“But Everything Is Supposed to Get Better After Bariatric Surgery!” Understanding Postoperative Suicide and Self-injury

| October 1, 2019 | 0 Comments

by Alexis Conason, PsyD, and Lisa DuBreuil, LICSW

Dr. Conason is in private practice in New York, New York. Ms. DuBreuil is with the Department of Psychiatry, Massachusetts General Hospital in Boston, Massachusetts.

Funding: No funding was provided.

Disclosures: The authors have no conflicts of interest relevant to the content of this article.

Abstract: Research indicates that patients are at increased risk for suicide and self-harm behaviors following bariatric surgery. In this article, the authors review the available literature on suicide and self-harm after surgery and explore possible explanations for this increased risk. We conclude with our recommendations to the bariatric team on how to minimize risks to patients. 

Keywords: Bariatric surgery, self-harm, suicide

Bariatric Times. 2019;16(10):16–21.

There is a common misperception among patients and providers that bariatric surgery is a panacea that will cure patients of all medical, psychiatric, and emotional ailments.1–3 This perspective can lead to unrealistic expectations of the surgery and disappointment when these expectations are not met. While there are numerous benefits to bariatric surgery, it is not a cure-all solution, and this misguided perspective can lead to negative consequences following the procedure for the patient, including feelings of failure and shame, depression, anxiety, and  lack of adherence to long-term follow-up care with the surgery center. These negative emotional consequences can occur alongside physical and/or nutritional complications that patients might experience following weight loss surgery (WLS).4,5

Insufficient education on the risks of bariatric surgery, including potential psychosocial consequences, might contribute to a patient’s overly optimistic view of the surgery. Risks associated with WLS might be downplayed by some in the bariatric surgery community, from the top down. For example, despite a number of studies providing strong evidence that Roux-en-Y gastric bypass surgery (RYGB) is associated with an increased risk of alcohol abuse, at the time of writing this article, this risk remains included under the “misconceptions” section of the American Society for Metabolic and Bariatric Surgery (ASMBS) website.6 Similarly, despite significant evidence that patients are at an increased risk for suicide following bariatric surgery, this risk also remains under the “misconceptions” section of the ASMBS website.6 Many of the research studies documenting increased risk of suicide following WLS focus on the successful outcomes of the surgery (e.g., improved diabetes control and cardiovascular markers), while only briefly mentioning their findings of increased rates of suicide, which further minimizes these risks by presenting them as low-prevalence behaviors.7,8 While suicide is indeed a low-prevalence behavior, it has a fatal outcome, and any significant increased risk in the post-WLS population should be taken seriously by the healthcare team, informing patients of these risks and monitoring their mood postsurgery. Currently, including the risk of  increased risk of suicide following WLS in patient informed consent documents prior to surgery is not standard practice, nor is routinely screening for suicidal symptoms following WLS.

Suicide is the act of purposely causing one’s own death; suicidal behaviors are actions related to the intent to cause one’s own death; and self harm is deliberate, self-inflicted injury to one’s body with (suicidal self-injury) or without (nonsuicidal self-injury) intent to die.9 It is important to note that even nonsuicidal self-harm behaviors can still result in serious injury or fatality. For example, someone who is engaging in cutting behaviors without intent to die might accidentally cut too deep or cut across a major artery that results in serious injury or death. In addition, nonsuicidal self-harm behavior has been identified as a risk factor for later suicidal behaviors.10 Thus, self-harming behaviors, even without intent to die, must be taken seriously.

This article reviews the existing research on suicide and self-harm following bariatric surgery. We first summarize the research detailing the rates of suicide and self-harm following bariatric surgery, explore possible explanations for the observed increased risk for suicide and self-harm behavior in patients following WLS, and provide recommendations to help minimize patient risk.

Rates of Suicide and Self-Injury Following Bariatric Surgery

Dating back to some of the earliest longitudinal studies of bariatric surgery, researchers observed that some of their participants were dying by suicide. For example, in 1995, Pories et al11 documented three suicides (plus 4 “questionable” auto accidents) out of 608 WLS patients who were followed over 14 years for a suicide rate of 0.49 to 0.66 percent, which can be compared to the national suicide rate in the United States (US) in 1995 of 0.20 percent for men and 0.04 percent for women. In another early observational study, Powers et al12 followed 131 patients who underwent gastric restriction surgery for an average of six years. One patient in their group died by suicide, (0.76%).12

More recent studies document an increased risk of suicide following bariatric surgery, including a meta-analysis by Peterhansel et al,13 which analyzed 28 studies with data on death by suicide following bariatric surgery. Based on their analysis, the estimated suicide rate for the bariatric surgery population is 4.1 deaths per 10,000 patients (95% confidence interval [CI]: 3.2–5.1/10,000). When compared to the World Health Organization’s (WHO) suicide data for the general population (1.0/10,000), the investigators reported a four-fold increased risk of death by suicide among patients who underwent WLS.13

