Risk of suicide after long-term follow-up from bariatric surgery

Obesity in adults

Obesity has increased in prevalence worldwide and WHO has declared it a global epidemic. Population-level preventive interventions have been insufficient to slow down this trajectory. Obesity is a complex, heterogeneous, chronic, and progressive disease, which substantially affects health, quality of life, and mortality. Lifestyle and behavioural interventions are key components of obesity management; however, when used alone, they provide substantial and durable response in a minority of people. Bariatric (metabolic) surgery remains the most effective and durable treatment, with proven benefits beyond weight loss, including for cardiovascular and renal health, and decreased rates of obesity-related cancers and mortality. Considerable progress has been made in the development of pharmacological agents that approach the weight loss efficacy of metabolic surgery, and relevant outcome data related to these agents' use are accumulating. However, all treatment approaches to obesity have been vastly underutilised.

The role of metabolic and bariatric surgery on the obesity pandemic in Latin America: A review of current practices and future directions

Latin America faces a significant public health challenge due to the high prevalence of obesity and its associated diseases. Metabolic and bariatric surgery is effective and safe to treat obesity when other treatments fail; however, its implementation in Latin America remains unsatisfactory. This review explores the current status, challenges, and innovations of metabolic and bariatric surgery in Latin America. We searched peer-reviewed journals in English and Spanish for relevant articles published between 1998 and 2023. We found that more than 20% of the Latin American population is affected by obesity. Unfortunately, only a limited number of patients have access to metabolic and bariatric surgery due to high cost, limited availability, and shortage of specialists. The review found that ongoing clinical trials are being conducted in Brazil, Mexico, Chile, and Venezuela, indicating some regional progress. However, published studies remain low in number compared with other regions. Furthermore, we summarized the clinical outcomes, risks, and perioperative assessments associated with metabolic and bariatric surgery. We discussed potential strategies to enhance the availability and affordability of this intervention. This review emphasizes the significance of metabolic and bariatric surgery in addressing the obesity pandemic, specifically for Latin America, and proposes directions for future research and innovation.

Mental Health, and Eating Disorders in Patients After Roux-en-Y Gastric Bypass Surgery (RYGB)

<b>Introduction:</b> Obesity, as one of the main health problems worldwide, is associated with an increased risk of developing mental and eating disorders and negative eating habits. Bariatric surgery allows for rapid weight loss and alleviates the symptoms of concomitant diseases in obese patients.<b>Aim:</b> Pre- and postoperative estimation of mental disorders and eating behaviors in patients after Roux-en-Y Gastric Bypass (RYGB).<b>Material and methods:</b> Analysis of data from up to 5 years of follow-up including clinical examination and questionnaires.<b>Results:</b> Following parameters decreased after RYGB: anxiety and hyperactivity from 32.81% to 21.88%, mood disorders - 31.25% to 20.31%, substance abuse - 40.63% to 28.13%, emotional eating - 76.56% to 29.69%, binge eating - 50% to 6.25%, night eating - 87.5% to 20.31%. Postoperative rates of: negative eating habits, daily intake of calories and sweetened beverages, flatulence, constipation, and abdominal pain decreased, while the rate of food intolerance and emesis increased.<b>Conclusions:</b> In our patients, the occurrence of: mental and eating disorders, negative eating habits, daily calories, sweetened beverages, coffee intake decreased after weight loss (as a result of RYGB), but water, vegetables and fruit consumption increased. Lower rate of flatulence, constipation, and abdominal pain, but higher of food intolerance and emesis were also confirmed after RYGB.

Changes in Serum Concentration of Antidepressants After Bariatric Surgery and Recommendations for Postbariatric Surgery Antidepressant Therapy

BACKGROUND

Bariatric surgery affects the absorption of medications including antidepressants, but data regarding these effects are limited.

OBJECTIVES

Our objectives were to review publicly available data regarding changes in antidepressant serum concentration following bariatric surgery in order to develop medication dosing recommendations in this patient population.

METHODS

A comprehensive literature review was performed utilizing key search terms in Pubmed. Additional data were retrieved from the Food and Drug Administration and DrugBank Online resources.

RESULTS

A total of twelve published articles were included in addition to the publicly available data from the Food and Drug Administration and DrugBank. The serum concentration of antidepressants following bariatric surgery demonstrated considerable variability between and within drug classes due to unique pharmacokinetic features, drug preparation, and formulation. Recommendations were developed from published data regarding changes in serum concentration and drug-specific pharmacokinetic data.

CONCLUSIONS

To our knowledge, this is the first study to propose medication dose-adjustment recommendations for patients on antidepressants undergoing bariatric surgery. We were limited by the relatively small amount of data available and recommend monitoring patients and use of clinical judgment along with this guidance.

The Unrestrained Overeating Behavior and Clinical Perspective

Obesity-related co-morbidities decrease life quality, reduce working ability, and lead to early death. In the adult population, eating addiction manifests with excessive food consumption and the unrestrained overeating behavior, which is associated with increased risk of morbidity and mortality and defined as the binge eating disorder (BED). This hedonic intake is correlated with fat preference and the total amount of dietary fat consumption is the most potent risk factor for weight gain. Long-term BED leads to greater sensitivity to the rewarding effects of palatable foods and results in obesity fatefully. Increased plasma concentrations of non-esterified free fatty acids and lipid-overloaded hypertrophic adipocytes may cause insulin resistance. In addition to dietary intake of high-fat diet, sedentary lifestyle leads to increased storage of triglycerides not only in adipose tissue but also ectopically in other tissues. Lipid-induced apoptosis, ceramide accumulation, reactive oxygen species overproduction, endoplasmic reticulum stress, and mitochondrial dysfunction play role in the pathogenesis of lipotoxicity. Food addiction and BED originate from complex action of dopaminergic, opioid, and cannabinoid systems. BED may also be associated with both obesity and major depressive disorder. For preventing morbidity and mortality, as well as decreasing the impact of obesity-related comorbidities in appropriately selected patients, opiate receptor antagonists and antidepressant combination are recommended. Pharmacotherapy alongside behavioral management improves quality of life and reduces the obesity risk; however, the number of licensed drugs is very few. Thus, stereotactic treatment is recommended to break down the refractory obesity and binge eating in obese patient. As recent applications in the field of non-invasive neuromodulation, transcranial magnetic stimulation and transcranial direct current stimulation are thought to be important in image-guided deep brain stimulation in humans. Chronic overnutrition most likely provides repetitive and persistent signals that up-regulate inhibitor of nuclear factor kappa B (NF-κB) kinase beta subunit/NF-κB (IKKβ/NF-κB) in the hypothalamus before the onset of obesity. However, how the mechanisms of high-fat diet-induced peripheral signals affect the hypothalamic arcuate nucleus remain largely unknown.

Long term outcomes of metabolic/bariatric surgery in adults

The prevalence of obesity continues to rise around the world, driving up the need for effective and durable treatments. The field of metabolic/bariatric surgery has grown rapidly in the past 25 years, with observational studies and randomized controlled trials investigating a broad range of long term outcomes. Metabolic/bariatric surgery results in durable and significant weight loss and improvements in comorbid conditions, including type 2 diabetes. Observational studies show that metabolic/bariatric surgery is associated with a lower incidence of cardiovascular events, cancer, and death. Weight regain is a risk in a fraction of patients, and an association exists between metabolic/bariatric surgery and an increased risk of developing substance and alcohol use disorders, suicidal ideation/attempts, and accidental death. Patients need lifelong follow-up to help to reduce the risk of these complications and other nutritional deficiencies. Different surgical procedures have important differences in risks and benefits, and a clear need exists for more long term research about less invasive and emerging procedures. Recent guidelines for the treatment of obesity and metabolic conditions have been updated to reflect this growth in knowledge, with an expansion of eligibility criteria, particularly people with type 2 diabetes and a body mass index between 30.0 and 34.9.

Bariatric surgery and mental health outcomes: an umbrella review

Aims

To evaluate the breadth, depth and effectiveness of the evidence quality of all existing studies on bariatric surgery and mental health outcomes.

Design

Umbrella review of existing Systematic review and meta-analyses.

Data sources

PubMed, Embase, Web of Science, and the Cochrane Liberally databases of Systematic review and meta-analyses, and hand searching the reference lists of eligible publications.

