 469–484.
77. Grilo CM, White MA, Masheb RM, Rothschild BS, Burke-
Martindale CH. Relation of childhood sexual abuse and other
forms of maltreatment to 12-month postoperative outcomes in
extremely obese gastric bypass patients. Obes Surg 2006; 16:
78. Clark M, Hanna B, Mai J et al. Sexual abuse survivors and
psychiatric hospitalization after bariatric surgery. Obes Surg 2007;
17: 465–469.
79. Silver H, Torquati A, Jensen G, Richards W. Weight, dietary
and physical activity behaviors two years after gastric bypass.
Obes Surg 2006; 16: 859–864.
80. Tompkins J, Bosch PR, Chenowith R, Tiede JL, Swain JM.
Changes in functional walking distance and health-related quality
of life after gastric bypass surgery. Phys Ther 2008; 88: 928–935.
81. Elkins G, Whitfield P, Marcus J, Symmonds R, Rodriguez J,
Cook T. Noncompliance with behavioral recommendations fol-
lowing bariatric surgery. Obes Surg 2005; 15: 546–551.
82. Paluska SA, Schwenk TL. Physical activity and mental health:
current concepts. Sports Med 2000; 29: 167–180.
83. Forbush S, Nof L, Echternach J, Hill C, Rainey J. Influence of
activity levels and energy intake on percent excess weight loss after
Roux-en-Y gastric bypass. Obes Surg 2011; 21: 1731–1738.
84. DiGiorgi M, Rosen DJ, Choi JJ et al. Re-emergence of diabetes
after gastric bypass in patients with mid- to long-term follow-up.
Surg Obes Relat Dis 2010; 6: 249–253.
85. Chikunguwo SM, Wolfe LG, Dodson P et al. Analysis of
factors associated with durable remission of diabetes after Roux-
en-Y gastric bypass. Surg Obes Relat Dis 2010; 6: 254–259.
86. Pillar G, Peled R, Lavie P. Recurrence of sleep apnea without
concomitant weight increase 7.5 years after weight reduction
surgery. Chest 1994; 106: 1702–1704.
87. Munoz D, Lal M, Chen E et al. Why patients seek bariatric
surgery: a qualitative and quantitative analysis of patient motiva-
tion. Obes Surg 2007; 17: 1487–1491.
88. Klockhoff H, Näslund I, Jones AW. Faster absorption of
ethanol and higher peak concentration in women after gastric
bypass surgery. Br J Clin Pharmacol 2002; 54: 587–591.
89. Woodard GA, Downey J, Hernandez-Boussard T, Morton
JM. Impaired alcohol metabolism after gastric bypass surgery: a
case-crossover trial. J Am Coll Surg 2011; 212: 209–214.
90. Maluenda F, Csendes A, De Aretxabala X et al. Alcohol
absorption modification after a laparoscopic sleeve gastrectomy
due to obesity. Obes Surg 2010; 20: 744–748.
91. Hagedorn JC, Encarnacion B, Brat GA, Morton JM. Does
gastric bypass alter alcohol metabolism? Surg Obes Relat Dis
2007; 3: 543–548.
92. Conason A, Teixeira J, Hsu C et al. Substance use following
bariatric weight loss surgery. Arch Surg 2012; 15: E1–E6.
93. Boenisch S, Bramesfeld A, Mergl R et al. The role of alcohol
use disorder and alcohol consumption in suicide attempts a
secondary analysis of 1,921 suicide attempts. Eur Psychiatry 2010;
25: 414–420.
94. Ariyasu H, Takaya K, Tagami T et al. Stomach is a major
source of circulating ghrelin, and feeding state determines plasma
ghrelin-like immunoreactivity levels in humans. J Clin Endocrinol
Metab 2001; 86: 4753–4758.
95. Cummings DE, Overduin J, Foster-Schubert KE. Gastric
bypass for obesity: mechanisms of weight loss and diabetes reso-
lution. J Clin Endocrinol Metab 2004; 89: 2608–2615.
96. Kotidis E, Koliakos G, Papavramidis T, Papavramidis S. The
effect of biliopancreatic diversion with pylorus-preserving sleeve
gastrectomy and duodenal switch on fasting serum ghrelin, leptin
and adiponectin levels: is there a hormonal contribution to the
weight-reducing effect of this procedure? Obes Surg 2006; 16:
97. Bohdjalian A, Langer F, Shakeri-Leidenmühler S et al. Sleeve
gastrectomy as sole and definitive bariatric procedure: 5-year
results for weight loss and ghrelin. Obes Surg 2010; 20: 535–540.
