Advertisement

Risk of Suicide after Long-term Follow-up from Bariatric Surgery

Published:September 14, 2010DOI:https://doi.org/10.1016/j.amjmed.2010.06.016

      Abstract

      Purpose

      Bariatric surgery is recognized as the treatment of choice for class III obesity (body mass index ≥40) and has been increasingly recommended for obese patients. Prior research has suggested an excess of deaths due to suicide following bariatric surgery, but few large long-term follow-up studies exist. We examined postbariatric surgery suicides by time since operation, sex, age, and suicide death rates as compared with US suicide rates.

      Methods

      Medical data following bariatric operations performed on Pennsylvania residents between January 1, 1995 and December 31, 2004 were obtained from the Pennsylvania Health Care Cost and Containment Council. Matching mortality data from suicides between September 1, 1996 and December 28, 2006 were obtained from the Division of Vital Records, Pennsylvania State Department of Health.

      Results

      There were 31 suicides (16,683 operations), for an overall rate of 6.6/10,000; 13.7 per 10,000 among men and 5.2 per 10,000 among women. About 30% of suicides occurred within the first 2 years following surgery, with almost 70% occurring within 3 years. For every age category except the youngest, suicide rates were higher among men than women. Age- and sex-matched suicide rates in the US population (ages 35-64 years) were 2.4/10,000 (men) and 0.7/10,000 (women).

      Conclusions

      Compared with age and sex-matched suicide rates in the US, there was a substantial excess of suicides among all patients who had bariatric surgery in Pennsylvania during a 10-year period. These data document a need to develop more comprehensive longer-term surveillance and follow-up methods in order to evaluate factors associated with postbariatric surgery suicide.

