Duodenal ulcer, suicide, psychopathology and alcoholism

Incidence of adverse mental health outcomes after sleeve gastrectomy compared with gastric bypass and restrictive bariatric procedures: a retrospective cohort study

OBJECTIVE

This study examined rates of suicide and hospitalization with psychiatric diagnoses after sleeve gastrectomy compared with gastric bypass and restrictive procedures (gastric banding/gastroplasty).

METHODS

This was a longitudinal retrospective cohort study comprising all patients who underwent primary bariatric surgery in New South Wales or Queensland, Australia, between July 2001 and December 2020. Hospital admission records, death registration, and cause of death records (if applicable) within these dates were extracted and linked. Primary outcome was death by suicide. Secondary outcomes were admissions with self-harm; substance-use disorder, schizophrenia, mood, anxiety, behavioral, and personality disorders; any of these; and psychiatric inpatient admission.

RESULTS

A total of 121,203 patients were included, with median follow-up of 4.5 years per patient. There were 77 suicides, with no evidence of difference in rates by surgery type (rates [95% CI] per 100,000 person years: 9.6 [5.0-18.4] restrictive, 10.8 [8.4-13.9] sleeve gastrectomy, 20.4 [9.7-42.8] gastric bypass; p = 0.18). Rates of admission with self-harm declined after restrictive and sleeve procedures. Admission with anxiety disorders, any psychiatric diagnosis, and as a psychiatric inpatient increased after sleeve gastrectomy and gastric bypass, but not restrictive procedures. Admissions with substance-use disorder increased after all surgery types.

CONCLUSIONS

Variable associations between bariatric surgeries and hospitalization with psychiatric diagnoses might indicate distinct vulnerabilities among patient cohorts or that differing anatomical and/or functional changes may contribute to effects on mental health.

Potential gut-brain mechanisms behind adverse mental health outcomes of bariatric surgery

Bariatric surgery induces sustained weight loss and metabolic benefits via notable effects on the gut-brain axis that lead to alterations in the neuroendocrine regulation of appetite and glycaemia. However, in a subset of patients, bariatric surgery is associated with adverse effects on mental health, including increased risk of suicide or self-harm as well as the emergence of depression and substance use disorders. The contributing factors behind these adverse effects are not well understood. Accumulating evidence indicates that there are important links between gut-derived hormones, microbial and bile acid profiles, and disorders of mood and substance use, which warrant further exploration in the context of changes in gut-brain signalling after bariatric surgery. Understanding the basis of these adverse effects is essential in order to optimize the health and well-being of people undergoing treatment for obesity.

Temporal associations between physical illnesses and mental disorders--results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)

Clinical and epidemiologic evidence has documented the significant associations between medical illnesses and psychiatric disorders. However, extensive research has focused on the comorbidity of medical conditions and depression, and most were cross sectional, focused on clinical samples, and grounded in DSM-III or DSM-III-R diagnostic criteria. The current prospective investigation examined associations among medical conditions at baseline and incident psychiatric disorders over a 3-year follow-up, using data from Waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Overall, the 3-year incidence rates of DSM-IV substance use, mood and anxiety disorders ranged from 0.65% (bipolar II) to 5.2% (alcohol abuse). Multiple regression analysis was conducted to examine the prospective physical-mental associations, while controlling for sociodemographic characteristics, psychological stress and health-related risk factors, and comorbid physical and psychiatric disorders. The present study represents, to our knowledge the largest population-based prospective study examining the physical-mental associations. Our results showed distinctly different patterns of comorbidity of medical illnesses with substance use, mood, and anxiety disorders. Stomach ulcer/gastritis, hypertension and arthritis emerged to be significant predictors of incident psychiatric disorders.

Suicidal behavior and alcohol abuse

Suicide is an escalating public health problem, and alcohol use has consistently been implicated in the precipitation of suicidal behavior. Alcohol abuse may lead to suicidality through disinhibition, impulsiveness and impaired judgment, but it may also be used as a means to ease the distress associated with committing an act of suicide. We reviewed evidence of the relationship between alcohol use and suicide through a search of MedLine and PsychInfo electronic databases. Multiple genetically-related intermediate phenotypes might influence the relationship between alcohol and suicide. Psychiatric disorders, including psychosis, mood disorders and anxiety disorders, as well as susceptibility to stress, might increase the risk of suicidal behavior, but may also have reciprocal influences with alcohol drinking patterns. Increased suicide risk may be heralded by social withdrawal, breakdown of social bonds, and social marginalization, which are common outcomes of untreated alcohol abuse and dependence. People with alcohol dependence or depression should be screened for other psychiatric symptoms and for suicidality. Programs for suicide prevention must take into account drinking habits and should reinforce healthy behavioral patterns.