98. Cani PD, Montoya ML, Neyrinck AM, Delzenne NM,
Lambert DM. Potential modulation of plasma ghrelin and
glucagon-like peptide-1 by anorexigenic cannabinoid compounds,
SR141716A (rimonabant) and oleoylethanolamide. Br J Nutr
2004; 92: 757–761.
99. Christensen R, Kristensen PK, Bartels EM, Bliddal H, Astrup
A. Efficacy and safety of the weight-loss drug rimonabant: a meta-
analysis of randomised trials. Lancet 2007; 370: 1706–1713.
100. Kluge M, Schüssler P, Dresler M et al. Effects of ghrelin on
psychopathology, sleep and secretion of cortisol and growth
hormone in patients with major depression. J Psychiatr Res 2011;
45: 421–426.
101. Bays H, Dujovne C. Anti-obesity drug development. Expert
Opin Investig Drugs 2002; 11: 1189–1204.
102. von Holstein CS. Long-term prognosis after partial gastrec-
tomy for gastroduodenal ulcer. World J Surg 2000; 24: 307–314.
103. Lundegårdh G, Helmick C, Zack M, Adami H-O. Mortality
among patients with partial gastrectomy for benign ulcer disease.
Dig Dis Sci 1994; 39: 340–346.
104. Perathoner A, Weiss H, Santner W et al. Vagal nerve dissec-
tion during pouch formation in laparoscopic Roux-Y-gastric
bypass for technical simplification: does it matter? Obes Surg
2009; 19: 412–417.
105. Date Y, Murakami N, Toshinai K et al. The role of the
gastric afferent vagal nerve in ghrelin-induced feeding and growth
hormone secretion in rats. Gastroenterology 2002; 123: 1120–
obesity reviews Suicide after bariatric surgery C. Peterhänsel et al.13
© 2013 The Authors
obesity reviews © 2013 International Association for the Study of Obesity
106. Rush AJ, George MS, Sackeim HA et al. Vagus nerve stimu-
lation (VNS) for treatment-resistant depressions: a multicenter
study. Biol Psychiatry 2000; 47: 276–286.
107. Sackeim HA, Rush AJ, George MS et al. Vagus nerve stimu-
lation (VNS™) for treatment-resistant depression: efficacy, side
effects, and predictors of outcome. Neuropsychopharmacology
2001; 25: 713–728.
108. Mitchell JE, Crosby R, de Zwaan M et al. Possible risk
factors for increased suicide following bariatric surgery. Obesity
(Silver Spring) 2012. doi: 10.1002/oby.20066.
109. Shen R, Dugay G, Rajaram K, Cabrera I, Siegel N, Ren C.
Impact of patient follow-up on weight loss after bariatric surgery.
Obes Surg 2004; 14: 514–519.
110. Harper J, Madan AK, Ternovits CA, Tichansky DS. What
happens to patients who do not follow-up after bariatric surgery?
Am Surg 2007; 73: 181–184.
111. Ziegler O, Sirveaux MA, Brunaud L, Reibel N, Quilliot D.
Medical follow up after bariatric surgery: nutritional and drug
issues. General recommendations for the prevention and treatment
of nutritional deficiencies. Diabetes Metab 2009; 35: 544–557.
112. Walfish S, Vance D, Fabricatore A. Psychological evaluation
of bariatric surgery applicants: procedures and reasons for delay or
denial of surgery. Obes Surg 2007; 17: 1578–1583.
113. Fabricatore A, Crerand C, Wadden T, Sarwer D, Krasucki J.
How do mental health professionals evaluate candidates for bari-
atric surgery? Survey results. Obes Surg 2006; 16: 567–573.
14 Suicide after bariatric surgery C. Peterhänsel et al.obesity reviews
© 2013 The Authors
obesity reviews © 2013 International Association for the Study of Obesity
... Of particular interest (see Peterhänsel et al., 2013, and references therein) is the risk of completed suicide post-bariatric surgery. A systematic review by Peterhänsel et al. (2013) provides meta-analytic data on 27 studies exploring the risk of completed suicide post-bariatric surgery. ...
... Of particular interest (see Peterhänsel et al., 2013, and references therein) is the risk of completed suicide post-bariatric surgery. A systematic review by Peterhänsel et al. (2013) provides meta-analytic data on 27 studies exploring the risk of completed suicide post-bariatric surgery. Table 1 shows the data which includes the number of completed suicides, the exposure (person-years), the country of origin and proportion of women of each study. ...
... Uncertainty quantification for both estimation of suicide rates and number of excluded studies was achieved through a parametric bootstrapping approach. Peterhänsel et al. (2013) considered a zero-truncated binomial model but did not consider covariate effects. We argue that a count model (e.g. ...