      Keywords

      Bariatric surgery has emerged as the treatment of choice for class III obesity,
      • McTigue K.M.
      • Harris R.
      • Hemphill B.
      • et al.
      Screening and interventions for obesity in adults: summary of the evidence for the U.S. Preventive Services Task Force.
      National Institutes of Health Consensus Development Panel
      Gastrointestinal surgery for severe obesity: National Institutes of Health Consensus Development Conference Statement.
      and by current criteria is appropriate for over 5% of the obese adult US population (body mass index [BMI] ≥40 or BMI ≥35 with comorbid conditions).
      • Hedley A.A.
      • Ogden C.L.
      • Johnson C.L.
      • Carroll M.D.
      • Curtin L.R.
      • Flegal K.M.
      Prevalence of overweight and obesity among US children, adolescents, and adults, 1999-2002.
      There are few studies of a longer-term follow-up of large samples of individuals who have had bariatric surgery. Although the reported short-term (eg, 30-day operative) mortality associated with these procedures is low,
      • Buchwald H.
      • Avidor Y.
      • Braunwald E.
      • et al.
      Bariatric surgery: a systematic review and meta-analysis.
      • Fernandez Jr, A.Z.
      • Demaria E.J.
      • Tichansky D.S.
      • et al.
      Multivariate analysis of risk factors for death following gastric bypass for treatment of morbid obesity.
      • Flum D.R.
      • Dellinger E.P.
      Impact of gastric bypass operation on survival: a population-based analysis.
      • Mason E.E.
      • Renquist K.E.
      • Jiang D.
      Perioperative risks and safety of surgery for severe obesity.
      The Longitudinal Assessment of Bariatric Surgery (LABS) Consortium
      Perioperative safety in the longitudinal assessment of bariatric surgery.
      • Flum D.R.
      • Belle S.H.
      • King W.C.
      • et al.
      Perioperative safety in the longitudinal assessment of bariatric surgery.
      • Buchwald H.
      • Estok R.
      • Fahrbach K.
      • Banel D.
      • Sledge I.
      Trends in mortality in bariatric surgery: a systematic review and meta-analysis.
      studies with longer-term follow-up have better characterized death rates and associated risk factors.
      • Flum D.R.
      • Dellinger E.P.
      Impact of gastric bypass operation on survival: a population-based analysis.
      • Buchwald H.
      • Estok R.
      • Fahrbach K.
      • Banel D.
      • Sledge I.
      Trends in mortality in bariatric surgery: a systematic review and meta-analysis.
      • Adams T.D.
      • Gress R.E.
      • Smith S.C.
      • et al.
      Long-term mortality after gastric bypass surgery.
      • Flum D.R.
      • Salem L.
      • Elrod J.A.
      • Dellinger E.P.
      • Cheadle A.
      • Chan L.
      Early mortality among Medicare beneficiaries undergoing bariatric surgical procedures.
      • Goldfeder L.
      • Ren C.
      • Gill J.
      Fatal complications of bariatric surgery.
      • Gould J.C.
      • Garren M.J.
      • Boll V.
      • Starling J.R.
      Laparoscopic gastric bypass: risks vs. benefits up to two years following surgery in super-super obese patients.
      • Kushner R.F.
      • Noble C.A.
      Long-term outcome of bariatric surgery: an interim analysis.
      • Omalu B.I.
      • Ives D.G.
      • Buhari A.M.
      • et al.
      Death rates and causes of death after bariatric surgery for Pennsylvania residents, 1995 to 2004.
      • Poulose B.K.
      • Griffin M.R.
      • Moore D.E.
      • et al.
      Risk factors for post-operative mortality in bariatric surgery.
      • Sjostrom L.
      • Narbro K.
      • Sjostrom C.D.
      • et al.
      Effects of bariatric surgery on mortality in Swedish obese subjects.
      • Zhang W.
      • Mason E.
      • Renquist K.
      • Zimmerman M.
      IBSR Contributors
      Factors influencing survival following surgical treatment of obesity.
      Several prior studies have documented an excess of suicide deaths post bariatric surgery,
      • Adams T.D.
      • Gress R.E.
      • Smith S.C.
      • et al.
      Long-term mortality after gastric bypass surgery.
      • Goldfeder L.
      • Ren C.
      • Gill J.
      Fatal complications of bariatric surgery.
      • Omalu B.I.
      • Ives D.G.
      • Buhari A.M.
      • et al.
      Death rates and causes of death after bariatric surgery for Pennsylvania residents, 1995 to 2004.
      • Mitchell J.
      • Lancaster K.
      • Burgard M.
      • et al.
      Long-term follow-up of patients' status after gastric bypass.
      • Pories W.J.
      • Swanson M.S.
      • MacDonald K.G.
      • et al.
      Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus.
      • Powers P.S.
      • Rosemurgy A.
      • Boyd F.
      • Perez A.
      Outcome of gastric restriction procedures: weight, psychiatric diagnoses, and satisfaction.
      with the majority of events occurring more than 1 year post surgery. Adams and colleagues
      • Adams T.D.
      • Gress R.E.
      • Smith S.C.
      • et al.
      Long-term mortality after gastric bypass surgery.
      found that the age, BMI, and sex-adjusted hazard of suicide in the surgical group was double that of matched controls, but the small absolute number of suicides (n=21 in the surgical group vs. 8 among controls) limited power to detect statistically significant differences.
      • Overall suicide rates among postbariatric surgery patients in Pennsylvania over 10 years were 6.6/10,000:13.7 per 10,000 among men and 5.2 per 10,000 among women. These are much higher than age and sex-matched US rates.
      • ∼70% of suicides occurred within 3 years after surgery, long past the usual 6-month monitoring period.
      • Suicides are not necessarily attributed to the bariatric surgery, but may be related to myriad factors.
      The reasons for an excess of suicides among these surgery patients are not known. The prevalence of depression and co-morbid mental illness is high among morbidly obese individuals
      • Maddi S.
      • Khoshaba D.
      • Persico M.
      • Bleecker F.
      • VanArsdall G.
      Psychosocial correlates of psychopathology in a national sample of the morbidly obese.
      • Papageorgiou G.
      • Papakonstantinou A.
      • Mamplekou E.
      • Terzis I.
      • Melissas J.
      Pre- and postoperative psychological characteristics in morbidly obese patients.
      • van Hout G.
      • van Oudheusden I.