In a large population-based study, Tindle et al14 investigated the rate of suicide following bariatric surgery using data from the state of Pennsylvania. They observed that, out of 16,683 people who underwent bariatric surgery between the years 1995 and 2004, 31 people died by suicide (6.6/100,000 person-years). The mean age of people who died by suicide was 45 years, the mean time to death was approximately three years following surgery, and men were more than twice as likely to die by suicide than women. The higher suicide rate in men was consistent with the suicide data for the general population, although the discrepancy in suicide rates by sex in the general population is even greater, with men being 3 to 4 times more likely to commit suicide than women. In this sample, the rates of suicide following bariatric surgery were substantially higher than the suicide rates for the general aged-matched population in the US for the same time period.14 Unfortunately, this study did not examine links between suicide and type of bariatric surgery. The authors of this study postulated that the suicide rates in their sample and in the general population were underestimated, suggesting that some of the deaths that occurred by other means, such as drug overdose or car accidents, should have been classified as suicide deaths, but were not.14

Another study examining the mortality rate of bariatric surgery patients in Pennsylvania reported 16 deaths classified as suicide (4% of the sample). An additional 14 deaths (3% of the sample) were classified as drug overdoses, not suicide;15 however, it is possible that some of these deaths actually were suicides. The authors concluded that there is an excessive rate of suicide in patients who undergo bariatric surgery.15

Utilizing data from a national registry in Sweden, a study by Backman et al16 reported that people who underwent RYGB surgery were 2.85 times more likely to be admitted to the hospital for a suicide attempt than people in the general population reference group. While there were higher rates of depression and suicide attempts prior to surgery in the RYGB surgery group, the risk of inpatient hospitalization for both depression and suicide attempts increased significantly in these patients following RYGB surgery, compared to the same group of patients before surgery and to the general population reference group.

Neovius et al17 analyzed data from two large Swedish bariatric surgery databases—the Swedish Obesity Study (SOS) and the Scandinavian Obesity Surgery Registry (SOReg). The Itrim Health Database, a database of people with body mass index (BMI) values in the “obese” range who used intensive lifestyle modification to lose weight, was used as a comparison group for the SOReg group. Neovius et al17 reported nine suicides (0.48% of the sample) in the surgery group compared to three suicides (0.15% of the sample) in the nonsurgery group. After including nonfatal self-harm in their analyses, the researchers found that suicide and self-harm were 1.78 times more likely to occur in individuals following WLS than their nonsurgery counterparts. Participants who underwent RYGB were at the highest risk (3.5-times-increased risk) followed by participants who underwent gastric banding surgery (2.4-times-increased risk) and vertical banded gastroplasty (2.3-times-increased risk), compared to the nonsurgery group. Increased rates of suicide were also observed in the SOReg database, with 33 suicides (0.16% of the sample, 5.17-times increased risk) in the RYGB surgery group, compared to five suicides (0.03% of the sample) in the lifestyle modification nonsurgery comparison group. When including nonfatal self-harm, they found that suicide and self-harm occurred 3.16 times more often in the RYGB group than in the lifestyle modification nonsurgery group.17

Another study examining data from three Swedish registries reported 17 suicides (0.08% of the sample) in the two years following RYGB surgery.18 In this sample, women who received WLS were 4.5 times more likely to die by suicide than those in the comparison group. The researchers also noted a 30-fold increased risk of self-harm behaviors in patients after their WLS who also had a history of self-harm behaviors in the two years prior to surgery. The authors note that self-harm behaviors tended to remain stable during the years leading up to surgery, but then increased dramatically in the two-year postoperative period.

A population-based study of patients who underwent RYGB surgery in Ontario, Canada, compared the incidence of self-harm behaviors requiring emergency medical services during the three years prior to WLS to the three years following WLS and found a significant increase in postoperative self-harm behaviors.19 The risk of self-harm behaviors increased by approximately 50 percent in the postoperative period, compared to the preoperative period. People aged 35 years or older, those with lower income status, those living in rural areas, and those with a history of depression were at highest risk. The postoperative rate for self-harm behaviors was 3.6 per 1,000 WLS patients annually, which is significantly higher than the rate of self-harm behaviors in the general population in Ontario, which is 1.2 per 1,000 patients annually.

A study by Adams et al8 revealed that RYGB surgery was associated with an increased risk of suicide generally, and an increased risk of suicide by poisoning specifically. In their sample, five out of 418 participants in the WLS group (1.2% of the group sample) died by suicide postsurgery. An additional two participants (0.5%) out of 417 in the surgery-seeking group died by suicide at some point after undergoing RYGB surgery, compared to no deaths by suicide in the “obesity” comparison group of 321 participants who never underwent surgery.

