Rate of Self-Harm May Increase After Bariatric Surgery

EBM Focus - Volume 11, Issue 12

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Reference - JAMA Surg 2016 Mar 1;151(3):226 (level 2 [mid-level] evidence)

  • Bariatric surgery has been associated with both positive and negative effects on mental health outcomes.
  • A recent cohort study evaluating 8,815 adults having bariatric surgery found an increase in self-harm emergencies in the 3 years after the surgery compared to the 3 years prior to surgery.
  • Patients having bariatric surgery should be assessed for postoperative changes to mental health status, especially if they have a history of mental health disorders.

Weight loss is often associated with a positive effect on mental health, but the reported effects of bariatric surgery on mental health outcomes have been inconsistent. While some studies have suggested bariatric surgery improves mental health quality of life and lowers the rate of depression (Psychol Health Med 2015;20(2):165, JAMA 2016 Jan 12;315(2):150), others have reported negative effects of bariatric surgery including increased rates of suicide and alcohol abuse (Am J Med 2010 Nov;123(11):1036, JAMA 2012 Jun 20;307(23):2516). To assess the effects of bariatric surgery on self-harm, a recent cohort study evaluated 8,815 adults aged 18-65 years (mean age 42 years, 81% female) having bariatric surgery. Patients were assessed for incidence of self-harm emergencies in the 3 years before and 3 years after bariatric surgery.

In the 5 years before surgery, 64% of patients had a diagnosis of anxiety, 7.8% depression, and 0.6% alcohol misuse. At least one self-harm emergency was reported in 1.3% of patients in the 3 years before or after bariatric surgery. Ninety-three percent of self-harm emergencies were reported in patients with previously diagnosed mental health disorders and most events (73%) were due to a medication overdose. The overall rate of self-harm emergencies each year was 2.33 per 1,000 patients during the preoperative period and 3.36 per 1,000 patients during the postoperative period (p = 0.007). In subgroup analyses by patient characteristics, a significant increase in the rate of self-harm after surgery was found for women, patients aged 35-65 years, patients with lower socioeconomic status, and patients living in rural areas.

Psychosocial history and behavioral evaluations are recommended as part of the preoperative management and medical clearance process for patients seeking bariatric surgery, but there is no consensus on the structure and content of these evaluations (Obesity (Silver Spring) 2013 Mar;21 Suppl 1:S1, Surg Obes Relat Dis 2013 May-Jun;9(3):474). Preoperative formal mental health evaluations are currently only recommended for patients with a history of psychiatric illness or substance abuse, and there are no recommendations for postoperative mental health assessment or management. While the results of the current study are limited to emergency department records which may not accurately estimate the full extent of self-harm incidence or capture patient intent, they do suggest that patients having bariatric surgery should be monitored and assessed for postoperative changes in mental health status. This assessment appears to be especially important in patients with a history of mental health disorder, as most self-harm emergencies were reported in this population.

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