      • van Heck G.
      Psychological profile of the morbidly obese.
      • Mather A.A.
      • Cox B.J.
      • Enns M.W.
      • Sareen J.
      Associations of obesity with psychiatric disorders and suicidal behaviors in a nationally representative sample.
      and bariatric surgery candidates.
      • Kalarchian M.A.
      • Marcus M.D.
      • Levine M.D.
      • et al.
      Psychiatric disorders among bariatric surgery candidates: relationship to obesity and functional health status.
      • Sarwer D.
      • Cohn N.
      • Gibbons L.
      • et al.
      Psychiatric diagnoses and psychiatric treatment among bariatric surgery candidates.
      Kalarchian and colleagues
      • Kalarchian M.A.
      • Marcus M.D.
      • Levine M.D.
      • et al.
      Psychiatric disorders among bariatric surgery candidates: relationship to obesity and functional health status.
      reported a 66% lifetime history of at least one axis I disorder (eg, mood, anxiety, substance use, or eating disorder) among candidates for bariatric surgery. Presence of an axis I disorder was significantly related to a higher baseline BMI and poorer functioning on all subscales of the SF-36, a validated measure of physical and emotional functional health status. Presurgical psychopathology may, in turn, contribute to postsurgical outcomes. Lifetime history of mood or anxiety disorder (compared with no history) has been associated with a significantly smaller decrease in BMI during the first 6 months following surgery.
      • Kalarchian M.A.
      • Marcus M.D.
      • Levine M.D.
      • Soulakova J.N.
      • Courcoulas A.P.
      • Wisinski M.S.C.
      Relationship of psychiatric disorders to 6-month outcomes after gastric bypass.
      Literature on aspects of suicide and obesity is less clear. Suicidal ideation
      • Mather A.A.
      • Cox B.J.
      • Enns M.W.
      • Sareen J.
      Associations of obesity with psychiatric disorders and suicidal behaviors in a nationally representative sample.
      • Carpenter K.M.
      • Hasin D.S.
      • Allison D.B.
      • Faith M.S.
      Relationships between obesity and DSM-IV major depressive disorder, suicide ideation, and suicide attempts: results from a general population study.
      • Eaton D.K.
      • Lowry R.
      • Brener N.D.
      • Galuska D.A.
      • Crosby A.E.
      Associations of body mass index and perceived weight with suicide ideation and suicide attempts among US high school students.
      and suicide attempts
      • Mather A.A.
      • Cox B.J.
      • Enns M.W.
      • Sareen J.
      Associations of obesity with psychiatric disorders and suicidal behaviors in a nationally representative sample.
      • Eaton D.K.
      • Lowry R.
      • Brener N.D.
      • Galuska D.A.
      • Crosby A.E.
      Associations of body mass index and perceived weight with suicide ideation and suicide attempts among US high school students.
      • Dong C.
      • Li W.D.
      • Li D.
      • Price R.A.
      Extreme obesity is associated with attempted suicides: results from a family study.
      increase with BMI, but suicide mortality bears a strong inverse relationship to BMI in men.
      • Carpenter K.M.
      • Hasin D.S.
      • Allison D.B.
      • Faith M.S.
      Relationships between obesity and DSM-IV major depressive disorder, suicide ideation, and suicide attempts: results from a general population study.
      • Magnusson P.K.E.
      • Rasmussen F.
      • Lawlor D.A.
      • Tynelius P.
      • Gunnell D.
      Association of body mass index with suicide mortality: a prospective cohort study of more than one million men.
      • Mukamal K.J.
      • Kawachi I.
      • Miller M.
      • Rimm E.B.
      Body mass index and risk of suicide among men.
      The role of weight change also appears to be important in understanding suicide risk.
      • Elovainio M.
      • Shipley M.J.
      • Ferrie J.E.
      • et al.
      Obesity, unexplained weight loss and suicide: the original Whitehall study.
      Sansone and colleagues
      • Sansone R.A.
      • Wiederman M.W.
      • Schumacher D.F.
      • Routsong-Weichers L.
      The prevalence of self-harm behaviors among a sample of gastric surgery candidates.
      reported that 10% of bariatric surgery candidates had a history of prior suicide attempts, a major risk factor for suicide mortality.
      • Hawton K.
      • van Heeringen K.
      Suicide.
      Despite perioperative psychological evaluation, there may be under-recognition and under-treatment of mental illness both before and after surgery,
      • McMahon M.M.
      • Sarr M.G.
      • Clark M.M.
      • et al.
      Clinical management after bariatric surgery: value of a multidisciplinary approach.
      • Sarwer D.B.
      • Wadden T.A.
      • Fabricatore A.N.
      Psychosocial and behavioral aspects of bariatric surgery.
      perhaps in part due to inconsistencies in the initial evaluation of bariatric surgery candidates.
      • Santry H.
      • Chin M.
      • Cagney K.
      • Alverdy J.
      • Lauderdale D.
      The use of multidisciplinary teams to evaluate bariatric surgery patients: results from a national survey in the U.S.A..
      Given the increasing utilization of bariatric surgery as an effective treatment of severe obesity,
      American Society for Metabolic & Bariatric Surgery
      Bariatric Surgical Society Takes on New Name, New Mission and New Surgery.
      • Santry H.P.
      • Gillen D.L.
      • Lauderdale D.S.
      Trends in bariatric surgical procedures.
      • Zhao Y.
      • Encinosa W.
      Statistical Brief #23: Bariatric Surgery Utilization and Outcomes in 1998 and 2004.
      it is critical to better characterize the suicide risks among postbariatric surgery patients.
      Detailed characteristics of suicides following bariatric surgery (eg, by time since surgery, age, sex, year of surgery) have not been widely published. We extend our prior work by describing these characteristics of all reported suicides among Pennsylvania residents who underwent bariatric surgery from January 1, 1995 to December 31, 2004 and died between September 1, 1996 and December 28, 2006. This study design captures suicides and methods of suicide related to all bariatric surgeries performed during this time period within the state of Pennsylvania, and therefore is not restricted to only a few major medical centers that may have unique selection criteria or follow-up programs.