Results

The search identified nine studies and 20 mental health outcomes from 1251 studies. Evidence shows that bariatric surgery is associated with significant improvement in areas such as anxiety, depression and eating disorders (including binge-eating disorder), and there is a significant harmful association with suicide, self-harm and alcohol use disorder (AUD). Among them, the most studied outcome is depression (4 articles). High-quality evidence proves that the score of depressive symptoms can be significantly improved after bariatric surgery within a two-year follow-up period and is not affected by the follow-up time. Low-quality evidence shows that bariatric surgery can significantly reduce depressive symptoms regardless of age and BMI, with an odds ratio (OR) of 0.49. Regardless of the postoperative BMI, the anxiety symptoms of women over 40 still decreased significantly, with an OR of 0.58. Regardless of the type of surgery, surgery can significantly reduce the incidence of eating disorders and symptoms. However, there is no obvious change in the follow-up time of AUD in the first two years after bariatric surgery, and the risk increases obviously in the third year, with an OR of 1.825. The evidence of moderate research shows that the risk of suicide and self-harm increases after bariatric surgery. The odds ratios in the same population and the control group were 1.9 and 3.8 times, respectively.

Conclusion

Bariatric surgery is beneficial for improving most mental health-related outcomes. However, we should be cautious about the increased risk of adverse mental health after surgery, such as suicide, self-harm, and AUD.

Bariatric Surgery and Suicide Risk in Patients With Obesity

OBJECTIVE

In a large multisite cohort of Veterans who underwent Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy, we compared the 5-year suicidal ideation and attempt rates with matched nonsurgical controls.

BACKGROUND

Bariatric surgery has significant health benefits but has also been associated with adverse mental health outcomes.

METHODS

Five-year rates of suicidal ideation and suicide attempts of Veterans who underwent Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy from the fiscal year 2000-2016 to matched nonsurgical controls using sequential stratification using cumulative incidence functions (ideation cohort: n=38,199; attempt cohort: n=38,661 after excluding patients with past-year outcome events). Adjusted differences in suicidal ideation and suicide attempts were estimated using a Cox regression with a robust sandwich variance estimator.

RESULTS

In the matched cohorts for suicidal ideation analyses, the mean age was 53.47 years and the majority were males (78.7%) and White (77.7%). Over 40% were treated for depression (41.8%), had a nonrecent depression diagnosis (40.9%), and 4.1% had past suicidal ideation or suicide attempts >1 year before index. Characteristics of the suicide attempt cohort were similar. Regression results found that risk of suicidal ideation was significantly higher for surgical patients (adjusted hazard ratio=1.21, 95% CI: 1.03-1.41), as was risk of suicide attempt (adjusted hazard ratio=1.62, 95% CI: 1.22-2.15).

CONCLUSIONS

Bariatric surgery appears to be associated with a greater risk of suicidal ideation and attempts than nonsurgical treatment of patients with severe obesity, suggesting that patients need careful monitoring for suicidal ideation and additional psychological support after bariatric surgery.

Pre-Operative Substance Use Disorder is Associated with Higher Risk of Long-Term Mortality Following Bariatric Surgery

PURPOSE

Metabolic and bariatric surgery (MBS) has been associated with reduced all-cause mortality. While the number of subjects with substance use disorders (SUD) before MBS has been documented, the impact of pre-operative SUD on long-term mortality following MBS is unknown. This study assessed long-term mortality of patients with and without pre-operative SUD who underwent MBS.

MATERIALS AND METHODS

Two statewide databases were used for this study: Utah Bariatric Surgery Registry (UBSR) and the Utah Population Database. Subjects who underwent MBS between 1997 and 2018 were linked to death records (1997-2021) to identify any death and cause for death following MBS. All deaths (internal, external, and unknown reasons), internal deaths, and external deaths were the primary outcomes of the study. External causes of death included death from injury, poisoning, and suicide. Internal causes of death included deaths that were associated with natural causes such as heart disease, cancer, and infections. A total of 17,215 patients were included in the analysis. Cox regression was used to estimate hazard ratios (HR) of controlled covariates, including the pre-operative SUD.

RESULTS

The subjects with pre-operative SUD had a 2.47 times higher risk of death as compared to those without SUD (HR = 2.47, p < 0.01). Those with pre-operative SUD had a higher internal cause of death than those without SUD by 129% (HR = 2.29, p < 0.01) and 216% higher external mortality risk than those without pre-operative SUD (HR = 3.16, p < 0.01).

CONCLUSION

Pre-operative SUD was associated with higher hazards of all-cause, internal cause, and external cause mortality in patients who undergo bariatric surgery.

The Influence of a Roux-en-Y Gastric Bypass on Plasma Concentrations of Antidepressants

PURPOSE

Roux-en-Y gastric bypass (RYGB) involves alterations of the gastrointestinal tract resulting in altered absorption. Patients with obesity have a higher prevalence of depression, and antidepressants are often prescribed. Alterations caused by RYGB could modify drug bioavailability and cause potential subtherapeutic plasma concentrations, increasing the risk of depressive relapse. The aim of this study was to describe the evolution of trough drug dose-normalized antidepressant plasma concentrations before and after RYGB.

MATERIALS AND METHODS

This naturalistic prospective case series considers patients with trough plasma concentrations in a 1-year timeframe before and after RYGB. Only antidepressants prescribed to at least three patients were included in the present study.

RESULTS

Thirteen patients (n = 12 females, median age 44 years, median BMI before intervention = 41.3 kg/m²) were included. Two patients were treated concurrently with fluoxetine and trazodone; the remaining patients were all treated with antidepressant monotherapy. Therapeutic drug monitoring (TDM) values for duloxetine (n = 3), escitalopram (n = 4), fluoxetine (n = 4), and trazodone (n = 4) before (median 4.7 weeks) and after (median 21.3 weeks) RYGB intervention were analyzed. Compared to preintervention, median [interquartile range] decreases in dose-normalized trough plasma concentrations for duloxetine (33% [- 47; - 23]), escitalopram (43% [- 51; - 31]), fluoxetine (9% [- 20; 0.2]), and trazodone (16% [- 29; 0.3]) were observed.

CONCLUSION

This study shows a decrease in plasma antidepressant concentrations following RYGB. TDM before and after RYGB, in addition to close monitoring of psychiatric symptomatology, may help optimize antidepressant treatment after bariatric surgery. These results also highlight the need for prospective studies assessing the clinical evidence available through TDM in these patients.

Psychopathology and eating behaviour in people with type 2 diabetes referred for bariatric surgery

PURPOSE

Psychopathology and disordered eating behaviours are putative pre-operative risk factors for suboptimal outcomes post-bariatric surgery. Documented psychopathology prevalence rates vary in bariatric candidate samples. Further, less attention has been paid to vulnerable subgroups such as people with diabetes who might be at an elevated risk. For these reasons, this study aimed to investigate the rates of psychopathology and disordered eating in pre-surgical candidates with type 2 diabetes mellitus (T2DM).

METHODS

Participants were 401 consecutive patients from a state-wide bariatric surgery service for people with T2DM. Psychopathology was measured using multi-modal assessment including diagnostic interview and battery of validated questionnaires. The mean age of the sample was 51 years with a mean BMI of 46 kg/m2. The majority of the sample was female (60.6%), born in Australia (87%) and 18.2% identified as Aboriginal and/or Torres Strait Islander.

RESULTS

Rates of current psychopathology in this sample included: major depressive disorder (MDD; 16.75%), generalised anxiety disorder (GAD; 20.25%), insomnia (17.75%) and binge eating disorder (BED; 10.75%). There were no significant differences on measures between people who endorsed Aboriginal and/or Torres Strait Islander status compared to those who did not endorse. The mean total score on the BES was 21.82 ± 10.40 (range 0-39), with 8.2% of participants meeting criteria for severe binge eating. Presence of an eating disorder was not significantly associated with degree of glycemic compensation. Average emotional eating scores were significantly higher in this study, compared to reference samples. Significantly increased binge eating severity and emotional eating severity was revealed for people with T2DM and comorbid MDD, social anxiety and eating disorders. Binge eating severity was associated with GAD, food addiction, substance use disorders, and history of suicide attempt but not emotional eating severity.

CONCLUSION

Amongst people with T2DM seeking bariatric surgery, MDD, GAD and emotional eating were common. Psychopathology in a sample of people with T2DM seeking bariatric surgery was significantly associated with severity of disordered eating. These findings suggest people with T2DM seeking bariatric surgery may be vulnerable to psychopathology and disordered eating with implications for early identification and intervention.

LEVEL OF EVIDENCE

Evidence obtained from cohort or case-control analytic studies.

Validity and Reliability of the Turkish Version of Mahony Psychological Assessment for Bariatric Surgery

Background

The aim of this study was to determine the validity and reliability of the Turkish version of Mahony Psychological Assessment for Bariatric Surgery which can be easily administered and used as a guide by health professionals who will be included in the treatment of patients who are potential candidates for bariatric surgery.