Davidson et al20 reported that participants in the WLS group who were younger than 35 years old, especially women, had a higher risk of all-cause mortality compared to the nonsurgery comparison group, attributable to death by external causes (i.e., suicide, unintentional injury unrelated to drugs, poisoning of undetermined intent, other externally caused deaths).

An earlier study by Adams et al7 reported four suicides (0.96%) and three poisonings of undetermined intent (0.72%) out of the 418 participants in the RYGB post-surgery group, a rate that was significantly higher compared to the control group.

Another study by Adams et al21 retrospectively examined data from a single surgery practice in Utah, following WLS patients postoperatively for 18 years compared to a matched nonsurgical group. Fifteen patients in the WLS group died by suicide (0.19% of the sample), compared to five patients in the nonsurgery group (0.06% of the sample), revealing a 1.71 greater risk of dying by suicide in patients who underwent WLS compared to their nonsurgery counterparts. There were an additional nine patients in the surgery group (0.11%) who died by poisoning of undetermined intent and 21 (0.26%) who died in accidents not related to drugs. It is possible that at least a portion of these deaths were misclassified as nonsuicides, which would indicate a much higher rate of suicide in the patient sample following WLS.

Goldfeder et al22 examined data from the City of New York Office of the Chief Medical Examiner between the years 1997 and 2005 to assess patient death following WLS. The investigators found one reported suicide among the 107 patient deaths post-WLS (0.93%). Unfortunately, this study was limited by a lack of investigation by the medical examiner into all reported deaths; thus, it is possible that all deaths by suicide following bariatric surgery during this time period were not captured in the study.

In their 2001 study, Mitchell et al23 observed one death by suicide (1.0%) out of 100 WLS patients who were followed for 13 to 15 years after their surgeries.

In contrast to the body of evidence documenting an increased risk of suicide following bariatric surgery, a minority of studies did not find any significant differences in risk of suicide. A study using a Danish nationwide registry did not find an increased suicide rate in patients following bariatric surgery compared to a nonsurgery control group over a four-year follow-up period.24 However, the researchers did find an increased rate of self-harm behaviors following bariatric surgery, with a hazard ratio of 3.23 in the surgery group.

Morgan et al25 examined a state-wide database capturing all patients undergoing bariatric surgery in Western Australia and reported the suicide rate of post-WLS patients, who were followed for five years, to be similar to that of the general population. They observed a higher rate of self-harm in patients who underwent bariatric surgery (0.9% of their sample), but the rates of self-harm did not change pre- to postsurgery. Of note, the sample in this study primarily underwent sleeve gastrectomy or laparoscopic adjustable banding procedures, with less than 10 percent of the sample undergoing RYGB. Their sample was also 78-percent female. These demographic characteristics (i.e., small number of RYGB procedures and male patients, both associated with higher risk of suicide) might explain why some of the findings in this study were different from those reported in other studies.

Recently, a study by Gordon et al26 examined data from the Longitudinal Assessment of Bariatric Surgery-2 (LABS-2) study and assessed bariatric patients presurgery and five years postsurgery. They found that, out of 2,458 participants, seven (0.24% of the sample) patients died by either confirmed or suspected suicide. There were no significant differences in preoperatively reported suicidal thoughts or behaviors compared to those reported postoperatively, but they did observe a decrease in reported suicidal behaviors during the first two years following WLS, compared to those reported preoperatively; however, by the postoperative five-years follow-up, reported suicidal behaviors increased to levels reported preoperatively.

In summary, there is a substantial body of evidence showing that patients are at a significantly increased risk of death by suicide following bariatric surgery compared to these same patients’ own presurgical histories, to BMI-matched reference groups, and to the general population. Research suggests that bariatric patients have an increased risk of self-harm behaviors and a four-times greater risk of suicide following bariatric surgery, with men who undergo RYGB surgery at the highest risk, compared to  men who undergo other types of WLS, women who undergo any type of WLS, and bariatric patients who do not undergo WLS.

Possible Explanations for Increased Risk of Suicide and Self-Harm Following Bariatric Surgery

Several mechanisms have been proposed to explain why patients are at an increased risk of self-harm and suicide following WLS, including changes in quality of life, new or re-emerging symptoms of depression, weight regain, impulsivity, recurrence of comorbid medical diseases, new or re-emerging eating disorders or distorted body image,  new or re-emerging alcohol or substance abuse, and metabolic changes. A prior history of suicide attempts and family history of suicide have also been suggested to increase the risk for postoperative self-harm or suicidal behaviors, though the science behind it remains unclear.

