Bariatric Surgery and Suicide Risk

Resolution or improvement of weight-related medical comorbidities is the primary reported reason individuals undergo bariatric surgery.^1–3 Other motivating factors could best be described under the umbrella of overall quality of life (improved mobility, self-confidence, and activities of daily living).

Most individuals experience a “honeymoon phase” during the initial postoperative year, during which there are improvements in these aforementioned areas, as well as a brief respite from depressive symptoms. ⁴ Despite this good news, the risk for suicide among postoperative individuals has been estimated to be as much as four times higher than that of the general population. ⁵ This startling statistic begs the question: What aspects of quality of life either do not improve or worsen after surgery?

Suicidality among treatment-seeking morbidly obese individuals is higher than among morbidly obese community samples, suggesting potential differences in health-related quality of life, perceived quality of life, and prevalence of affective disorders. ⁶ The existing literature on suicide and bariatric surgery is characterized by a lack of theoretical underpinnings, variable methodologies and lengths of follow-up, and small sample sizes. Rigby et al. ⁷ have attempted to examine suicidality among surgical and nonsurgical weight management patients utilizing the interpersonal theory of suicidal behavior. More studies such as these will help to provide a framework for future investigations into causes and contributors to increased suicidality.

Peterhänsel et al., in their systematic review, found that the majority of recorded suicides occurred between 18 months and 5 years postoperatively. ⁵ Unfortunately, because postoperative attrition is high, there is a gap in our understanding of what would cause this delayed risk onset, although several reasons have been put forth, often involving a complex interplay of medical and psychosocial events.^8–10 Among individuals who have had their type 2 diabetes resolved with bariatric surgery, ∼35% see a return of their disease within 5 years. ¹¹ Affective disorders may resume presurgical levels and require ongoing treatment. Postsurgical lifestyle changes can negatively impact marital or family relationships, causing deterioration of stable social support networks. Finally, lack of improvement in body image despite significant weight loss can be psychologically devastating.^6,12

Clinical researchers need to move beyond studying changes in the initial “honeymoon” phase to investigating long-term (5–10 years) outcomes with an eye on existing knowledge of suicide risk among those with chronic diseases. The psychological literature is rich with social and interpersonal theories of suicide that could readily be applied to the bariatric population. Methodological designs grounded in any or a combination of established theories such as Beck's hopelessness theory, Joiner's interpersonal theory, and Linehan's emotion dysregulation theory would help flesh out contributors to increased risk.^13–15 Bariatric surgery is gaining greater acceptance in the public as an effective treatment option for morbidly obese adolescents, and understanding long-term risks in such a young population is paramount to ensuring successful outcomes.

Patients seeking bariatric surgery are often doing so as their “last resort” when all other options have failed them. Postoperative weight regain, worsening health, or quality of life can be particularly disheartening then and increase risk of suicidality for some individuals. Clinicians need to discuss this risk in more depth with patients during the preoperative process, especially because many patients are eventually lost to follow-up. These discussions should be had not only during the mandatory psychological evaluation when individual risk is assessed but also with the bariatrician and surgeons when discussing general risk factors associated with bariatric surgery. Providing this information up front may help to dispel the commonly held unrealistic perception of bariatric surgery as a “magic bullet” for weight loss and happiness.