Methods

A total of 310 patients who were admitted to health institutions for bariatric surgery in 3 different provinces of Turkey answered these questions in the Turkish translation of Mahony Psychological Assessment for Bariatric Surgery. Eating disorder examination questionnaire was also administered to the patients in addition to Mahony Psychological Assessment for Bariatric Surgery.

Results

Early life problems due to weight scores of women were significantly higher than men (P = .001). Among the age groups, both the early life problems due to weight scores (P = .008) and dysphoric feelings about weight scores (P < .001) of the 18-44 age group were significantly higher than the participants who are over the age of 45. There is a weak-to-medium and positive correlation between the total Mahony Psychological Assessment for Bariatric Surgery total scores and all the subscale and total scores of the Eating Disorder Examination Questionnaire (P < .05 for all). These correlation results support the co-validity of Mahony Psychological Assessment for Bariatric Surgery and Eating Disorder Examination Questionnaire. Internal consistency of the Mahony Psychological Assessment for Bariatric Surgery was at a high level except for the subscale of positive treatment attitude and supportive environment. Cronbach's ɑ values were calculated to be 0.902 for the subscale of emotional and binge eating, 0.820 for the early life problems due to weight, 0.856 for the dysphoric feelings about weight, 0.539 for the positive treatment attitude and supportive environment, and 0.919 for the whole scale.

Conclusion

The analyses have shown that the Turkish version of Mahony Psychological Assessment for Bariatric Surgery may be used in clinical interviews and psychiatric evaluation of bariatric surgery patients in Turkey.

Metabolic surgery in treatment of obese Japanese patients with type 2 diabetes: a joint consensus statement from the Japanese Society for Treatment of Obesity, the Japan Diabetes Society, and the Japan Society for the Study of Obesity

Bariatric surgery has been shown to have a variety of metabolically beneficial effects for patients with type 2 diabetes (T2D), and is now also called metabolic surgery. At the 2nd Diabetes Surgery Summit held in 2015 in London, the indication for bariatric and metabolic surgery was included in the “algorithm for patients with type T2D”. With this background, the Japanese Society for Treatment of Obesity (JSTO), the Japan Diabetes Society (JDS) and the Japan Society for the Study of Obesity (JASSO) have formed a joint committee to develop a consensus statement regarding bariatric and metabolic surgery for the treatment of Japanese patients with T2D. Eventually, the consensus statement was announced at the joint meeting of the 38th Annual Meeting of JSTO and the 41st Annual Meeting of JASSO convened in Toyama on March 21, 2021. In preparing the consensus statement, we used Japanese data as much as possible as scientific evidence to consider the indication criteria, and set two types of recommendation grades, “recommendation” and “consideration”, for items for which recommendations are possible. We hope that this statement will be helpful in providing evidence-based high-quality care through bariatric and metabolic surgery for the treatment of obese Japanese patients with T2D.

Psychosocial Consequences of Bariatric Surgery: Two Sides of a Coin: a Scoping Review

This scoping review summarizes current evidence with regard to the impact of bariatric surgery on psychological health in adults with obesity. While a large body of evidence reports major metabolic benefit and improved quality of life, there is also ample evidence suggesting an increased incidence of self-harming behavior, a greater likelihood of developing an alcohol problem and higher rates of completed suicide among bariatric patients. Being able to identify the "at risk" patient population requires more longitudinal research into the risk factors for psychological complications after bariatric surgery. Bariatric surgery remains an extremely valuable long-term treatment option for managing obesity; however, there is a need to invest in mitigating psychological complications after the surgery, such as depression, alcohol consumption, and other self-harming behaviors.

Preoperative body-related emotional distress and culture as predictors of outcomes of bariatric surgery

PURPOSE

Findings concerning the impact of bariatric surgical intervention on both psychological variables and weight loss are often controversial and misconstrued the world over. The aim of this study was to classify bariatric surgery patients according to patterns of preoperative measures that may predict postoperative psychological and physiological outcomes and to compare these patterns between two distinct cultures.

METHODS

Of 169 consecutive bariatric surgery candidates from Israel and 81 candidates from the United States, 73 and 35 patients, respectively consented to be included in a follow-up phase. Body image dissatisfaction, emotional eating behaviors, risk of suicide, depressive symptoms, anxious symptoms, and percent excess weight loss were measured. K-means clustering procedure was used to classify bariatric surgery patients according to their preoperative body-related emotional distress, which was composed of body image dissatisfaction and emotional eating. The joint effect of culture and body-related emotional distress cluster on psychological distress was tested.

RESULTS

The cluster analysis revealed two preoperative body-related emotional distress patterns: high body-related emotional distress and low body-related emotional distress. Following surgery, US patients showed a higher risk of suicide and lower excess weight loss than Israeli patients within only the high body-related emotional distress cluster (a significant interaction effect).

CONCLUSION

Preoperative assessment of body-related emotional distress patterns among bariatric surgery candidates may enable professionals to identify potential postoperative risks of suicide, anxiety, and decreased weight loss. The relationship between the body-related emotional distress cluster and outcome measures is culture dependent.

LEVEL III

Case-control analytic study.

Suicidality risk among adults with binge-eating disorder

OBJECTIVE

To estimate relative suicidality risk associated with binge-eating disorder (BED).

METHODS

Retrospective study of patients identified as having BED (N = 1042) and a matched general population cohort (N = 10,420) from the Optum electronic health record database between January 2009 and September 2015. Patients had ≥1 outpatient encounter with a provider who recognized BED during the 12-month baseline preceding entry date. Incidence and relative risk of suicidality were assessed.

RESULTS

Incidence per 1000 person-years (95% CI) of suicidal ideation and suicide attempts, respectively, was 31.1 (23.1, 41.0) and 12.7 (7.9, 19.4) in the BED cohort and 5.8 (4.7, 7.1) and 1.4 (0.9, 2.2) in the comparator cohort. Risk of suicidal ideation and suicide attempts was greater in the BED cohort (HR [95% CIs], 6.43 [4.42, 9.37]) than in the comparator cohort (HR [95% CI], 9.47 [4.99, 17.98]) during follow-up. After adjusting for psychiatric comorbidities, associations of suicidal ideation and suicide attempts with BED remained elevated in patients with BED having histories of suicidality.

CONCLUSIONS

Findings suggest that history of suicidality may result in an increased risk of suicidal ideation and suicide attempts in patients with BED relative to the general population. Psychiatric comorbidity burden may explain the elevated risk of these conditions in BED.

Psychological characteristics of patients seeking bariatric treatment versus those seeking medical treatment for obesity: is bariatric surgery a last best hope?

PURPOSE

Bariatric surgery (BS) is considered the most effective treatment for severe obesity. Nevertheless, long-term studies have identified some concerning issues, such as increased postoperative rates of suicide and substance use disorders. Some investigators have postulated that these postoperative issues might result from differences in psychological characteristics between patients with obesity seeking BS and those seeking non-surgical (medical) care. The aim of this study was to explore the psychological differences between patients seeking BS and those seeking non-surgical care.

METHODS

151 patients seeking BS (BS group) and 95 patients seeking medical care (non-surgery group) completed questionnaires measuring depression, anxiety, self-esteem, body dissatisfaction, hopelessness and weight-loss expectations (WLE).

RESULTS

There were no differences between the BS and non-surgery groups in depression, anxiety or self-esteem. Body dissatisfaction and WLE were greater in the BS group than in the non-surgery group. Contrary to our hypothesis, the non-surgery group showed higher levels of hopelessness than the BS group. Correlation analyses revealed very similar associations between psychological characteristics for both groups. Hierarchical regression and moderation analyses identified self-esteem as the factor most predictive of hopelessness in both groups.

CONCLUSIONS

We found few differences in psychological characteristics between groups. The lower level of hopelessness in the BS group might be seen as a form of protection leading up to surgery but may result from the patient's view of BS as their "last best hope". Further studies are needed to understand the evolution of these psychological characteristics after surgery and their possible effects on postoperative outcomes.

LEVEL OF EVIDENCE

Level III, case-control analytic studies.

Relationship between depression, weight, and patient satisfaction 2 years after bariatric surgery

BACKGROUND

Findings regarding longer term symptoms of depression and the impact of depression on outcomes such as weight loss and patient satisfaction, are mixed or lacking.

OBJECTIVES

This study sought to understand the relationship between depression, weight loss, and patient satisfaction in the two years after bariatric surgery.

SETTING

This study used data from a multi-institutional, statewide quality improvement collaborative of 45 different bariatric surgery sites.