      Methods

      Data were obtained from the following 2 sources: the Pennsylvania Health Care Cost and Containment Council database,
      Pennsylvania Health Care Cost Containment Council (PHC4)
      PHC4 database.
      to identify patients hospitalized for bariatric surgery, and the Division of Vital Records, Pennsylvania State Department of Health, to determine suicides (as judged by the coroner or medical examiner) and obtain copies of death certificates.
      The Pennsylvania Health Care Cost and Containment Council collects data in the state of Pennsylvania, including all hospital discharges and ambulatory/outpatient procedure records each year from hospitals and freestanding ambulatory surgery centers. The hospitals and freestanding surgery centers are required by law to electronically submit quarterly administrative data for all inpatient discharges and select specified ambulatory/outpatient procedures within 90 days after the end of a quarter.
      The study design and methods of ascertainment of bariatric surgery cases has been previously described in detail.
      • Omalu B.I.
      • Ives D.G.
      • Buhari A.M.
      • et al.
      Death rates and causes of death after bariatric surgery for Pennsylvania residents, 1995 to 2004.
      All state-resident patients who underwent bariatric surgery in Pennsylvania were identified in the Pennsylvania Health Care Cost and Containment Council database. Each study subject fulfilled the following criteria: all inpatient discharges with International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes of 278.00 (obesity, unspecified) or 278.01 (morbid obesity); and all inpatient discharges with major diagnostic group code 10 and diagnostic related group code 288 (operating procedures for obesity). Thus, to be included, an individual would need to have International Classification of Diseases, Ninth Revision, Clinical Modification code 278 or 278.01, and group codes 10 and 288.
      The following variables were collated for each patient: age at surgery, sex, race, date and year of surgery, hospital where the surgery was performed, county in which the surgery was performed, and primary operating surgeon. After identification of the patient cohort, the data were directly matched with the database of the Division of Vital Records, Pennsylvania State Department of Health, using the Social Security number of patients in addition to age and sex. The matching was performed directly between the staffs of the Pennsylvania Health Care Cost and Containment Council and the Division of Vital Records. A positive match would occur only if a patient had died and the death certificate was archived by the Division of Vital Records. Suicide was determined by the county coroner or medical examiner.
      The death certificates of the patients who had undergone bariatric surgery and who had died from suicide within the study period (n=31) were made available to us for review. Pennsylvania residents who died outside the state would be missed by the surveillance methods. Less than 2% of Pennsylvania residents are estimated to have died outside the state (personal communication with the state of Pennsylvania Department of Health, 2008).
      Previous studies have documented the completeness of the Pennsylvania vital statistics system.
      • Ives D.G.
      • Fitzpatrick A.L.
      • Bild D.E.
      • et al.
      Surveillance and ascertainment of cardiovascular events : the Cardiovascular Health Study.
      We selected only Pennsylvania residents so that we would have a population-based study and because of the decreased likelihood that they would move out of the state after bariatric surgery. We did not obtain information on patients from outside Pennsylvania or outside the US who had undergone bariatric surgery during this time in Pennsylvania hospitals. For estimations of rates and follow-up, we used only the first bariatric surgical procedure for each patient. The study was deemed exempt by the Institutional Review Board at the University of Pittsburgh.
      We compared the suicide rates/10,000 person-years of follow-up with reported US suicide rates
      National Center for Health Statistics
      Table 46: Death rates for suicide, according to sex, race, Hispanic origin, and age: United States, selected years 1950-2002.
      and with suicide rates in the state of Pennsylvania.
      Pennsylvania Department of Health, Bureau of Health Statistics and Research
      Pennsylvania Vital Statistics.
      To our knowledge, there are no available suicide rates for a truly comparable population of morbidly obese individuals who did not have bariatric surgery (eg, who met similar criteria for bariatric surgery such that they would have been selected by a bariatric surgery center to have the procedure.)
      We performed data analysis with SPSS statistical software (SPSS Categories 4.1 for Windows; SPSS Inc, Chicago, Ill). We estimated suicide rates by the time since surgical procedures to the date of death. Person-years of observations were accumulated from the date of surgery to the date of death or to the end of the study.
      The number of nonwhite patients was very low and therefore we used the total and age-specific death rates rather than race-specific rates. The manners of death listed on the death certificates were reviewed by 2 of us (HAT and LHK).

