Suicide attempts increase in wake of weight-loss surgery

By Melissa Healy
Los Angeles Times

In the three years after they go under the knife, patients who have bariatric surgery to aid in weight loss are more likely than they were before the operation to attempt suicide or end up in the hospital after doing harm to themselves, new research says.
As complications of weightloss surgery go, the hazard was rare. A Canadian study that tracked 8,815 bariatric surgery patients found that in their three post-surgical years, just 1.3 percent of those patients landed in the hospital following a selfharm emergency, whi*****luded intentional drug overdoses or suicide attempts by other means.
But that rate of self-injurious behavior represented a 54 percent increase over that seen in the same patient population during the three years before these patients had surgery.
Published last week in the journal JAMA Surgery, the new research sheds light on a grim fact about obesity: Long before an obese patient enters the OR, he or she is more likely to suffer depression and a wide range of other psychiatric ills than is the average person of normal weight. Several studies have established that bariatric surgery patients are as much as four times likelier than those who are not to attempt suicide.
In the three years before undergoing bariatric surgery, participants in the current study already were twice as likely to intentionally harm them selves as were those in the general population.
But in the three years following their surgery, these patients' already outsized burden of mental illness increased; during the post-surgical period studied, the participants were three times more likely to have a self-harm emergency than were those in the general population.
Among those most likely to experience self-harm events following surgery were lowincome patients and those living in rural areas.
The new research highlights a little-recognized challenge patients face in the wake of surgery that replumbs the stomach but also drives far-reaching changes beyond the digestive system.
The authors of the current study suggest changes in patients' ability to metabolize alcohol in the wake of bariatric surgery might be implicated in some patients' worsening mental health.
Following certain bariatric surgery procedures that bypass parts of the stomach, patients who drink alcohol often find their tolerance low and become inebriated quickly. Such changes, wrote the new study's authors, might affect some patients' risk-taking behavior and ability to suppress self-destructive impulses while under the influence.
The authors also suggested that addictive behaviors which, for some, have contributed to obesity in the first place might be displaced toward other substances, including medications, following surgery that limits stomach capacity. In the current study, 68 percent of the 168 selfharm emergencies noted were attributed primarily to medication overdoses.
But the study's authors also urged further research into the possibility that altered brain chemistry wrought by the surgical replumbing of the digestive tract might contribute to depression or suicidal behavior.
The research also underscores the need for bariatric surgery practices -- a specialty seeing rapid growth -- to attend to the mental health of their obese patients not just before surgery but for several years beyond. Most of the bariatric patients' psychological crises occurred in the second and third years after surgery, a period when there was little interaction between patients and the practices that provided their bariatric services.
In the three years before undergoing bariatric surg ery, partic ip ants in the current study already were twice as likely to intentionally harm themselves as were those in the general population.Suicide attempts increase in wake of weight-loss surgery
By Melissa Healy
Los Angeles Times
In the three years after they go under the knife, patients who have bariatric surgery to aid in weight loss are more likely than they were before the operation to attempt suicide or end up in the hospital after doing harm to themselves, new research says.
As complications of weightloss surgery go, the hazard was rare. A Canadian study that tracked 8,815 bariatric surgery patients found that in their three post-surgical years, just 1.3 percent of those patients landed in the hospital following a selfharm emergency, whi*****luded intentional drug overdoses or suicide attempts by other means.
But that rate of self-injurious behavior represented a 54 percent increase over that seen in the same patient population during the three years before these patients had surgery.
Published last week in the journal JAMA Surgery, the new research sheds light on a grim fact about obesity: Long before an obese patient enters the OR, he or she is more likely to suffer depression and a wide range of other psychiatric ills than is the average person of normal weight. Several studies have established that bariatric surgery patients are as much as four times likelier than those who are not to attempt suicide.
In the three years before undergoing bariatric surgery, participants in the current study already were twice as likely to intentionally harm them selves as were those in the general population.
But in the three years following their surgery, these patients' already outsized burden of mental illness increased; during the post-surgical period studied, the participants were three times more likely to have a self-harm emergency than were those in the general population.
Among those most likely to experience self-harm events following surgery were lowincome patients and those living in rural areas.
The new research highlights a little-recognized challenge patients face in the wake of surgery that replumbs the stomach but also drives far-reaching changes beyond the digestive system.
The authors of the current study suggest changes in patients' ability to metabolize alcohol in the wake of bariatric surgery might be implicated in some patients' worsening mental health.
Following certain bariatric surgery procedures that bypass parts of the stomach, patients who drink alcohol often find their tolerance low and become inebriated quickly. Such changes, wrote the new study's authors, might affect some patients' risk-taking behavior and ability to suppress self-destructive impulses while under the influence.
The authors also suggested that addictive behaviors which, for some, have contributed to obesity in the first place might be displaced toward other substances, including medications, following surgery that limits stomach capacity. In the current study, 68 percent of the 168 selfharm emergencies noted were attributed primarily to medication overdoses.
But the study's authors also urged further research into the possibility that altered brain chemistry wrought by the surgical replumbing of the digestive tract might contribute to depression or suicidal behavior.
The research also underscores the need for bariatric surgery practices -- a specialty seeing rapid growth -- to attend to the mental health of their obese patients not just before surgery but for several years beyond. Most of the bariatric patients' psychological crises occurred in the second and third years after surgery, a period when there was little interaction between patients and the practices that provided their bariatric services.
In the three years before undergoing bariatric surg ery, partic ip ants in the current study already were twice as likely to intentionally harm themselves as were those in the general population.