METHODS

Participants included patients (N = 1991) who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) between 2015-2018. Participants self-reported symptoms of depression (Patient Health Questionnaire-8 [PHQ-8]), satisfaction with surgery, and weight presurgery and 1 year and 2 years postsurgery.

RESULTS

Compared to presurgery, fewer patients' PHQ-8 scores indicated clinically significant depression (PHQ-8≥10) at 1 year (P < .001; 14.3% versus 5.1%) and 2 years postsurgery (P < .0001; 8.7%). There was a significant increase in the prevalence of clinical depression from the first to second year postsurgery (P < .0001; 5.1% versus 8.7%). Higher PHQ-8 at baseline was related to less weight loss (%Total Weight Loss [%TWL] and %Excess Weight Loss [%EWL]) at 1 year postsurgery (P < .001), with a trend toward statistical significance at 2 years (P = .06). Postoperative depression was related to lower %TWL and %EWL, and less reduction in body mass index (BMI) at 1 year (P < .001) and 2 years (P < .0001). Baseline and postoperative depression were associated with lower patient satisfaction at both postoperative time points.

CONCLUSIONS

This study suggests improvements in depression up to 2 years postbariatric surgery, although it appears that the prevalence of depression increases after the first year. Depression, both pre- and postbariatric surgery, may impact weight loss and patient satisfaction.

Mediators of suicidality 12 years after bariatric surgery relative to a nonsurgery comparison group

BACKGROUND

Individuals undergoing bariatric surgery report higher levels of suicidality than the general population, but it is unknown what mediates this phenomenon or how this compares with individuals with severe obesity not receiving surgery.

OBJECTIVES

We evaluated suicidality in 131 individuals 12 years post surgery compared with 205 individuals with severe obesity who did not undergo surgery. Changes in health-related quality of life (HRQOL) and metabolic health were assessed as mediators of suicidality.

SETTING

University.

METHODS

Suicidality was assessed with the Suicide Behaviors Questionnaire-Revised at 12 years. Metabolic health and HRQOL (Short Form-36 [SF-36] Mental Component Summary score, Physical Component Summary score, and Impact of Weight on Quality of Life-Lite) were assessed at baseline and 2 and 6 years. The effects of bariatric surgery on suicidality at 12 years were assessed through univariate and multivariate sequential moderated mediation models, with changes in metabolic health and HRQOL from 0-2 years and 2-6 years as mediators.

RESULTS

Suicidality was higher in the surgery group versus the nonsurgery group (estimate [est.] = .708, SE = .292, P < .05). Only the indirect pathways at 2 years after surgery for SF-36 Mental Component Summary in the univariate models (est. = -.172, SE = .080, P < .05) and for SF-36 Physical Component Summary in the multivariate model (est. = .593, SE = .281, P < .05) were significant.

CONCLUSION

Individuals undergoing bariatric surgery reported higher levels of suicidality at 12 years, which was mediated by less improvement in the mental and physical components of HRQOL in the first 2 years after surgery, suggesting the need for additional clinical monitoring.

Psychological outcomes following surgical and endoscopic bariatric procedures: A systematic review

Obesity is a leading global epidemic. Bariatric surgery is the only treatment demonstrating substantial long-term weight loss and medical benefits. However, there is limited research on the psychological outcomes following surgery. Therefore, the primary aim of this study was to systematically review depression, anxiety, and binge eating outcomes at different time points following bariatric surgery and identify whether bariatric surgery significantly reduces psychological symptoms over time. These outcomes were also examined among endoscopic bariatric procedures as a secondary aim. Forty-eight studies met inclusion criteria. Findings suggested that most patients experience a short-term reduction in anxiety and depression symptoms from pre-surgery. Over time, however, these symptoms increase and may even return to pre-surgery levels. Furthermore, while binge eating was uncommon after surgery, other disordered eating patterns may emerge. Binge eating may also restart over time as the stomach enlarges again. Overall, the complex psychological difficulties faced by individuals with obesity continue after surgery and may contribute to longer-term weight recidivism. More comprehensive and standardised psychological assessment procedures, including clinical interviews and longer-term follow-up, may provide insight into the psychological mechanisms maintaining weight management issues, and may serve as a starting point for improving the long-term success of patients with obesity.

New Role for Growth/Differentiation Factor 15 in the Survival of Transplanted Brown Adipose Tissues in Cooperation with Interleukin-6

To identify factors involved in the earliest phase of the differentiation of human embryonic stem cells (hESCs) into brown adipocytes (BAs), we performed multi-time point microarray analyses. We found that growth/differentiation factor 15 (GDF15) expressions were specifically upregulated within three days of differentiation, when expressions of immature hESC markers were sustained. Although GDF15 expressions continued to increase in the subsequent differentiation phases, GDF15-deficient hESCs differentiated into mature BAs (Day 10) without apparent abnormalities. In addition, GDF15-deficient mice had normal brown adipose tissue (BAT) and were metabolically healthy. Unexpectedly, we found that interleukin-6 (IL6) expression was significantly lowered in the BAT of GDF15^-/- mice. In addition, GDF15^-/- hESCs showed abortive IL6 expressions in the later phase (>Day 6) of the differentiation. Interestingly, GDF15 expression was markedly repressed throughout the whole course of the differentiation of IL6^-/- hESCs into BAs, indicating IL6 is essential for the induction of GDF15 in the differentiation of hESCs. Finally, intraperitoneally transplanted BAT grafts of GDF15^-/- donor mice, but not those of wild-type (WT) mice, failed in the long-term survival (12 weeks) in GDF15^-/- recipient mice. Collectively, GDF15 is required for long-term survival of BAT grafts by creating a mutual gene induction loop with IL6.

Psychosocial Outcomes Following Adolescent Metabolic and Bariatric Surgery: a Systematic Review and Meta-Analysis

BACKGROUND

Metabolic and bariatric surgery is an effective strategy to curb the natural history of obesity progression and improve psychosocial status in the short term for adolescents with severe obesity. The medium- and long-term psychosocial impact of bariatric surgery in this population is not established.

METHODS

We searched MEDLINE (Ovid), EMBASE, Web of Science, PsycInfo, and the Cochrane Libraries through October 2017 for reports of weight loss surgery (roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric banding) on adolescents with severe obesity (age ≤ 21 years) having ≥ 6 months of follow-up. The primary outcome for inclusion in systematic review was use of a validated quality of life (QoL) or other psychosocial instrument at baseline and postoperatively. We used standardized mean difference (SMD) and random-effects modeling to provide summary estimates across different instruments.

RESULTS

We reviewed 5155 studies, of which 20 studies met inclusion criteria for qualitative synthesis. There were 14 studies and 9 unique cohorts encompassing 573 patients which were eligible for meta-analysis regarding postoperative change in QoL. Across surgical procedures, there was significant improvement in QoL of 1.40 SMD (95% confidence interval 0.95 to 1.86; I² = 89%; p < 0.001) at last follow-up (range 9-94 months). Trends in QoL improvement demonstrated the greatest improvement at 12 months; however, significant improvement was sustained at longest follow-up of 60+ months.

CONCLUSIONS

Weight loss surgery is associated with sustained improvement in QoL for adolescents with severe obesity across surgical procedures. Long-term data for psychosocial outcomes reflecting other mental health domains is lacking.

Follow-up after bariatric surgery: A review

Bariatric surgery is becoming increasingly popular in the treatment of severely obese patients who failed to lose weight with the help of non-surgical interventions. Such patients are at increased risk for premature death, type 2 diabetes, high blood pressure, gallstones, coronary heart disease, dyslipidemia, some cancers, anxiety, depression, and degenerative joint disorders. Although bariatric surgery appears to be the most effective and durable treatment option for obesity, it is associated with a number of surgical and medical complications. These include a range of conditions, of which dumping syndrome and malnutrition due to malabsorption of vitamins and minerals are the most common. To achieve better surgery outcomes, a number of postsurgical strategies must be considered. The aim of this review was to describe possible complications, ailments, and important moments in the follow-up after bariatric surgery. Adequate lifelong monitoring is crucial for the achievement of long-lasting goals and reduction of post-bariatric complications.

Mental Health in Bariatric Surgery: Selection, Access, and Outcomes

Severe obesity has many psychiatric consequences that can be influenced by bariatric surgery. The goal of this article is to review these challenges, including the mental health status of patients with severe obesity, the evaluation of surgical candidates, and the early and late effects of the operations, and to offer some recommendations to manage these challenges. The failure of the insurance-mandated preoperative psychosocial evaluation is also discussed.