Preoperative suicidal behavior. One theory on why risk of suicide and self-harm increases in patients following WLS is because they are at greater risk for suicide and self-harm, in general, preoperatively, compared to patients with lower weights, and this risk continues to persist after surgery. For example, Backman et al16 reported that their RYGB cohort exhibited a higher risk of attempted suicide before surgery compared to the “nonobese” reference group. Similarly, Sansone et al27 reported that nine percent of bariatric surgery candidates had a history of prior suicide attempts, and Powers et al12 reported a case of suicide post-WLS had a familial history of suicide as well as had made several prior suicide attempts preoperatively. Lagerros et al18 reported that patients who engaged in preoperative self-harm were 30 times more likely to engage in these behaviors following surgery, and concluded that a diagnosis of self-harm behavior within two years prior to WLS significantly predicted the risk of self-harm behaviors in the two years after bariatric surgery. Gordon et al26 reported that patients with a preoperative history of suicidal behavior had a 17-times increased risk of postoperative suicidal behavior.

In the general suicide literature, one of the strongest predictors for future suicidal behavior is past suicidal behavior. An individual who has made a suicide attempt or engaged in self-harm behaviors in the past is more likely to make another suicide attempt in the future than someone who has never made a suicide attempt or engaged in self-harm in the past. However, the elevated rates of suicide attempts and self-harm behaviors observed in bariatric patients prior to surgery do not explain why this risk becomes even greater after surgery. Without any other variables impacting this behavior, we would expect the rate of suicide to remain stable from preoperation to postoperation in this patient population. But research shows this not to be the case, suggesting there is more behind why risk for self-harm and suicidal behaviors increases in bariatric patients following WLS than just the presence of preoperative psychopathology. In a study by Neovius et al,18 investigators controlled for self-harm history at baseline (the surgery groups had nearly twice the prevalence compared to the nonsurgery control group) and other preoperative risk factors by comparing to a subgroup of participants with no diagnosed psychiatric disorders or prior history of self-harm. The investigators reported that the risk of self-harm and suicide was still significantly higher following bariatric surgery compared to matched controls.

Changes in quality of life. A variance in levels of impact that bariatric surgery has on quality of life (QOL) factors has been observed, from long-term improvements in QOL in some patients to transient improvements, no improvements, or even worsened QOL post-surgery in other patients. Adams et al8 suggested that WLS, per se, does not cause an increased risk of suicide in patients postooperatively; rather, poor QOL issues that were present preoperatively and persisted postoperatively, in combination with unrealistically high and, thus, unmet expectations of surgical outcomes by the patient cause the increased risk of suicide. Mitchell et al28 noted that a subset of patients continued to experience QOL impairments or even worsened QOL following WLS, which might have led to feelings of disappointment or failure and contributed to an increase  in postoperative self-harm or suicidal behaviors, compared to these patients’ preoperative behaviors.

Looking at domain-specific QOL, Mitchell et al28 reported that, while many patients experienced improvements in sexual functioning following WLS, some experienced physical impairments, especially related to negative body image. Bariatric patients postoperatively might have also experienced exacerbations of relationship problems. Marital issues that were present prior to surgery tended to remain after surgery, and the changes that one partner experienced following WLS might have created a destabilization in the marital dynamics, resulting in a worsening of relationship problems. Gordon et al26 found that patients who divorced their spouses during the five-year postoperative period of bariatric surgery demonstrated increased risk of suicidal ideation and self-harm. Mitchell et al28 also noted that postoperative improvements in self-esteem were transient, and that some patients did not experience improvements at all following WLS. This suggests that lack of improvement or only transient improvement in both overall QOL and specific domains of QOL, such as sexual functioning, relationships, and self-esteem, can contribute to increased symptoms of depression and feelings of hopelessness, which might translate into suicidal behavior following bariatric surgery.

Depression. Another possible explanation for the increased risk of suicide and self-harm post-WLS is the elevated rate of depression that is present before surgery and that tends to remain or only transiently improve after surgery. Again, combined with any unrealistically high expectations a patient might have had going into surgery, the continuation of these symptoms could contribute to increased suicide risk. Symptoms of depression might be particularly difficult for patients to cope with if they experienced improved mood right after surgery only to have the depression fully return later. Tindle et al14 observed that most of the suicides in their study occurred 2 to 4 years postoperatively, a time period when psychological issues that might have briefly improved following surgery (such as body image dissatisfaction or mood disorders) tend to recur, reverting back to preoperative levels.

People who meet the BMI criterion for morbid obesity (BMI>40 kg/m2) and people who seek bariatric surgery tend to have higher rates of depression than the general population. In their study, Backman et al16 observed a significantly higher rate of depression in RYGB candidates that did not improve following surgery. Similarly, Adams et al7 also found that participants who underwent bariatric surgery did not experience any improvements in psychological symptoms, including depression, as measured by the Short Form 36 Mental Component score. In their meta-analysis, Peterhansel et al13 noted that, in studies that provided explanations for suicide, depression was the most frequently cited cause.