      Results

      There were 31 total suicides. Mean age of the deceased was 45 years, and they were primarily female (65%, Table 1) and white (94%). Mean time to death was about 3 years after surgery, with 10% occurring in the first year, 29% within the first 2 years, and 68% within 3 years after surgery (Table 2). The distribution of suicides by year of bariatric surgery is shown in Table 3. The incidence of suicide was 6.6 per 10,000 person-years. Men had higher rates of suicide in each age category except those aged 24 years or younger (Table 4). The overall rate of suicide among men was over twice that of women (13.7 vs 5.2 per 10,000). Men aged 45-54 years had the highest rates of suicide (21.7 per 10,000), while women under age 35 years had the highest rates (about 14.0 per 10,000). These rates are substantiallly higher than those of the general age-matched US population over the same time period (ie, US suicide rates age 35-64 years for men 2.4/10,000 and 0.7/10,000 for women).
      National Center for Health Statistics
      Table 46: Death rates for suicide, according to sex, race, Hispanic origin, and age: United States, selected years 1950-2002.
      Similarly, for Pennsylvania, suicide rates age 35-64 years in 2005 were 2.5/10,000 for men and 0.6/10,000 for women.
      Pennsylvania Department of Health, Bureau of Health Statistics and Research
      Pennsylvania Vital Statistics.
      Table 1Characteristics of Suicide after Bariatric Surgery
      nMean Age at Death (Years)Time from Surgery to Death (Years)
      Women20443.5
      Men11482.1
      Total31453.0
      Table 2Distribution of Time Between Bariatric Surgery and Suicide in Years
      YearsnCumulative %
      <1310
      1-<2629
      2-<31268
      3-<4377
      4-<5387
      ≥54100
      Total31
      Table 3Risk of Suicide Death Versus Year of Procedure
      YearNumber of ProceduresSuicide (n)
      199532
      19962052
      19973662
      19985241
      19996871
      200010945
      200120154
      200231648
      200347784
      200438184
      Total16,68331
      Table 4Incidence of Suicide by Age and Sex Per 10,000 Person-Years
      MenWomenTotal
      AgePerson-YearsSuicideProceduresRate/10,000Person-YearsSuicideProceduresRate/10,000Men and Women
      ≤241071425249614.0603
      25-341261245115.935495289814.13349
      35-44279929427.112,969644274.65369
      45-542761695421.716,762441932.45147
      55-64118014438.53945315797.62022
      ≥6552141193
      Total800111294913.738,65020137345.216,683
      Suicides were categorized according to 4 main modes of death: drug overdose (n=16), gunshot wound (n=9), carbon monoxide poisoning (n=4), and hanging (n=2) (Table 5).
      Table 5Suicides in Pennsylvania Following Bariatric Surgery: 1996-2007
      Mode of DeathRace and SexSuicide (n)
      Drug/pill overdose (n=16)White female11
      White male3
      Black female1
      Hispanic female1
      Gunshot wound (n=9)White female3
      White male6
      Carbon monoxide (n=4)White female3
      White male1
      Hanging (n=2)White female1
      White male1