Predictors of suicidal ideation one-year post-bariatric surgery: Results from the Toronto Bari-Psych Cohort Study

OBJECTIVE

Previous studies have shown higher rates of death by suicide, suicide attempts, suicidal ideation and non-suicidal self-directed violence (NS-SDV) in bariatric surgery patients.

METHODS

Data came from the Toronto Bari-Psych Cohort study of adult patients who underwent bariatric surgery between 2010 and 2016. The MINI International Neuropsychiatric Interview was used to obtain lifetime psychodiagnostic data. Information about lifetime suicidal ideation, suicide attempts, NS-SDV and hospitalizations related to any of these phenomena was collected during clinical interview. Pre-surgery sociodemographic data, lifetime psychiatric disorders, mental health symptoms, mental health treatment, suicidal ideation and surgical complications were covariates. Logistic regression analyses were used to examine the relationship between these variables and suicidal ideation one-year post-surgery.

RESULTS

Among a total of 284 participants, 4.2% reported a past suicide attempt and 15.1% reported past suicidal ideation. One-year post-surgery, no suicide attempts were reported. In the multivariate regression model, a history of suicidal ideation was the strongest predictor of suicidal ideation one-year post-surgery (p < 0.01), followed by younger age (p = 0.05). Mental health symptoms decreased from pre to post-surgery.

CONCLUSION

One-year post-surgery, a history of suicidal ideation was the strongest predictor of post-surgery suicidal ideation. Results should be interpreted with caution given the short duration of follow-up.

Bariatric Surgery and Type 1 Diabetes: Unanswered Questions

In recent decades there has been an alarming increase in the prevalence of obesity in patients with type 1 diabetes leading to the development of insulin resistance and cardiometabolic complications, with mechanisms poorly clarified. While bariatric surgery has long been considered an effective treatment option for patients with type 2 diabetes, the evidence regarding its benefits on weight loss and the prevention of complications in T1DM patients is scarce, with controversial outcomes. Bariatric surgery has been associated with a significant reduction in daily insulin requirement, along with a considerable reduction in body mass index, results which were sustained in the long term. Furthermore, studies suggest that bariatric surgery in type 1 diabetes results in the improvement of comorbidities related to obesity including hypertension and dyslipidemia. However, regarding glycemic control, the reduction of mean glycosylated hemoglobin was modest or statistically insignificant in most studies. The reasons for these results are yet to be elucidated; possible explanations include preservation of beta cell mass and increased residual function post-surgery, improvement in insulin action, altered GLP-1 function, timing of surgery, and association with residual islet cell mass. A number of concerns regarding safety issues have arisen due to the reporting of peri-operative and post-operative adverse events. The most significant complications are metabolic and include diabetic ketoacidosis, severe hypoglycemia and glucose fluctuations. Further prospective clinical studies are required to provide evidence for the effect of bariatric surgery on T1DM patients. The results may offer a better knowledge for the selection of people living with diabetes who will benefit more from a metabolic surgery.

Risk of Suicide and Self-harm Is Increased After Bariatric Surgery-a Systematic Review and Meta-analysis

BACKGROUND

Bariatric surgery is endorsed by multiple societies as the most effective treatment for obesity. Psychosocial functioning has also been noted to improve for most patients after bariatric surgery. However, some studies have shown an increase in post-operative suicide risk. The aim of this study was to review the published literature and evaluate the association of bariatric surgery with suicide events and suicide/self-harm attempts in patients who have undergone weight loss surgery.

METHODS

MEDLINE and Embase were searched from inception through January 2018 for retrospective or prospective studies reporting mortality outcomes and self-harm or suicide rates after bariatric procedures. The primary outcome was the pooled event rate with 95% confidence interval (95% CI) for suicide. Secondary outcomes were suicide/self-harm attempts after bariatric surgery compared to same population prior to surgery and to matched control subjects, with the respective calculated odds ratios (OR) and 95% CI.

RESULTS

From 227 citations, 32 studies with 148,643 subjects were eligible for inclusion. The patients were predominantly females (76.9%). Roux-en-Y gastric bypass (RYGB) was the most commonly performed procedure (58.9%). The post-bariatric suicide event rate was 2.7/1000 patients (95% CI 0.0019-0.0038), while the suicide/self-harm attempt event rate was 17/1000 patients (95% CI 0.01-0.03). The self-harm/suicide attempt risk was higher after bariatric surgery within the same population with OR of 1.9 (95% CI 1.23-2.95), and compared to matched control subjects, OR 3.8 (95% CI, 2.19-6.59).

CONCLUSIONS

Post-bariatric surgery patients had higher self-harm/suicide attempt risk compared to age-, sex-, and BMI-matched controls. Various pre- and post-surgical psychosocial, pharmacokinetic, physiologic, and medical factors may be involved.

Suicidal thoughts and behaviors in adolescents who underwent bariatric surgery

BACKGROUND

Extant literature warns of elevated suicide risks in adults postbariatric surgery, making understanding risks for adolescent patients imperative.

OBJECTIVES

To examine prevalence and predictors/correlates of suicidal thoughts and behaviors (STBs) in adolescents with severe obesity who did/did not undergo bariatric surgery from presurgery/baseline to 4 years postsurgery.

SETTING

Five academic medical centers.

METHODS

Using a prospective observational design, surgical adolescents (n = 153; 79% female, 65% white, mean [M]_age = 17 yr, M_{body mass index[BMI]} = 52 kg/m²) and nonsurgical comparators (n = 70; 80% female, 54% white, M_age = 16 yr, M_BMI = 47 kg/m²) completed psychometrically sound assessments at presurgery/baseline and postsurgery years 2 and 4 (year 4: n = 117 surgical [M_BMI = 38 kg/m²], n = 56 nonsurgical [M_BMI = 48 kg/m²]).

RESULTS

For the surgical group, rates of STBs were low (year 2 [1.3%-4.6%]; year 4 [2.6%-7.9%], similar to national base rates. Groups did not differ on a year 4 postsurgical STBs (post-STBs) composite (post-STBs: ideation/plan/attempt; n = 18 surgical [16%], n = 10 nonsurgical [18%]; odds ratio = .95, P = .90). For the surgical group, predictors/correlates identified within the broader suicide literature (e.g., psychopathology [P < .01], victimization [P < .05], dysregulation [P < .001], drug use [P < .05], and knowing an attemptor/completer [P < .001]) were significantly associated with post-STBs. Surgery-specific factors (e.g., percent weight loss, weight satisfaction) were nonsignificant. Of those reporting a lifetime attempt history at year 4, only a minority (4/13 surgical, 3/9 nonsurgical) reported a first attempt during the study period. Of 3 decedents (2 surgical, 1 nonsurgical), none were confirmed suicides.

CONCLUSIONS

The present study indicates that undergoing bariatric surgery in adolescence does not heighten (or lower) risk of STB engagement across the initial 4 years after surgery. Suicide risks present before surgery persisted, and also newly emerged in a subgroup with poorer psychosocial health.

Prediction of Suicide and Nonfatal Self-harm After Bariatric Surgery: A Risk Score Based on Sociodemographic Factors, Lifestyle Behavior, and Mental Health: A Nonrandomized Controlled Trial

OBJECTIVE

To identify preoperative sociodemographic and health-related factors that predict higher risk of nonfatal self-harm and suicide after bariatric surgery.

BACKGROUND

Evidence is emerging that bariatric surgery is related to an increased risk of suicide and self-harm, but knowledge on whether certain preoperative characteristics further enhance the excess risk is scarce.

METHODS

The nonrandomized, prospective, controlled Swedish Obese Subjects study was linked to 2 Nationwide Swedish registers. The bariatric surgery group (N = 2007, per-protocol) underwent gastric bypass, banding or vertical banded gastroplasty, and matched controls (N = 2040) received usual care. Participants were recruited from 1987 to 2001, and information on the outcome (a death by suicide or nonfatal self-harm event) was retrieved until the end of 2016. Subhazard ratios (sub-HR) were calculated using competing risk regression analysis.

RESULTS

The risk for self-harm/suicide was almost twice as high in surgical patients compared to control patients both before and after adjusting for various baseline factors [adjusted sub-HR = 1.98, 95% confidence interval (CI) = 1.34-2.93]. Male sex, previous healthcare visits for self-harm or mental disorders, psychiatric drug use, and sleep difficulties predicted higher risk of self-harm/suicide in the multivariate models conducted in the surgery group. Interaction tests further indicated that the excess risk for self-harm/suicide related to bariatric surgery was stronger in men (sub-HR = 3.31, 95% CI = 1.73-6.31) than in women (sub-HR = 1.54, 95% CI = 1.02-2.32) (P = 0.007 for adjusted interaction). A simple-to-use score was developed to identify those at highest risk of these events in the surgery group.