Some research suggests that antidepressant medication might not be absorbed as effectively by patients following bariatric surgery, which may require them to take significantly higher doses of the medication postoperatively, compared to their preoperative dose.27 If medications are not managed properly postoperatively, it is more likely that symptoms of depression will worsen, which could increase the risk for suicide.

The increased rates of mood disorders, including major depressive disorder, in individuals at higher weights might be related to the widespread social weight bias, internalized weight bias, and feelings of marginalization this patient population often experiences. People in larger bodies are more likely to internalize stigma compared to people in other marginalized groups, and this internalized weight bias is associated with a number of health consequences, including increased risk of depression.29,30

Weight regain. A number of studies have cited weight regain as a contributing factor to the increased risk of suicide in patients following WLS. In their meta-analysis, Peterhansel et al13 observed an association between weight regain and increased symptoms of suicidal ideation. Tindle et al14 found that most of the acts of suicide in their sample occurred during the time period when patients are most likely to regain weight after surgery (2–4 years postoperatively).14 Powers et al12 noted that the one patient in their study who committed suicide had regained most of the weight initially lost. In contrast, Neovius et al17 found that the increased risk of suicide and self-harm in the study sample of  patients who underwent WLS was not related to poor weight loss outcomes.

Weight regain should be considered in context of the negative effects of weight stigma to help clarify why it might increase the risk of suicide in patients following WLS. Patients who undergo bariatric surgery have likely lived many years in a larger body, and thus have likely experienced the stigma, marginalization, and discrimination commonly directed toward people with higher weights. If internalized, the stigma might lead the individual to self-blame for his or her weight status and/or for other perceived problems or challenges, including weight regain following WLS. Internalized weight bias can make it more difficult for postoperative patients to adhere to good self-care habits and/or to follow up with their surgery team regarding any health issues they are experiencing, including increased physiological and emotional stress, depression, low self-esteem, body dissatisfaction, disordered eating, and decreased physical activity.30

For post-WLS patients, weight regain might be particularly distressing if they experienced improvements in how they were treated socially as they became thinner (e.g., people might hold doors open for them, motorists might stop to allow them to walk across the street, or they might have more dating opportunities), only to have these courtesies stop once they were again in a larger body. Returning to a marginalized status after experiencing temporary relief from harassment, stigma, discrimination, and weight bias might result in overwhelming feelings of self-blame, shame, and disappointment in the patient; the healthcare  team should remain  empathic and supportive of all bariatric patients throughout their entire treatment journey, pre- and postoperatively.

Recurrence of comorbid diseases. While some medical illnesses temporarily improve following bariatric surgery, postoperative patients can experience a recurrence of ailments with which they struggled preoperatively. In a meta-analysis, Peterhansel et al13 observed that many diseases, including sleep apnea and diabetes, tended to reemerge and even worsen long-term following WLS (3 years postsurgery). In their review article, Mitchell et al28 also noted that, while many people experience improvements in Type 2 diabetes (T2D), some patients remain symptomatic, experience a recurrence, and or experience a worsening of symptoms following WLS.

Mitchell et al28 suggested that reemergence and/or worsening of medical ailments might contribute to a sense of failure and disappointment in bariatric patients following WLS, which in turn might increase the risk of suicide, especially if the alleviation of these diseases was a key factor in a patient’s decision to undergo the surgery. Gordon et al26 observed that postoperative worsening of health conditions was associated with an increased risk of suicidal ideation and self-harm in post-WLS patients. Recurrence of medical issues linked to weight regain could be particularly difficult for postoperative patients to cope with due to the increased shame and stigma associated with these comorbid illnesses, such as T2D and obstructive sleep apnea. Pervasive weight bias in medical settings can result in healthcare professionals blaming the patients for these ailments. Patients might internalize that these illnesses are their fault due to failing to reduce their weight through the lifestyle interventions (i.e., diet, exercise) often recommended by medical professionals, and this can contribute to the deep shame patients might feel regarding these diagnoses. This shame and guilt increases their reluctance to seek medical care, including attending follow-up appointments with bariatric specialists, as they anticipate further disappointment, judgment, and blame by members of the healthcare team.

New or re-emerging eating disorders, disordered eating, or distorted body image. Eating disorders, disordered eating, and body image are other areas in which postoperative patients may not always experience the hoped for improvements following WLS. Mitchell et al28 noted that a subgroup of patients will develop or redevelop loss of control of eating following WLS, including subjective binge eating and self-induced vomiting.