      Discussion

      We examined all suicides occurring between 1996 and 2006 among postbariatric surgery patients residing in Pennsylvania. There were 31 total suicides in this population, for an overall rate of 13.7 per 10,000 among men and 5.2 per 10,000 among women. It is very likely that suicide deaths were also underestimated because some of the deaths were listed as drug overdose, rather than suicide, on the death certificate. In this case, the suicide rate postbariatric surgery would be even higher than what we have reported. In addition, the deaths due to drug overdose, whether intentional or not, are also a cause for concern.
      A recent report from the Agency for Healthcare Research and Quality estimated that in 2004 there were 121,055 bariatric surgery procedures done in the US.
      • Shekelle P.G.
      • Morton S.C.
      • Maglione M.A.
      • et al.
      Southern California-RAND Evidence-Based Practice Center.
      Even more recent figures from the American Society for Metabolic and Bariatric Surgery report 225,000 procedures annually.
      American Society for Metabolic & Bariatric Surgery
      Bariatric Surgical Society Takes on New Name, New Mission and New Surgery.
      Annual rates of bariatric surgery have increased substantially over the past decade (eg, 400% from 1998-2002)
      • Zhao Y.
      • Encinosa W.
      Statistical Brief #23: Bariatric Surgery Utilization and Outcomes in 1998 and 2004.
      and are expected to increase further given the effectiveness of bariatric surgery for weight loss and possible associated reductions in morbidity and mortality.
      • McTigue K.M.
      • Harris R.
      • Hemphill B.
      • et al.
      Screening and interventions for obesity in adults: summary of the evidence for the U.S. Preventive Services Task Force.
      • Sjostrom L.
      • Narbro K.
      • Sjostrom C.D.
      • et al.
      Effects of bariatric surgery on mortality in Swedish obese subjects.
      • Maggard M.A.
      • Shugarman L.R.
      • Suttorp M.
      • et al.
      Meta-analysis: surgical treatment of obesity.
      Estimating conservatively using the 2004 Agency for Healthcare Research and Quality rates, if the overall suicide rate of the current study (6.6/10,000 person-years) were applicable to the total US sample, then there would have been approximately 500 suicide deaths between 2004 and 2010 (excluding deaths from other causes) among those who had bariatric surgery in 2004.
      What are the possible etiologies for the high suicide rate demonstrated among postbariatric surgery patients? First, it is not possible for this study to determine whether the participants were at higher likelihood of committing suicide before bariatric surgery. Our data cannot separate the host characteristics such as increased risk before surgery (eg, related to mental illness, distress, or depression) from the effects of bariatric surgery itself. Nor can we determine from our data whether the risk of suicide is increased among individuals who were unsuccessful, that is, who regained weight after the bariatric surgery. Interestingly, the majority of suicides in this study occurred at the time point well documented for both routine and significant weight re-gain (ie, within 2-4 years),
      • Magro D.
      • Geloneze B.
      • Delfini R.
      • Pareja B.
      • Callejas F.
      • Pareja J.
      Long-term weight regain after gastric bypass: a 5-year prospective study.
      as well as the timeframe when routine follow-up from the bariatric surgery program itself may be waning. It is possible that patients who were initially successful with weight loss eventually re-gained their weight and became depressed. However, mental health problems may become manifest even without weight re-gain. Improvements in body image and affective disorders tend to occur in the first 1-2 years following bariatric surgery, but then may revert to preoperative levels by 3 years, despite sustained weight loss.
      • Sarwer D.B.
      • Wadden T.A.
      • Fabricatore A.N.
      Psychosocial and behavioral aspects of bariatric surgery.
      Case reports detailing forensic and medical characteristics of completed suicide following bariatric surgery further illustrate this paradox.
      • Omalu B.I.
      • Cho P.
      • Shakir A.M.
      • et al.
      Suicides following bariatric surgery for the treatment of obesity.
      It may be possible that presurgical psychological distress, whether diagnosed or not, could be exacerbated if the results of surgery were disappointing or failed to yield hoped-for improvements in quality of life. Furthermore, body image has been shown to have poor correlation with actual weight loss,
      • Hrabosky J.
      • Masheb R.
      • White M.
      • Rothschild B.
      • Burke-Martindale C.
      • Grilo C.
      A prospective study of body dissatisfaction and concerns in extremely obese gastric bypass patients: 6- and 12-month postoperative outcomes.
      suggesting that other factors may be driving worsening dissatisfaction with body image over time. Recurrence of pre-existing psychiatric disorders could go unrecognized and be associated with suicide. Finally, preliminary evidence suggests that postbariatric surgery patients may be more susceptible to substances such as alcohol, which could theoretically contribute to unfavorable outcomes.
      • Hagedorn J.C.
      • Encarnacion B.
      • Brat G.A.
      • Morton J.M.
      Does gastric bypass alter alcohol metabolism?.
      The absolute suicide rates are low (even though much higher than those of the general population). Small select follow-up studies of short duration might miss the increased risk of suicide due to lack of power, underscoring the need for large sample sizes to adequately study this phenomenon.
      • Stolley P.D.
      • Kuller L.H.
      The need for epidemiologists and surgeons to cooperate in the evaluation of surgical therapies.
      There are no large randomized clinical trials of bariatric surgery. The Swedish Obesity Study
      • Sjostrom L.
      • Narbro K.
      • Sjostrom C.D.
      • et al.
      Effects of bariatric surgery on mortality in Swedish obese subjects.
      was not a true randomized trial and also, unfortunately, it does not provide any data on suicides. A comparison of similar obese individuals who have not had bariatric surgery is unlikely to be very helpful for several reasons.
      Comparisons with obese individuals would not be ideal because of the substantial selection bias with bariatric surgery, including exclusion of some depressed individuals, poorer or uninsured patients, those who are less compliant with behavioral changes or who do not demonstrate reasonable likelihood of follow-up after surgery, and those who have other chronic diseases and health behaviors such as heavy alcohol consumption or cigarette smoking. Some investigators have compared obese individuals who have been admitted to the hospital (i.e., in-hospital obesity patients) with bariatric surgery patients, presuming both groups are in the hospital for a procedure and are, therefore, comparable. However, this represents a bias, because the reason that obese people are admitted to the hospital is not generally for their obesity in isolation, but because they have an active illness or disease that may or may not be associated with their obesity. Therefore, they will tend to have much higher mortality than obese individuals who were admitted for bariatric surgery. This is commonly referred to as Berksonian Bias.
      • Lilienfeld D.E.
      • Stolley P.D.
      Foundations of Epidemiology.
      Despite the strengths of the study, which include the ability to capture causes of death for all individuals who underwent bariatric surgery in the state of Pennsylvania from 1995-2004, our study is limited by several factors. We lack information on the frequency of suicides among the different bariatric surgery programs. That is, are the suicide rates different in relationship to the characteristics of the programs, such as size of program, type of surgery performed, and extent of medical and psychological follow up? In addition, characteristics of both the suicides and nonsuicide participants, and whether the risk of suicide can be identified by certain premorbid (ie, before the bariatric surgery) factors, are also important to understand. Unfortunately, the design of our study, which identified suicides by the death certificate, did not capture detailed individual characteristics of the suicides.
      This limitation is important, because some suicides could theoretically be preventable after bariatric surgery by more careful monitoring and treatment of mental indices, including mood disorders, whether the increased suicide is due to host characteristics, results of surgery, or a combination. However, there is not enough existing evidence to determine if such additional monitoring would indeed prevent suicides. Another limitation is that the number of suicides is likely to be underreported due to reasons noted above (eg, labeling a true suicide as a drug overdose on the death certificate). Finally, our study is limited by the absence of a truly comparable group of nonoperated severely obese individuals who were evaluated and approved for bariatric surgery, such as has been achieved in trials of presurgical weight loss.
      • Solomon H.
      • Liu G.Y.
      • Alami R.
      • Morton J.
      • Curet M.J.
      Benefits to patients choosing preoperative weight loss in gastric bypass surgery: new results of a randomized trial.
      Knowledge gaps in this area may be narrowed by augmenting the current system of follow-up and by requiring timely reporting of suicides through both the Surgical Review Committee's Center of Excellence or the American College of Surgeons' mechanism for mandated bariatric surgery outcomes reporting. Mandatory registries (or sub-registries within the Center of Excellence models) requiring detailed reporting from unfavorable surgical outcomes would serve to better track these rare but important suicide events and collect information to inform future research. Additional studies are needed to examine whether suicide is associated with: 1) surgery success or failure (ie, inadequate weight loss or significant weight regain); 2) lifetime or current history of psychiatric disorder; or 3) psychosocial problems. It will also be important to determine both the feasibility and usefulness of intensified and prolonged postbariatric surgery monitoring.
      Intensified postbariatric surgery monitoring, especially longer than the recommended 6 months, would, in turn, allow for assessment of factors that may be related to postsurgery suicides. An international consortium led by investigators from the United Kingdom recently published surgical guidelines stating that “established procedures should be monitored with prospective databases to analyze outcome variations and to identify late and rare events (p. 1105).”
      • McCulloch P.
      • Altman D.G.
      • Campbell W.B.
      • et al.
      No surgical innovation without evaluation: the IDEAL recommendations.
      Another approach to improve monitoring of bariatric surgery patients in the future would be a continual mortality surveillance of sudden death in the US through the National Suicide Database,
      Centers for Disease Control and Prevention
      National Violent Death Reporting System.
      which is collected from medical examiners and coroners and maintained at the National Center for Health Statistics. Unfortunately, this database currently does not contain any information on body weight or on bariatric surgery. However, if this information were added, the database could support retrospective inquiry to determine the situations related to suicide, and also attempt to pinpoint the suicides in relationship to specific surgical programs, including the quality of the follow-up, behavioral support, and other factors. Regardless of method, a systematic, long-term monitoring program should be implemented, similar to postmarketing surveillance for an approved drug. If bariatric surgery were a medication or medical device, postmarketing studies would be required and followed by the US Food and Drug Administration. A longer-term mechanism needs to be structured to adequately capture the important information related to these unfortunate and possibly preventable outcomes.