CONCLUSIONS

Our findings suggest that male sex, psychiatric disorder history, and sleep difficulties are important predictors for nonfatal self-harm and suicide in postbariatric patients. High-risk patients who undergo surgery might require regular postoperative psychosocial monitoring to reduce the risk for future self-harm behaviors.

The feasibility of a behavioral group intervention after weight-loss surgery: A randomized pilot trial

Background

Formal psychosocial support programs after weight-loss surgery are limited in scope and availability.

Objective

This randomized pilot study evaluated the feasibility of a postoperative behavioral intervention program.

Materials and methods

Postoperative weight-loss surgery patients (N = 50) were recruited from February 2017–July 2017 and randomized to a four-month behavioral program or usual care wait-list. Outcomes evaluated in addition to feasibility included health-related quality of life (Short Form -36), psychosocial functioning and adherence. Secondary outcomes included within-group changes for each outcome.

Results

Out of eight possible sessions, intervention participants attended a mean of 4.2 sessions. Intervention group participants experienced greater improvements in the social functioning domain of health-related quality of life compared to usual care. Self-reported dietary adherence in the intervention group remained stable, while usual care group dietary adherence declined. Within the intervention group, participants also reported gains in the physical function, pain and general health aspects of quality life from baseline to post-treatment. No differences in weight, mood or other eating behaviors (e.g., loss of control, emotional eating) were evident between groups.

Conclusion

Though participation in a postoperative behavioral intervention varied, the program helped participants to maintain aspects of quality of life and self-reported adherence to dietary recommendations.

Trial registration

ClinicalTrials.gov NCT03092479

Clinical Characteristics of Roux-en-Y Gastric Bypass Patients with Death from Accidental Overdose or Intentional Self-Harm: a Descriptive Study

PURPOSE

The objective of this descriptive study was to identify clinical characteristics of Roux-en-Y gastric bypass (RYGB) patients who died from intentional self-harm or accidental overdose postoperatively.

MATERIALS AND METHODS

This retrospective, descriptive study included RYGB patients from a large rural medical center that completed surgery between January 2004 and December 2014 and died from intentional self-harm or accidental overdose through December 2015. Specific causes of death were obtained from the National Death Index and clinical data from electronic health records. Clinical characteristics explored were age, sex, time to surgery, weight loss expectations, postoperative weight loss, medication, diagnoses, psychiatric histories (diagnoses, self-harm, suicidal ideation and behaviors, medications, substance use, preoperative Beck Depression Inventory-II scores), pain, social support, and reported life stressors.

RESULTS

Overall, 22 patients of 146 total deceased patients died from intention self-harm (n = 6) or accidental overdose (n = 16) over the study period (77.3% female, mean age at time of surgery = 38.4 ± 9.1 years). Younger age (< 40 years), history of self-harm or depression, preoperative pain, and use of opioids at the time of surgery emerged as common characteristics in weight loss surgery patients who died from intentional self-harm or accidental overdose. No trends regarding social support, life stressors, or actual or expected weight loss were identified.

CONCLUSION

Certain weight loss surgery patients may be at risk for death from self-harm or overdose and may benefit from greater surveillance postoperatively.

Incidence and Risk Factors for Mortality Following Bariatric Surgery: a Nationwide Registry Study

BACKGROUND

Although bariatric surgery (BS) is considered safe, concern remains regarding severe post-operative adverse events and mortality. Using a national BS registry, the aim of this study was to assess the incidence, etiologies, and risk factors for mortality following BS.

METHODS

Prospective data from the National Registry of Bariatric Surgery in Israel (NRBS) including age, gender, BMI, comorbidities, and surgical procedure information were collected for all patients who underwent BS in Israel between June 2013 and June 2016. The primary study outcome was the 3.5-year post-BS mortality rate, obtained by cross-referencing with the Israel population registry.

RESULTS

Of the 28,755 patients analyzed (67.3% females, mean age 42.0 ± 12.5 years, and preoperative BMI 42.14 ± 5.21 kg/m²), 76% underwent sleeve gastrectomy (SG), 99.1% of the surgeries were performed laparoscopically, and 50.8% of the surgeries were performed in private medical centers. Overall, 95 deaths occurred during the study period (146.9/100,000 person years). The 30-day rate of post-operative mortality was 0.04% (n = 12). Male gender (HR = 1.94, 95%CI 1.16-3.25), age (HR = 1.06, 95%CI 1.04-1.09), BMI (HR = 1.08, 95%CI 1.05-1.11), and depression (HR = 2.38, 95%CI 1.25-4.52) were independently associated with an increased risk of all-cause 3.5-year mortality, while married status (HR = 0.43, 95%CI 0.26-0.71) was associated with a decreased risk.

CONCLUSION

Mortality after BS is low. Nevertheless, a variety of risk factors including male gender, advanced age, unmarried status, higher BMI, and preoperative depressive disorder were associated with higher mortality rates. Special attention should be given to these "at-risk" BS patients.

Is weight regain after bariatric surgery associated with psychiatric comorbidity? A systematic review and meta-analysis

Bariatric surgery has been recognized as the gold standard treatment for severe obesity. Although postbariatric surgery patients usually achieve and maintain substantial weight loss, a group of individuals may exhibit weight regain. Several factors are proposed to weight regain, including psychiatric comorbidity. The objective of the study is to conduct a systematic review and meta-analysis of studies investigating the relationship between psychiatric comorbidity and weight regain. A systematic review through PubMed, Web of Science, Cochrane Library, Scopus, and PsycINFO was performed, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). After a stepwise selection, 13 articles were included in the qualitative analysis and 5 were included for a meta-analysis. Women was majority in most of the studies (87.6%), and a bypass procedure was the bariatric intervention most evaluated (66.8%), followed by gastric banding (32.1%) and sleeve (1.1%). Higher rates of postbariatric surgery eating psychopathology were reported in patients with weight regain. However, the association between general psychopathology and weight regain was not consistent across the studies. In the meta-analysis, the odds of eating psychopathology in the weight regain group was higher compared with the nonweight regain group (OR = 2.2, 95% CI 1.54-3.15). Postbariatric surgery eating psychopathology seems to play an important role in weight regain.

Long-term adverse events after sleeve gastrectomy or gastric bypass: a 7-year nationwide, observational, population-based, cohort study

BACKGROUND

Concerns are rising about the late adverse events following gastric bypass and sleeve gastrectomy. We aimed to assess, over a 7-year period, the late adverse events after gastric bypass and sleeve gastrectomy compared with matched control groups.

METHODS

In this nationwide, observational, population-based, cohort study, we used data extracted from the French National Health Insurance (Système National des Données de Santé) database. All patients undergoing gastric bypass or sleeve gastrectomy in France in 2009, except those who had undergone bariatric surgery in the previous 4 years before inclusion, were matched with control patients with obesity in terms of age, sex, BMI category, baseline antidiabetic therapy, and baseline insulin therapy. Exclusion criteria for the control group included cancer, pregnancy, chronic infectious disease, serious acute or chronic disease in 2008-09, or previous (2005-09) or forthcoming (2010-11) bariatric surgery. The incidence rate was calculated for each type of adverse event leading to inpatient hospital admission over a 7-year period; incidence rate ratios (with 95% CIs) were computed to compare the rate of complications among the bariatric surgery and control groups. Risks of complications during follow-up were compared using Cox proportional-hazards regression analyses. Data were analysed according to the intention-to-treat methodology.

FINDINGS

From Jan 1, 2009, to Dec 31, 2009, 8966 patients who underwent bariatric surgery (7359 [82%] women; mean age 40·4 years [SD 11·3]) and 8966 matched controls (7359 [82%] women; mean age 40·9 years [11·4]) were included in analyses 4955 (55%) off 8966 patients in the bariatric surgery group had a primary gastric bypass and 4011 (45%) patients had sleeve gastrectomy. With a mean follow-up of 6·8 years (SD 0·2), mortality was lower in the gastric bypass group than in its control group (hazard ratio 0·64 [95% CI 0·52-0·78]; p<0·0001) and in the sleeve gastrectomy group than in its control group (0·38 [0·29-0·50]; p<0·0001). The gastric bypass and sleeve gastrectomy groups had higher risk than did their control groups for invasive gastrointestinal surgery or endoscopy (incidence rate ratio 2·4 [95% CI 2·1-2·7], p<0·0001, for gastric bypass vs control and 1·5 [1·3-1·7], p<0·0001, for sleeve gastrectomy vs control); for gastrointestinal disorders not leading to invasive procedures (1·9 [1·7-2·1]), p<0·0001, for gastric bypass vs control and 1·2 [1·1-1·4], p<0·0001, for sleeve gastrectomy vs control); and for nutritional disorders (4·9 [3·8-6·4], p<0·0001, for gastric bypass vs control and 1·8 [1·3-2·5], p<0·0001, for sleeve gastrectomy vs control). For psychiatric disorders, there was no significant association (1·1 [0·9-1·4], p=0·190, for gastric bypass vs control and 1·1 [0·8-1·3], p=0·645, for sleeve gastrectomy vs control), except for gastric bypass and alcohol dependence (1·8 [1·1-2·8], p=0·0124).