Full-text available
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.
... While the results were encouraging, with long-term follow-up data suggesting that some postoperative patients did not experience psychological benefits or reported increased rates of depression and BED recurrence (16,18). People are concerned about the potential risks of mental health disorders after bariatric surgery, including self-harm, suicide, and substance abuse (19,20). One study reported that patients after bariatric surgery had a 1.98-fold increased risk of suicide compared to usual care of patients with obesity (21). ...
... The prevalence of suicide after bariatric surgery was 0.3% (41). Peterhansel et al. (19) who reviewed suicide after bariatric surgery, reported that suicide rates were estimated at 4.1 per 10,000 people per year, with aboveaverage suicide rates in bariatric surgery patients. Lack of improvement in quality of life after surgery, persistent or recurrent sexual dysfunction and interpersonal problems, and limited physical activity can all lead to an increased risk of suicide (20). ...
Full-text available
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.
... und Zielorientierung[42] evaluieren Reflexion von individuellem Emotions-und Stressmanagement[42] sowie Evaluierung der Copingstrategien (u. a. Entspannungstraining, Achtsamkeitsübungen) und der Rückfallprophylaxe Intrinsische Motivation[24], Selbstführsorge und Selbstwirksamkeit fördern und stärken Spezielle Aspekte, die bei PatientInnen nach bariatrischer Operation besonders berücksichtigt werden sollten: -Jegliche Psychopathologie kann das Outcome beeinflussen[43][44][45] -Abklärung der Suizidalität[44,[46][47][48] -Suchtverlagerung[36], Substanzmissbrauch und selbstschädigendes Verhalten[43,[46][47][48][49][50] -Förderung des positiven Einflusses von psychosozialen Interventionen[48] -Abklärung traumatischer Erlebnisse[25] -Längerfristige postoperative Begleitung begünstigt den Erhalt der Gewichtsreduktion[51] ...
... und Zielorientierung[42] evaluieren Reflexion von individuellem Emotions-und Stressmanagement[42] sowie Evaluierung der Copingstrategien (u. a. Entspannungstraining, Achtsamkeitsübungen) und der Rückfallprophylaxe Intrinsische Motivation[24], Selbstführsorge und Selbstwirksamkeit fördern und stärken Spezielle Aspekte, die bei PatientInnen nach bariatrischer Operation besonders berücksichtigt werden sollten: -Jegliche Psychopathologie kann das Outcome beeinflussen[43][44][45] -Abklärung der Suizidalität[44,[46][47][48] -Suchtverlagerung[36], Substanzmissbrauch und selbstschädigendes Verhalten[43,[46][47][48][49][50] -Förderung des positiven Einflusses von psychosozialen Interventionen[48] -Abklärung traumatischer Erlebnisse[25] -Längerfristige postoperative Begleitung begünstigt den Erhalt der Gewichtsreduktion[51] ...
Full-text available
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.
... Adams et al. reported that externally caused death in the MBS group was 58% higher than in the non-surgery group (p = 0.04) [4]. Further, Tindle et al. and Peterhansel et al. both reported higher rates of suicide in the MBS group compared to the standard population [33,34]. ...
Full-text available
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
... Several works including systematic reviews and metaanalyses have studied risk factors of suicide in the general population [10][11][12][13][14], children and adolescents [15][16][17], young adults [17][18][19][20][21][22][23][24], prisoners [25][26][27][28], inpatients [24,26,[29][30][31], and older adults [32][33][34]. Risk factors for suicide have been studied alongside psychiatric conditions like adult attachment [35], depression [23,32,36,37], bingeeating disorder [38], bipolar disorder [15,26,39,40], obsessive-compulsive disorder (OCD) [41], mental disorders [20], psychosis [42], schizophrenia [43,44], self-harm [21,27,45,46], substance use disorders [24], and physiological health conditions like bladder cancer [31], bariatric surgery [47], human immunodeficiency viruses (HIV) [48], and smoking [49]. ...
Full-text available
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.
... New psychological problems can also arise in the postoperative period in some patients and should be identified and receive appropriate support (mainly suicidal risk and addictive disorders). The risk of suicide attempts and death by suicide are increased two to four-fold after bariatric surgery compared to obese patients who are not operated upon [24,25]. This increased risk, which is seen for all surgical procedures, is seen more frequently in patients with a past history of suicide attempts and in patients with a history of substance use disorder (but the risk is not related to the intensity of weight loss) [26]. ...
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).
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.
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.
Conference Paper
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.
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.
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.