      Acknowledgment

      The authors gratefully acknowledge Ms. Monica Love for preparing this manuscript for publication, and Mr. Alhaji Buhari for statistical support.

      References

        • McTigue K.M.
        • Harris R.
        • Hemphill B.
        • et al.
        Screening and interventions for obesity in adults: summary of the evidence for the U.S..
        Ann Intern Med. 2003; 139: 933-949
        • National Institutes of Health Consensus Development Panel
        Gastrointestinal surgery for severe obesity: National Institutes of Health Consensus Development Conference Statement.
        Am J Clin Nutr. 1992; 55: 615S-619S
        • Hedley A.A.
        • Ogden C.L.
        • Johnson C.L.
        • Carroll M.D.
        • Curtin L.R.
        • Flegal K.M.
        Prevalence of overweight and obesity among US children, adolescents, and adults, 1999-2002.
        JAMA. 2004; 291: 2847-2850
        • Buchwald H.
        • Avidor Y.
        • Braunwald E.
        • et al.
        Bariatric surgery: a systematic review and meta-analysis.
        JAMA. 2004; 292: 1724-1737
        • Fernandez Jr, A.Z.
        • Demaria E.J.
        • Tichansky D.S.
        • et al.
        Multivariate analysis of risk factors for death following gastric bypass for treatment of morbid obesity.
        Ann Surg. 2004; 239: 698-703
        • Flum D.R.
        • Dellinger E.P.
        Impact of gastric bypass operation on survival: a population-based analysis.
        J Am Coll Surg. 2004; 199: 543-551
        • Mason E.E.
        • Renquist K.E.
        • Jiang D.
        Perioperative risks and safety of surgery for severe obesity.
        Am J Clin Nutr. 1992; 55: 573S-576S
        • The Longitudinal Assessment of Bariatric Surgery (LABS) Consortium
        Perioperative safety in the longitudinal assessment of bariatric surgery.
        N Engl J Med. 2009; 361: 445-454
        • Flum D.R.
        • Belle S.H.
        • King W.C.
        • et al.
        Perioperative safety in the longitudinal assessment of bariatric surgery.
        N Engl J Med. 2009; 361: 445-454
        • Buchwald H.
        • Estok R.
        • Fahrbach K.
        • Banel D.
        • Sledge I.
        Trends in mortality in bariatric surgery: a systematic review and meta-analysis.
        Surgery. 2007; 142: 621-635
        • Adams T.D.
        • Gress R.E.
        • Smith S.C.
        • et al.
        Long-term mortality after gastric bypass surgery.
        N Engl J Med. 2007; 357: 753-761
        • Flum D.R.
        • Salem L.
        • Elrod J.A.
        • Dellinger E.P.
        • Cheadle A.
        • Chan L.
        Early mortality among Medicare beneficiaries undergoing bariatric surgical procedures.
        JAMA. 2005; 294: 1903-1908
        • Goldfeder L.
        • Ren C.
        • Gill J.
        Fatal complications of bariatric surgery.
        Obes Surg. 2006; 16: 1050-1056
        • Gould J.C.
        • Garren M.J.
        • Boll V.
        • Starling J.R.
        Laparoscopic gastric bypass: risks vs. benefits up to two years following surgery in super-super obese patients.
        Surgery. 2006; 140: 524-531
        • Kushner R.F.
        • Noble C.A.
        Long-term outcome of bariatric surgery: an interim analysis.
        Mayo Clinic Proc. 2006; 81: S46-S51
        • Omalu B.I.
        • Ives D.G.
        • Buhari A.M.
        • et al.
        Death rates and causes of death after bariatric surgery for Pennsylvania residents, 1995 to 2004.
        Arch Surg. 2007; 142: 923-929
        • Poulose B.K.
        • Griffin M.R.
        • Moore D.E.
        • et al.
        Risk factors for post-operative mortality in bariatric surgery.
        J Surg Res. 2005; 127: 1-7
        • Sjostrom L.
        • Narbro K.
        • Sjostrom C.D.
        • et al.
        Effects of bariatric surgery on mortality in Swedish obese subjects.
        N Engl J Med. 2007; 357: 741-752
        • Zhang W.
        • Mason E.
        • Renquist K.
        • Zimmerman M.
        • IBSR Contributors
        Factors influencing survival following surgical treatment of obesity.
        Obes Surg. 2005; 15: 43-50
        • Mitchell J.
        • Lancaster K.
        • Burgard M.
        • et al.
        Long-term follow-up of patients' status after gastric bypass.
        Obes Surg. 2001; 11: 464-468
        • Pories W.J.
        • Swanson M.S.
        • MacDonald K.G.
        • et al.
        Who would have thought it?.
        Ann Surg. 1995; 222: 339-352
        • Powers P.S.
        • Rosemurgy A.
        • Boyd F.
        • Perez A.
        Outcome of gastric restriction procedures: weight, psychiatric diagnoses, and satisfaction.
        Obes Surg. 1997; 7: 471-477
        • Maddi S.
        • Khoshaba D.
        • Persico M.
        • Bleecker F.
        • VanArsdall G.
        Psychosocial correlates of psychopathology in a national sample of the morbidly obese.
        Obes Surg. 1997; 7: 397-404
        • Papageorgiou G.
        • Papakonstantinou A.
        • Mamplekou E.
        • Terzis I.
        • Melissas J.
        Pre- and postoperative psychological characteristics in morbidly obese patients.
        Obes Surg. 2002; 12: 534-539
        • van Hout G.
        • van Oudheusden I.
        • van Heck G.
        Psychological profile of the morbidly obese.
        Obes Surg. 2004; 14: 579-588
        • Mather A.A.
        • Cox B.J.
        • Enns M.W.
        • Sareen J.
        Associations of obesity with psychiatric disorders and suicidal behaviors in a nationally representative sample.
        J Psychosom Res. 2009; 66: 277-285
        • Kalarchian M.A.
        • Marcus M.D.
        • Levine M.D.
        • et al.
        Psychiatric disorders among bariatric surgery candidates: relationship to obesity and functional health status.
        Am J Psychiatry. 2007; 164: 328-334
        • Sarwer D.
        • Cohn N.
        • Gibbons L.
        • et al.
        Psychiatric diagnoses and psychiatric treatment among bariatric surgery candidates.
        Obes Surg. 2004; 14: 1148-1156
        • Kalarchian M.A.
        • Marcus M.D.
        • Levine M.D.
        • Soulakova J.N.
        • Courcoulas A.P.
        • Wisinski M.S.C.
        Relationship of psychiatric disorders to 6-month outcomes after gastric bypass.
        Surg Obes Relat Dis. 2008; 4: 544-549
        • Carpenter K.M.
        • Hasin D.S.
        • Allison D.B.
        • Faith M.S.
        Relationships between obesity and DSM-IV major depressive disorder, suicide ideation, and suicide attempts: results from a general population study.
        Am J Public Health. 2000; 90: 251-257