INTERPRETATION

Despite lower 7-year mortality, patients undergoing gastric bypass or sleeve gastrectomy had higher risk of hospital admission at least once for late adverse events, except for psychiatric disorders, than did control patients, with a higher risk observed after gastric bypass than with sleeve gastrectomy.

FUNDING

None.

Depression and Suicide After Bariatric Surgery

PURPOSE OF REVIEW

Individuals with morbid obesity benefit from bariatric surgery with respect to weight loss and decreases in obesity-related somatic disorders. This paper focuses on psychosocial outcomes and provides a narrative review of recent meta-analyses and controlled studies concerning postoperative depression and suicide.

RECENT FINDINGS

Considerable evidence shows short- and medium-term improvement in depressive symptoms after surgery. However, a subgroup of patients exhibits erosion of these improvements or new onset of depression in the long run. Some studies have found an increased risk for suicide among postoperative patients. Prospective longitudinal examinations of factors contributing to the increased risk for postoperative depression and suicide and the interaction between these factors are warranted. The inclusion of mental health professionals in bariatric teams would help to monitor patients for negative psychosocial outcomes and to identify those patients who are vulnerable to depression, suicide, and any other forms of deliberated self-harm following surgery.

A Review of Psychosocial Risk Factors Among Transgender Patients Seeking Bariatric Surgery

As nearly one third of transgender individuals in the USA are obese, more transgender patients may pursue bariatric surgery as a means of sustaining weight loss. Transgender individuals, like bariatric surgery patients, have high rates of mood pathology, substance use, abuse, and self-harm behaviors. However, there is no research on transgender bariatric surgery candidates. The aim of this review is to elucidate potential psychosocial risk factors, including sex hormone management, which may impact surgical clearance, presurgical psychosocial assessment, and treatment recommendations.

Intranasal glucagon acutely increases energy expenditure without inducing hyperglycaemia in overweight/obese adults

AIM

To assess the acute effects of 0.7 mg intranasal glucagon (ING) vs intranasal placebo (INP) on food intake and resting energy expenditure (REE).

METHODS

A single-blind, crossover study was conducted in 19 overweight/obese adults (15 men, 4 women). REE was assessed by indirect calorimetry over 90 minutes, after which appetite was assessed using a visual analogue scale, and ad libitum caloric intake was assessed. Plasma samples were obtained at baseline and at 15-minute intervals post-treatment up to 90 minutes.

RESULTS

ING increased total REE (INP 61.5 ± 1.2 kcal vs ING 69.4 ± 1.2 kcal; P = 0.027). There were no between-treatment differences in blood glucose, food intake and appetite. There were no adverse effects.

CONCLUSION

ING acutely increases REE without increasing plasma glucose. Longer term studies with multiple daily dosing will establish whether this affects body weight.

Psychometric Characteristics of the Revised Illness Perception Questionnaire (IPQ-R) in People Undergoing Weight Loss Surgery

The Illness Perception Questionnaire-Revised (IPQ-R) has been used extensively across many health conditions to measure patient illness and treatment perceptions. The constructs have an association with treatment adaptation and adherence which, in turn, are considered core factors involved in bariatric surgery outcome. This study examines the factorial validity and internal reliability of a modified (IPQ-R) in bariatric surgery candidates. After wording modifications, participants (N = 310) completed the IPQ-R as part of standard pre-surgery assessments. After removal of two items, confirmatory factor analysis (CFA) supported the original 7-factor solution of the Beliefs scale, with good to marginal subscale internal consistency. Exploratory factor analysis (EFA), with two items removed only partially supported the original 5-factor Causal Attributions scale. Internal consistency was unacceptably low for two subscales. Further research is needed to generate new items which better fit the IPQ-R to this population before research can explore the relevance of illness perceptions.

Evaluation of the association of bariatric surgery with subsequent depression

BACKGROUND/OBJECTIVES

Bariatric surgery is helpful in enabling sustained weight loss, but effects on depression are unclear. Reductions in depression-related symptoms and increases in suicide rate have both been observed after bariatric surgery, but these observations are confounded by the presence of pre-existing depression. The goal of this study is to evaluate the effect of bariatric surgery on subsequent depression diagnosis.

SUBJECTS/METHODS

In this observational study, a prospective cohort study was simulated by evaluating depression risk based on diagnostic codes. An administrative database was utilized for this study, containing records and observations between 1 January 2008 through 29 February 2016 of enrolled patients in the United States. Individuals considered in this analysis were enrolled in a commercial health insurance program, observed for at least 6 months prior to surgery, and met the eligibility criteria for bariatric surgery. In all, 777,140 individuals were considered in total.

RESULTS

Bariatric surgery was found to be significantly associated with subsequent depression relative to both non-surgery controls (HR = 1.31, 95% CI, 1.27-1.34, P < 2e-32) and non-bariatric abdominal surgery controls (HR = 2.15, 95% CI, 2.09-2.22, P < 2e-32). Patients with pre-surgical psychiatric screening had a reduced depression hazard ratio with respect to patients without (HR = 0.85, 95% CI, 0.81-0.89, P = 3.208e-12). Men were found to be more susceptible to post-bariatric surgery depression compared with women. Pre-surgical psychiatric evaluations reduced the magnitude of this effect. Relative to bariatric surgeries as a whole, vertical sleeve gastrectomy had a lower incidence of depression, while Roux-en Y Gastric Bypass and revision/removal surgeries had higher rates.

CONCLUSIONS

In individuals without a history of depression, bariatric surgery is associated with subsequent diagnosis of depression. This study provides guidance for patients considering bariatric surgery and their clinicians in terms of evaluating potential risks and benefits of surgery.

Mental health quality of life after bariatric surgery: A systematic review and meta-analysis of randomized clinical trials

Recent literature has raised concerns regarding the risk of adverse psychiatric events among bariatric surgery patients. However, the relationship between weight loss therapy and psychiatric outcomes is confounded by baseline psychosocial characteristics in observational studies. To understand the impact of bariatric surgery on the risk of adverse mental health outcomes, we conducted a systematic review and meta-analysis of randomized controlled trials that compared surgical and non-surgical treatments and assessed mental health quality of life (QoL). We evaluated the PubMed, EMBASE, Web of Science PsycINFO, Clinicaltrials.gov and Cochrane databases through 7 March 2018. Pooled standardized mean differences (SMDs) for mental health QoL scores were estimated using random effects models. Eleven randomized trials with 731 participants were included in the final analyses. Surgery was not associated with an improvement in mental health QoL from baseline as compared to non-surgical intervention (SMD: 0.02, 95% confidence interval [CI] -0.22 to 0.25). Final mental health QoL scores were similar for surgically and non-surgically treated patients (SMD: 0.37, 95% CI -0.07 to 0.81). Subgroup analyses assessing the effect of specific surgical interventions, and varying lengths of follow-up did not identify a beneficial effect of bariatric surgery on mental health QoL outcomes. These results, in conjunction with the fact that individuals who choose bariatric surgery tend to have high-risk baseline characteristics, suggest that intensive mental health follow-up following surgery should be routinely considered.

Psychosomatic and Psychosocial Questions Regarding Bariatric Surgery: What Do We Know, or What Do We Think We Know?

SUBJECT

In view of the epidemic increase in severe obesity and the ineffectiveness of conservative weight-loss interventions, bariatric surgery delivers compelling results for patients with class II (BMI ≥ 35 kg/m²) and class III obesity (BMI ≥ 40 kg/m²), not only in reducing weight over the long term, but also in reducing obesity-related somatic comorbidity and improving psychosocial functioning and quality of life. Investigations into the psychosocial aspects of obesity surgery have proliferated over the last 15 years, providing a huge amount of essential research data. Yet the results are partly contradictory and highly dependent on the duration of follow-up.

