Patients who underwent gastric bypass surgery were at a much higher risk of self-harm than before the surgery, according to a new longitudinal cohort analysis.
Researchers led by Junaid Bhatti, PhD, at the Sunnybrook Research Institute in Toronto, looked at a cohort of 8,814 women, 81% of them women, and found that self-harm emergencies increased from 2.33 per 1,000 patient years before surgery to 3.63 after surgery (risk ratio 1.54, 95% CI 1.03-2.30; P=0.007).
Post-surgery emergencies were highest among patients over 35 (RR 1.76, 95% CI 1.05-2.94; P=0.03), those with low-income (RR 2.09, 95% CI 1.20-3.65; P=0.01), and those who live in rural areas (RR 6.49, 95% CI 1.42-29.63; P=0.02), according to the authors, who published their results in JAMA Surgery.
The study “underscores the unique vulnerability of patients undergoing bariatric surgery and forces us to look closely at why suicide rates are more than 4 times higher in these patients than the general population,” wrote Amir Ghaferi, MD, and Carol Lindsay-Westphal, PhD, both at the University of Michigan, wrote in an accompanying editorial. “Bariatric surgery is more than just an operation — it is time we recognize and treat it is as such.”
In the study, 111 (1.3%) of the patients had at least one self-harm emergency before or after surgery, 11 experienced emergencies both before and after, 37 before surgery, and 63 after it. In addition, 147 of the events (93.0%) were in patients diagnosed with a mental health disorder within five years before the surgery. The most common way that patients sought self-harm was intentional overdose (72.8%). Self-hanging accounted for 20.9% of the events.
All of the patients who underwent bariatric surgery lived in Ontario, Canada. Researchers compared the incidence of self-harm emergencies three years before surgery and three years after surgery. All adults were 18-65, and 80.1% were older than 35. They underwent bariatric surgery at some time from April 2006 to March 2011. The data on self-harm emergencies were recorded on emergency visits to the hospital.
Craig Primack, MD, at the Scottsdale Weight Loss Center in Arizona, wrote in an email to MedPage Today that bariatric surgery should be considered a treatment, and not a cure.
“In my practice, a subset of patients believe that many of their problems stem from their weight: (poor job, still single, bad marriage, no close friends, etc.) and when they get down to a specific weight then everything will be OK,” he wrote. “When they get to that number (or close to it) and realize that they will not achieve the thing they thought their weight would fix, they stop losing weight to literally stall and not have to face the fact that when they are at their goal they still are single, still have a bad job, etc.”
The authors noted that the study has several limitations. The data did not account for surgery-related factors like failure to lose weight or increases in post-operative stress. The database was not comprehensive because some of the patients may have had bariatric surgery outside of Ontario, and determining intent for substance abuse or intoxication can be difficult, so the ICD-10 codes used may have been misleading. In addition, calculating self-harm attempts by emergency visits may have underestimated the actual suicide rate, and suicide deaths often preclude an emergency room visit.
“These findings imply that more work is needed to understand why self-harm behaviors increase in the postoperative period and how these risks might be reduced,” concluded the authors.