        • Eaton D.K.
        • Lowry R.
        • Brener N.D.
        • Galuska D.A.
        • Crosby A.E.
        Associations of body mass index and perceived weight with suicide ideation and suicide attempts among US high school students.
        Arch Pediatr Adolesc Med. 2005; 159: 513-519
        • Dong C.
        • Li W.D.
        • Li D.
        • Price R.A.
        Extreme obesity is associated with attempted suicides: results from a family study.
        Int J Obes (Lond). 2006; 30: 388-390
        • Magnusson P.K.E.
        • Rasmussen F.
        • Lawlor D.A.
        • Tynelius P.
        • Gunnell D.
        Association of body mass index with suicide mortality: a prospective cohort study of more than one million men.
        Am J Epidemiol. 2006; 163: 1-8
        • Mukamal K.J.
        • Kawachi I.
        • Miller M.
        • Rimm E.B.
        Body mass index and risk of suicide among men.
        Arch Intern Med. 2007; 167: 468-475
        • Elovainio M.
        • Shipley M.J.
        • Ferrie J.E.
        • et al.
        Obesity, unexplained weight loss and suicide: the original Whitehall study.
        J Affect Disord. 2009; 116: 218-221
        • Sansone R.A.
        • Wiederman M.W.
        • Schumacher D.F.
        • Routsong-Weichers L.
        The prevalence of self-harm behaviors among a sample of gastric surgery candidates.
        J Psychosom Res. 2008; 65: 441-444
        • Hawton K.
        • van Heeringen K.
        Suicide.
        Lancet. 2009; 373: 1372-1381
        • McMahon M.M.
        • Sarr M.G.
        • Clark M.M.
        • et al.
        Clinical management after bariatric surgery: value of a multidisciplinary approach.
        Mayo Clinic Proc. 2006; 81: S34-S45
        • Sarwer D.B.
        • Wadden T.A.
        • Fabricatore A.N.
        Psychosocial and behavioral aspects of bariatric surgery.
        Obes Res. 2005; 13: 639-648
        • Santry H.
        • Chin M.
        • Cagney K.
        • Alverdy J.
        • Lauderdale D.
        The use of multidisciplinary teams to evaluate bariatric surgery patients: results from a national survey in the U.S.A..
        Obes Surg. 2006; 16: 59-66
        • American Society for Metabolic & Bariatric Surgery
        Bariatric Surgical Society Takes on New Name, New Mission and New Surgery.
        American Society for Metabolic & Bariatric Surgery, Gainesville, FL2007
        • Santry H.P.
        • Gillen D.L.
        • Lauderdale D.S.
        Trends in bariatric surgical procedures.
        JAMA. 2005; 294: 1909-1917
        • Zhao Y.
        • Encinosa W.
        Statistical Brief #23: Bariatric Surgery Utilization and Outcomes in 1998 and 2004.
        Agency for Healthcare Research and Quality, Rockville, MD2007
        • Pennsylvania Health Care Cost Containment Council (PHC4)
        PHC4 database.
        (Accessed August 25, 2010.)
        • Ives D.G.
        • Fitzpatrick A.L.
        • Bild D.E.
        • et al.
        Surveillance and ascertainment of cardiovascular events : the Cardiovascular Health Study.
        Ann Epidemiol. 1995; 45: 278-285
        • National Center for Health Statistics
        Table 46: Death rates for suicide, according to sex, race, Hispanic origin, and age: United States, selected years 1950-2002.
        in: Health, United States, 2005: With Chartbook on Trends in the Health of Americans. National Center for Health Statistics, Hyattsville, MD2005: 221-223
        • Pennsylvania Department of Health, Bureau of Health Statistics and Research
        Pennsylvania Vital Statistics.
        Pennsylvania Department of Health, Harrisburg, PA2007
        • Shekelle P.G.
        • Morton S.C.
        • Maglione M.A.
        • et al.
        Southern California-RAND Evidence-Based Practice Center.
        Evidence Report/Technology Assessment No. 103: Pharmacological and Surgical Treatment of Obesity (AHRQ Publication No. 04-E028-2). Agency for Healthcare Research and Quality, Rockwille, MD2004
        • Maggard M.A.
        • Shugarman L.R.
        • Suttorp M.
        • et al.
        Meta-analysis: surgical treatment of obesity.
        Ann Intern Med. 2005; 142: 547-559
        • Magro D.
        • Geloneze B.
        • Delfini R.
        • Pareja B.
        • Callejas F.
        • Pareja J.
        Long-term weight regain after gastric bypass: a 5-year prospective study.
        Obes Surg. 2008; 18: 648-651
        • Omalu B.I.
        • Cho P.
        • Shakir A.M.
        • et al.
        Suicides following bariatric surgery for the treatment of obesity.
        Surg Obes Relat Dis. 2005; 1: 447-449
        • Hrabosky J.
        • Masheb R.
        • White M.
        • Rothschild B.
        • Burke-Martindale C.
        • Grilo C.
        A prospective study of body dissatisfaction and concerns in extremely obese gastric bypass patients: 6- and 12-month postoperative outcomes.
        Obes Surg. 2006; 16: 1615-1621
        • Hagedorn J.C.
        • Encarnacion B.
        • Brat G.A.
        • Morton J.M.
        Does gastric bypass alter alcohol metabolism?.
        Surg Obes Relat Dis. 2007; 3: 543-548
        • Stolley P.D.
        • Kuller L.H.
        The need for epidemiologists and surgeons to cooperate in the evaluation of surgical therapies.
        Surgery. 1975; 78: 123-125
        • Lilienfeld D.E.
        • Stolley P.D.
        Foundations of Epidemiology.
        3rd edition. Oxford University Press, New York1994
        • Solomon H.
        • Liu G.Y.
        • Alami R.
        • Morton J.
        • Curet M.J.
        Benefits to patients choosing preoperative weight loss in gastric bypass surgery: new results of a randomized trial.
        J Am Coll Surg. 2009; 208: 241-245
        • McCulloch P.
        • Altman D.G.
        • Campbell W.B.
        • et al.
        No surgical innovation without evaluation: the IDEAL recommendations.
        Lancet. 2009; 374: 1105-1112
        • Centers for Disease Control and Prevention
        National Violent Death Reporting System.
        (Accessed August 25, 2010.)

      Linked Article

      • Risk of Suicide and Bariatric Surgery
        The American Journal of MedicineVol. 124Issue 8
        • Preview
          We read with great interest the paper by Tindle et al,1 which reported an increased rate of suicide among Pennsylvania residents who underwent bariatric surgery. The authors discussed in depth the possibility that such an increase represents a late effect of bariatric surgery itself or, perhaps, of failure in obtaining long-term satisfactory weight control in some patients.
        • Full-Text
        • PDF