METHODS

Based of a narrative review, this article provides an overview of the current status and recent developments of the reciprocal effects between bariatric surgery and psychosocial functioning. The review focused on eight domains representing important psychosomatic and psychosocial aspects of bariatric surgery.

RESULTS

Especially in cases of class II and III obesity, bariatric surgery is the only means to reduce bodyweight significantly and permanently, though they carry with them the associated risk factors of metabolic, cardiovascular, and oncological diseases.With regard to psychosocial and psychosomatic aspects, studies with a short-term catamnesis (approx. 3 years) speak in favor of an improvement in the quality of life including mental disorders. If we consider studies with longer follow-ups, however, the results are not as uniform. In particular, we observe an increase in harmful alcohol consumption, self-harm behavior, and suicide risk.

CONCLUSIONS

In light of mental well-being and thus also quality of life, bariatric surgery would appear to convey an elevated risk for a minority of patients.Yet identifying these patients before surgery has so far been insufficient.

A longitudinal examination of suicide-related thoughts and behaviors among bariatric surgery patients

BACKGROUND

Past research suggests self-harm/suicidality are more common among adults who have undergone bariatric surgery than the general population.

OBJECTIVES

To compare prevalence of self-harm/suicidal ideation over time and identify presurgery risk factors for postsurgery self-harm/suicidal ideation.

SETTING

The Longitudinal Assessment of Bariatric Surgery-2 is a cohort study with presurgery and annual postsurgery assessments conducted at 10 U.S. hospitals.

METHODS

Adults with severe obesity undergoing bariatric surgery between March 2006 and April 2009 (n = 2458). Five-year follow-up is reported. Self-reported history of suicidality assessed retrospectively via the Suicide Behavior Questionnaire-Revised (SBQ-R) and self-reported self-harm/suicidal ideation assessed prospectively via the Beck Depression Inventory-Version 1 (BDI-1).

RESULTS

The SBQ-R was completed by 1540 participants; 2217 completed the BDI-1 pre- and postsurgery. Over 75% of participants were female, with a median age of 46 years and body mass index of 45.9 kg/m². Approximately one fourth of participants (395/1534) reported a presurgery history of suicidal thoughts or behavior (SBQ-R). The prevalence of self-harm/suicidal ideation (BDI-1) was 5.3% (95% confidence interval [CI], 3.7-6.8) presurgery and 3.8% (95% CI, 2.5-5.1) at year 1 postsurgery (P = .06). Prevalence increased over time postsurgery to 6.6% (95% CI, 4.6-8.6) at year 5 (P = .001) but was not significantly different than presurgery (P = .12).

CONCLUSIONS

A large cohort of adults with severe obesity who underwent bariatric surgery had a prevalence of self-harm/suicidal ideation that may have decreased in the first postoperative year but increased over time to presurgery levels, suggesting screening for self-harm/suicidality is warranted throughout long-term postoperative care. Several risk factors were identified that may help with enhanced monitoring.

MANAGEMENT OF ENDOCRINE DISEASE: Which metabolic procedure? Comparing outcomes in sleeve gastrectomy and Roux-en Y gastric bypass

Obesity and its associated comorbidities have become one of the largest challenges for health care in the near future. Conservative therapy for obesity and related comorbidities has a very high failure rate and poor long-term results. Similarly, the conservative and medical management of the majority of metabolic diseases such as type 2 diabetes mellitus are only able to slow down disease progression but have no causal effect on the disease process. Obesity surgery has evolved as a highly effective therapy for severe obesity achieving long-lasting weight loss. Furthermore, several studies have demonstrated the beneficial effects of obesity surgery on reduction of overall mortality, reduction of cardiovascular events and superior control of obesity-related diseases such as type 2 diabetes mellitus, dyslipidemia and also the non-alcoholic steatohepatitis compared to medical therapy. Based on these findings, the term 'metabolic surgery' with the focus on treating metabolic diseases independent of body weight has been coined. Of great interest are recent studies that show that even existing complications of metabolic diseases such as diabetic nephropathy or the non-alcoholic steatohepatitis can be reversed by metabolic surgery. Although metabolic surgery has proven to be a safe and effective treatment for obesity, resolution of comorbidities and enhancing quality of life, it is still uncertain and unclear, which surgical procedure is the most effective to achieve these metabolic effects. The aim of this review is to compare the effects of the two currently most widely used metabolic operations, the Roux-en-Y gastric bypass and the sleeve gastrectomy in the treatment of obesity and its related comorbidities.

Prevalence of All-Cause Mortality and Suicide among Bariatric Surgery Cohorts: A Meta-Analysis

INTRODUCTION

Prior meta-analysis has reported mortality rates among post-operative bariatric patients, but they have not considered psychiatric factors like suicide contributing to mortality.

OBJECTIVES

The current meta-analysis aims to determine the pooled prevalence for mortality and suicide amongst cohorts using reported suicides post bariatric surgery. It is also the aim of the current meta-analytical study to determine moderators that could account for the heterogeneity found.

RESULTS

In our study, the pooled prevalence of mortality in the studies which reported suicidal mortality was 1.8% and the prevalence of suicide was 0.3%. Mean body mass index (BMI) and the duration of follow-up appear to be significant moderators.

CONCLUSIONS

Given the prevalence of suicide post bariatric surgery, it is highly important for bariatric teams to consider both the medical and psychiatric well-being of individuals pre- and post-operatively.

Anxiety behavior and hypothalamic-pituitary-adrenal axis altered in a female rat model of vertical sleeve gastrectomy

Surgical weight loss results in a host of metabolic changes that culminate in net positive health benefit to the patients. However, the psychological impact of these surgeries has not been fully studied. On one hand, surgical weight loss has been reported to improve standard quality of life and resolution of symptoms of depression. But on the other hand, reports of self-harm and increased ER visits for self-harm suggest other psychological difficulties. Inability to handle anxiety following surgical weight loss has alarming potential ramifications for these gastric surgery patients. In the present study, we used models of diet-induced obesity and vertical sleeve gastrectomy (VSG) to ask whether anxiety behavior and hypothalamic-pituitary-adrenal (HPA) axis gene changes were affected by surgical weight loss under two diet regimens: i.e. low-fat diet (LFD) and high-fat diet (HFD). We show reduced exploratory behavior in the open field test but increased time in the open arms of the elevated plus maze. Furthermore, we show increased plasma levels of corticosterone in female VSG recipients in the estrus phase and increased levels of hypothalamic arginine-vasopressin (avp), pro-opiomelanocortin (pomc), and tyrosine hydroxylase (th). We report reduced dopamine receptor D1 (drd1) gene in prefrontal cortex (PFC) in VSG animals in comparison to Sham. Further we report diet-driven changes in stress-relevant gene targets in the hypothalamus (oxt, pomc, crhr1) and adrenal (nr3c1, nr3c2, mc2r). Taken together, these data suggest a significant impact of both surgical weight loss and diet on the HPA axis and further impact on behavior. Additional assessment is necessary to determine whether molecular and hormonal changes of surgical weight loss are the source of these findings.

Psychiatric Diagnoses and Weight Loss Among Adolescents Receiving Sleeve Gastrectomy

BACKGROUND AND OBJECTIVES

Severe obesity is associated with higher risk of psychiatric difficulties. Bariatric surgery is the most effective treatment of severe obesity. Few guidelines exist regarding the association of psychiatric diagnoses in adolescents and outcomes after surgery because of the lack of longitudinal research. Our objective is to evaluate the rates of psychiatric diagnoses in adolescents undergoing surgery compared with those not receiving surgery and the association of preoperative psychiatric diagnoses with postsurgical weight loss outcomes.

METHODS

Adolescents (N = 222) referred for psychological evaluation at one institution for bariatric surgery (2009-2017) completed semistructured clinical interviews to assess the presence and number of psychiatric diagnoses. Comparison analyses were conducted between those who did not end up receiving surgery (N = 53) and those who did (N = 169). Using longitudinal modeling, we assessed the association of preoperative diagnoses with weight loss outcomes between 3 and 12 months after surgery.

RESULTS

Seventy-one percent of adolescents qualified for a psychiatric disorder. There were no differences in rates of specific disorders or numbers of diagnoses between those receiving surgery and those not receiving surgery. The presence or absence or number of diagnoses before surgery was not associated with weight loss outcomes after surgery.

CONCLUSIONS

Psychiatric diagnoses are prevalent among adolescents with severe obesity. These diagnoses are not associated with weight loss outcomes. The presurgical psychological evaluation serves as an opportunity to identify adolescents experiencing psychiatric problems and provide them with care but should not necessarily be considered a contraindication to surgery.