I read this earlier yesterday. I believe that the sheer despair of morbid obesity has a lot to do with the mental health of WLS patients. It's no wonder there is such a burden mentally.

Obviously, there is a need for post-op support, including mental health.

I agree with what you said...with a twist.

When we were MO, weren't we all already "hurting" ourselves (i.e. committing suicide slowly with food)? Even if your gain was hormonal/endocrine, why couldn't we just STOP putting food in our mouths? IN my case I was SO HUNGRY, yet if I tallied the calories I was eating plenty. Why couldn't my rational mind overcome my emotional/pseuodo-physical mind?

So this study which suggests that "people who were hurting themselves before WLS continue to hurt themselves after WLS surgery" ISN'T groundbreaking. People who hurt themselves are still continuing to hurt themselves just like people who cut themselves (because it feels good/relieves stress) will have an increased propensity to cut themselves when faced with stressful stimuli.

Sorry..not earth shattering.

App 3 years post op my iron (ferritin) tanked... Some of my other critical vitamins - minerals got low. Too Low, even though I took my vitamins and minerals. Low iron - vit B12, D, proteins can leads to low energy- depression.

Plus year 3rd was a year that I started gaining weight.. And felt badly about it... It took me a while - and lots of efforts to bring my numbers (vitamins minerals - and proteins) within normal range and stop gaining weight... And lose the regain. Year 3 and 4 were very critical for me...I got iron infusions, stop drinking too much wine, got hernia surgery.. And overall cleaned my diet...

I can understand why some people may consider just to give up...

For most of us the first year or so is like magic. It is easy to stick to the plan and weight is easy to lose. Then reality sets in along with plain old boredom. The plan is boring, the exercise is boring and the weight loss slows and stops.

The regain part is really depressing. People need support and understanding. The psychological exam before surgery is supposed to deal with people who should not have surgery. Sometimes they slip through.

Everyone is not mentally strong enough for the challenges of weight loss surgery.

At a recent support group, a distraught parent attended saying their thirty-something child had gone back to old eating habits. A member warned trying to control the situation would likely lead to more problems. Of course, the suggestion of counseling was mentioned. No easy solutions, uff-da.

I think there must be multiple factors contributing to this study's findings. Many getting surgery have undiagnosed mental health problems that become evident only after surgery, often highlighted by the new challenges facing them. Many getting surgery have well managed mental health problems that become slightly unstable after surgery (meds needs to be adjusted, etc). Many lose the major coping skill they have to deal with stress (compulsive eating).

I also suspect that the gut-hormone-brain connection is altered in weight loss surgery in ways that may impact mood. Perhaps the reduced carborhydrate intake may impact dopamine and serotonin and that folks with deficiencies in these were overeating refined carbs in an attempt to boost these feel good brain chemicals before having surgery.

One of the challenges of wls, is that it makes you confront that weight loss, in itself, doesn't make you happy over the long term. I think its like winning the lottery for some people. The first year or two as a millionaire is euphoric, but over time, the money doesn't transform life's basic difficulties...relationships with others and our own inner world. For some people that bought into the fairytale that wls was "the answer", even when hitting their goal weight, it eventually falls short of a miracle cure for life's woes. Possibly some people can't deal with this disappointment.

Not surprising. Depressed people are the ones who commit suicide; some people who are fat become depressed, but many people become fate because they are depressed... So becoming thin doesn't address the depression.

Moreover, aCcording to several studies, one of the things that also happens is that people who suffered from depression before surgery experience a decrease in depression for the first two years after surgery, but after the two year mark, their depression often returns to the same level that it was pre-op, and -- in about 25% of those cases (I don't remember the exact number) -- it actually increases to levels greater than before surgery.

There are number of reasons for this. One of the greatest reasons is that once they lose the weight, people realize that the problems that they originally attributed to their weight (interpersonal relationships, problems getting/keeping a job or getting promotions, etc.) still exist because they had nothing (or very little) to do with their weight in the first place. IN some cases, they are mental health issues completely separate from weight. In other cases, people expected that their problems would just go away when they lost the weight, and when that doesn't happen, they have to look at alternate causes for the problems... and these are usually internal issues rather than external ones (personality traits, communication issues/styles, etc.).

Another common reason for depression after weight loss is that people are disappointed with their new bodies. Many people have an image of what their thin body will look like or what they hope it will look like (they sometimes expect it to look just like it did when they were young and thin, and that DOESN'T happen!) and when reality doesn't match that vision, depression can result. Most of us don't think of a new healthier body as one that looks like a melted candle or has massive amounts of excess skin. Plastic surgery can remove excess skin (for those who can afford it) but sometimes people are disappointed with the results, esepcially if they cannot afford the additional cost of "contouring", and even for those who have plastic surgery, the scars are sometimes significant and there can be serious complications.

A final common reason for depression after WLS is that people find it difficult to keep the weight off and find it depressing to have to keep fighting the same psychological "food demons" that they did before surgery. Some people, despite saying that they know that "surgery is only a tool", still expect that some of the psych issues and bad habits will just magically go away and that they will no longer struggle with their weight. Reality can be depressing.

Dorry, didn't mean to write a novella, but I did a lot of research on this a few years ago in preparation for a couple of professional presentations on this topic.

Thanks for sharing your professional insight Lora.