Eating disorders and disordered eating are associated with subjective distress, which could play a role in the increased suicide risk observed in patients following WLS. Body image, a feature strongly linked to eating disorders and disordered eating, similarly might improve only transiently, might not improve at all, or might even worsen following WLS. Patients who experience initial improvements in body image after surgery might find a recurrence of body image dissatisfaction or a worsening of symptoms as they either regain weight or struggle with excess skin. Others have difficulty adjusting to a body that looks dramatically different from the one in which they had lived most of their lives. These difficulties can be compounded as these patients attempt to navigate through a society that is now treating them differently following weight loss.

New or re-emerging alcohol and/or substance use. There is substantial research documenting increased risk of alcohol abuse following RYGB surgery, and new research  suggests there is an increased risk of alcohol abuse following vertical sleeve gastrectomy (VSG) surgery, as well. Recent research also suggests that post-WLS patients might be more prone to abusing other substances as well, including opioids.31 Neovius et al12 observed that substance abuse diagnoses were common following bariatric surgery (48% in the SOS database and 51% in the SOReg database).

As Peterhansel et al13 noted in their review, alcoholism has been an established risk factor for suicide attempts and might contribute to the increased risk of suicide observed in patients who have undergone bariatric surgery. Mitchell et al28 highlighted the changes in alcohol pharmacokinetics and alcohol sensitivity that occur following WLS. They posited that, given the roles that alcohol consumption and alcohol use disorders often play in suicide attempts, the changes in alcohol pharmacokinetics that have been observed  in patients who have undergone bariatric surgery might help explain the increased risk of suicide in this patient population, especially in those who had  RYGB surgery, where these changes with alcohol seem to be most pronounced. Perhaps not coincidentally, patients who had RYGB also seem to be at the highest risk for postoperative suicide and/or self-harm compared to patients who had other types of WLS.17

Metabolic changes following surgery. Peterhansel et al13 noted that ghrelin, a peptide hormone that is decreased following bariatric surgery, is often implicated in suicide risk. There is some research to suggest that a decrease in ghrelin levels might be related to increased depressive symptoms and suicidal thoughts and behaviors, while an increase in ghrelin might have an antidepressant effect. In his commentary, Dixon noted that ghrelin has also been implicated in learning, memory, reward, motivation, stress response, anxiety, and depression.32 VSG, currently the most popular bariatric procedure worldwide, is specifically designed to reduce levels of circulating ghrelin, and an increased risk of suicide has been observed in patients who undergo partial gastrectomy, a surgical procedure that is similar to VSG, for the treatment of ulcer diseases. The effects of VSG on depression and suicidal behavior are not yet known.

There is also some research linking low levels of neuropeptide Y (NPY), which might also be decreased in patients following bariatric surgery, with depression and suicidal behavior.28 Mitchell et al28 noted that, post-RYGB surgery, patients experience postprandial hyperinsulinemic hypoglycemia with neuroglycopenia, a syndrome characterized by lightheadedness, sweating, confusion, loss of consciousness, or seizure following consumption of a large amount of carbohydrates, and the investigators posited that confusion related to this condition might contribute to suicidal behavior following bariatric surgery.

Unrealistic expectations. Kovacs et al24 framed their findings of increased self-harm behaviors following WLS in the context of overly high or unrealistic expectations that patients might have regarding the positive effects that WLS may have on psychological and/or physical functioning. When these expectations are not met, Kovacs et al24 postulated, patients might exhibit  “acting out” and “help-seeking” behaviors. Mitchell et al28 described how people seeking bariatric surgery might see the surgery as their  “only chance” for relief from the problems they associate with their weight. When bariatric surgery does not provide the “cure-all” solution they had hoped for, these patients might feel as though they have lost their last hope. Hopelessness plays a key role in suicide.33–35 This hopelessness might be especially poignant when people blame themselves for the perceived failure and disappointment of surgery. Self-blame can lead to intense negative feelings about oneself, where suicide might be viewed as the only way out.

Recommendations for the Bariatric Team

The suggested increased risk of suicide and self-harm following bariatric surgery poses unique challenges to the bariatric surgery team. While suicide is a low-base-rate behavior, its fatal nature requires that this increased risk must be taken seriously and that significant efforts should be made to minimize the risks to patients considering WLS.

Include a behavioral health professional on the multidisicplinary healthcare team. Having a behavioral health professional on the bariatric treatment team, preferably one who has experience in treating internalized weight stigma, is critical to achieving optimal outcomes in bariatric patients undergoing WLS. Licensed behavioral health professionals are uniquely trained to conduct suicide assessments, recognize risk factors, develop safety planning, and initiate interventions and other essential treatment techniques for patients to minimize risk of suicide. It is important to consider that many patients, especially during the preoperative approval process, will work hard to “look good” for the treatment team and might not readily disclose suicide risk factors or symptoms of mood disorders. Behavioral health professionals can help patients feel more comfortable discussing sensitive issues, such as mental health, by developing a therapeutic alliance with the patient that is built on trust. While behavioral health professionals will not be able to prevent every suicide (especially if patients do not disclose suicidal ideation or other risk factors), they do have unique training that is invaluable in a setting where patients are at an increased risk for suicide and other behavioral health issues. It might not be feasible for every bariatric surgery practice to have a behavioral health professional on staff; however, it is essential that all bariatric programs work closely with licensed mental health professionals in the community. Patients who are thought to be struggling with behavioral health issues, including suicidal thoughts and behaviors, should be referred to a licensed mental health professional for further assessment and treatment as soon as possible. If a patient seems to be at imminent risk for suicide, he or she should be directed to the closest hospital emergency room.

Conduct suicide assessments. There are some simple self-report assessments that can easily be administered to patients postoperatively to assess for depression and suicide risk. One commonly used self-report assessment is the Patient Health Questionnaire-2 (PHQ-2; Item 9 assesses for suicidal ideation).36 The Beck Depression Inventory-2 (BDI-2) also assesses for suicidal ideation with one item;37 however, unlike the PHQ-2, the BDI-2 is not available in the public domain and is recommended to be administered by a trained mental health professional. Another evidence-based measure is the Columbia Suicide Severity Rating Scale,38 a simple and easy-to-use, six-item instrument that classifies people into three risk categories of low risk, moderate risk, and high risk based on their responses to the questions. The scale is free for public use. If a patient discloses risk of suicide on an assessment, they should be referred to a behavioral health professional for further assessment or directed to their local hospital emergency room if at imminent risk. The research findings that indicate that suicide tends to occur longer-term post-WLS emphasize the need for long-term assessment (e.g., Gordon et al21 found that suicidal ideation and behaviors were continuing to rise at five years of follow-up). Additional scales include the Sheehan Suicidal Tracking Scale and the Hamilton Anxiety Rating Scale (HAM-1).

Help patients considering WLS set realistic expectations for surgery outcomes through education on its risks, benefits, and possible side effects. People seeking WLS might have unrealistic expectations for how the surgery will improve their quality of life; this could be due to cultural influences (i.e.,  society that values thinness as the “cure-all” solution) and the information provided preoperatively to patients through the bariatric program itself.  While many bariatric surgery centers might pride themselves on managing patient expectations regarding surgery outcomes, they still might promote an overly optimistic outlook. For example, prospective patients attending a presurgical information or orientation session might be presented, in a single afternoon, with a lot of information on the different surgical procedures offered by the program, with little time or opportunity to process and reflect on the provided information. Some programs might ask postoperative patients to share their stories at meetings for prospective patients; however, these postoperative patients might be in the “honeymoon” period after surgery (3–12 months postoperation), and thus are less likely to have experienced any serious complications during this short time. In addition, the postoperative patients selected for this task might be the “success stories” of the surgery centers. These types of presentations can contribute to an overly optimistic view of surgery by prospective patients.

Prospective patients might be reluctant to hear or acknowledge that WLS might not make them cosmetically thin, “happy,” or cure or improve many of their psychosocial issues. They might latch onto the positive outcomes of surgery presented in the preoperative process and ignore the risks of surgery, especially when the risks are not emphasized or are minimized by the surgery team.

Educating patients about the psychosocial risks of surgery is essential in helping them develop realistic expectations of surgery. Bariatric professionals should allow patients the time and opportunity to examine their hopes, expectations, and motivations for getting WLS, while making sure they are provided accurate, realistic information about postsurgery living and given the opportunity to hear from patients who have had a variety of outcomes. Patients who participate in several informational sessions over time will be more likely to absorb and retain information compared to patients who attend only one long seminar.

Prospective patients should also be educated on “red flags” that signal the potential emergence of depression, substance abuse, and suicidal thinking. They should be educated on key symptoms of depression (i.e., feeling sad more often than not, crying frequently, loss of interest and pleasure in things they used to enjoy, low motivation, changes in appetite, increased irritability, changes in sleep), substance abuse (e.g., drinking/using drugs to get intoxicated, using substances in isolation, using substances more frequently or in larger amounts than usual, experiencing blackouts, driving while under the influence), and suicidal behaviors (e.g., feelings of hopelessness and helplessness, feeling like a burden, increased thoughts of death and dying, thinking about methods to kill themselves). Patients should be encouraged to contact the surgery center right away if they start experiencing symptoms, and it should be emphasized that erring on the side of caution is always better than just waiting to see if the symptoms go away on their own. In other words, even if a patient isn’t sure he or she is experiencing symptoms of depression, the patient should contact the surgery center and speak with someone (ideally a behavioral health professional on the treatment team) for an assessment. Patients should also be provided with mental health resources, including a list of local behavioral health professionals trained in the postoperative care of bariatric surgery patients. If there are no local behavioral health professionals trained in bariatric surgery or if a patient is experiencing mobility issues, licensed professionals who provide telemental health sessions can also be a good resource. Furthermore, national referral numbers and crisis support hotlines should be provided in the pre- and postsurgical information packets for all patients.

Postsurgery complications, such as suicidal behaviors, self-harm, mood disorders, substance use disorders (SUDs), eating disorders (EDs), body image dissatisfaction, unwelcome shifts and changes in relationships, and mixed feelings about life in their “new body” need to be discussed openly with all bariatric patients and presented as real possibilities, even for patients who work hard to be successful. Patients also should be given up-to-date data on long-term (i.e., 5–20 years) results of WLS, including weight regain and the recurrence of diseases. Knowing ahead of time that these outcomes can reoccur, that the patient is not to blame, and that the bariatric team knows this and is ready to help, will make it easier for patients to come forward after surgery when they are struggling.

Create a safe and comfortable environment for patients by minimizing weight bias. Bariatric professionals are not immune to the pervasive weight bias in our society, and this can impact interactions with higher-weight patients seeking treatment. In addition, higher weight patients might be members of other social groups that experience oppression, inequalities, and/or marginalization (e.g., due to race, gender, sexuality, or religion), and this additional burden might worsen their medical and mental healthcare in bariatric centers and elsewhere.

A clinician’s weight bias can be communicated both directly and indirectly, and clinicians are often unaware of the messages that higher-weight patients are receiving from their interactions with healthcare providers and from the clinical environment itself. Schwartz et al39 found that bariatric health professionals showed significant weight bias toward their patients and held implicit views of people with overweight or obesity as lazy, stupid, and worthless. Interestingly, factors that mitigated this bias among healthcare professionals were having a higher BMI themselves, having higher-weight friends, and having an understanding of the experience of living in a larger body. Since people at higher weights might blame themselves when health-related issues occur and likely have had a history of unpleasant or shaming experiences in medical settings, stigmatizing experiences in a bariatric setting might lead patients to withhold information or drop out of treatment rather than speak up about what is not working for them or hold providers accountable. In contrast, when patients feel comfortable with their surgery team, they might be more likely to attend follow-up appointments and disclose emotional struggles. In our clinical observations, one of the most common reasons that patients discontinue contact with their surgery team is due to a feeling of being judged by their healthcare team. This is particularly relevant for patients who are regaining weight and might feel as if they have “failed” or will be reprimanded by their surgery team. The process of regaining weight might induce shame in some patients, in part due to the high post-surgery expectations they have and the narrative that, if they just follow the rules and do what they are supposed to do, they will achieve sustainable long-term weight loss. Preoperative education about potential postoperative weight regain can help normalize weight regain and decrease feelings of shame in the patient if it occurs.

Shifting the focus away from weight is a powerful tool in creating a safe and comfortable environment for patients after WLS and can help remove the shame and judgment around weight regain. Practitioners might consider adopting a weight-inclusive perspective that focuses on how patients are functioning and feeling in their bodies rather than on their appearance or the numbers on the scale. Encouraging patients to focus on things over which they have more direct control, such as self-care, finding positive social support, and minimizing exposure to weight-stigmatizing social media, can increase a healthy sense of control and self-efficacy. Connecting patients to size-inclusive social media and other resources can help them realize that people of all shapes and sizes can function well and lead enjoyable lives.

Conclusion

Substantial evidence suggests that bariatric surgery patients are at an increased risk for suicide and self-harm behaviors following bariatric surgery. There are a number of plausible explanations for this increased risk, including the postoperative re-emergence of symptoms of mental illness that were present preoperatively in combination with the feelings of disappointment that can occur when unrealistically high expectations of surgical outcomes are not met. Metabolic changes affecting gut peptides, the absorption and metabolization of alcohol, and the absorption of psychiatric medications might also explain why some patients experience an increased risk of self-harm and/or suicidal behaviors following WLS. While suicide occurs at a low frequency among this patient population, its fatality means we must take the increased risk very seriously. We cannot prevent all acts of suicide, but there are steps that the bariatric team can take to minimize risks to their patients. Providing education on the benefits, risks, and potential suboptimal outcomes of WLS can guide patients in making better informed decisions regarding their treatment , developing more realistic expectations of surgery, setting achievable goals, and reducing shame if suboptimal outcomes occur. Having a trained mental health clinician on staff can help identify and treat patients more quickly and effectively who are struggling with mood disorders. Creating a safe, welcoming, and nonjudgmental environment for all bariatric patients, with empathic, supportive staff who are educated on identifying and eliminating weight bias in the clinic, can help patients feel more comfortable disclosing when they are struggling. From a weight-inclusive perspective, encouraging bariatric patients to focus on positive self-care behaviors and acceptance of themselves and others rather than on appearance and weight can go a long way in achieving optimal post-surgery outcomes.

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