Mortality among patients with partial gastrectomy for benign ulcer disease

Partial gastrectomy for benign ulcer disease may influence future risk of death, eg, through changes in life-style or metabolism. To reveal such possible long-term effects, we analyzed a population-based cohort of 6459 patients operated on from 1950 through 1958 and followed through 1985. We found a lower overall mortality than in the general Swedish population (standardized mortality ratio = 0.94; 95% confidence interval 0.91-0.97). Mortality was decreased among those with duodenal ulcers, Billroth II operations, and older age at operation but increased as time passed after operation. Mortality was significantly (P < 0.05) increased from tuberculosis, alcoholism, emphysema, stomach ulcer, intestinal obstruction, gallbladder or biliary disease, suicide, and accidental falls but decreased from ischemic heart disease and cerebrovascular disease. Preoperative selection of healthy patients and the probable increased prevalence of risk factors for ulcer disease (smoking, alcoholism, and lower socioeconomic status) in this cohort explain most of these findings. Apart from intestinal obstruction, gallbladder or biliary tract diseases, and tuberculosis, the surgical procedure did not appear to increase mortality beyond one year after operation.

Peptic ulcer among urban bus drivers in Denmark

As part of a survey on the work environment of bus drivers, 2045 (83%) of 2465 male bus drivers in the three major cities in Denmark in 1978 answered a postal questionnaire on health and working conditions. In order to evaluate the relative occurrence of peptic ulcer among the bus drivers, a follow-up study was also conducted. All hospital discharges with a peptic ulcer diagnosis among the bus drivers were registered from the Danish National Patient Register. All Danish men were used as reference group. On the basis of the 1978-questionnaire association between occupational and psychosocial factors and subsequent hospital discharge with a peptic ulcer diagnosis was studied. The prevalence of abdominal pain alleviated by food intake was 12% among bus drivers and 6% in the reference group. The incidence of hospital discharge with duodenal ulcer among younger bus drivers was twice the incidence among Danish men in the same age group. The incidence of all manifestations of peptic ulcer disease among bus drivers did not differ from the incidence among Danish men. Of occupational and psycho-social factors, wage dissatisfaction and smoking showed statistically significant association with hospital discharge with PU in a 6 3/4-year period. Job dissatisfaction, stress symptoms and lack of some social network factors tended to increase the risk of hospital discharge with PU.

Suicide: a guide to risk factors, assessment, and treatment of suicidal patients

This article summarizes what is known about risk factors for suicide in both adolescent and adult populations. It also translates this knowledge base into practical considerations for the physician on the assessment and treatment of suicidal patients. Since most patients who commit suicide have seen a physician in the weeks to month prior to their deaths, and many kill themselves with medications prescribed by their doctors, the physician's early detection and treatment of suicidal behaviors and associated psychiatric disorders in his or her patients becomes a major suicide prevention strategy.

Factors which influence the incidence and course of peptic ulcer

The present review concentrates on environmental factors which influence the outcome of peptic ulcer disease by acting from the outside. Endogenous risk factors, such as acid output, pepsin secretion and serum pepsinogen, gastritis and mucosal defense, blood group, and secretor status, are only dealt with when they help to explain the mechanism by which exogenous risk factors affect the upper gastrointestinal mucosa. After outlining the wax and wane of peptic ulcer, it is concluded that these changes resulted from similar temporal patterns of occupational workload in the general population. Cross sectional studies also support the contention of occupational workload being a risk factor in peptic ulcer, explaining several characteristic features of peptic ulcer, such as its sex, race, and social class distribution, increased incidence in immigrant workers, seasonal variation, healing by bed rest, and urban versus rural distribution. Susceptible subjects may react to a rise in occupational workload and acute exposure to stressful life events by increased gastric secretion which, in turn, leads to ulceration and symptoms. Cigarette smoking, intake of aspirin and related drugs, dietary salt, and alcohol abuse represent additional environmental risk factors, which form the etiologic link of the association of peptic ulcer with chronic lung disease, rheumatoid arthritis, hypertensive disease, and liver cirrhosis, respectively.

Suicide in alcoholism. A prospective study of 55 cases with autopsy findings

In a previous paper we reported prospective ratings for 88 alcoholic suicides. At the initial admission they had more often signs of peptic ulcer, depression, dysphoria and brittleness than other alcoholics. In 55 of these alcoholics an autopsy was performed at the Department of Forensic Medicine, University Hospital, Lund. In 37 cases the blood alcohol level was measured (at time of death). Alcoholics with brittleness had more often blood alcohol levels over 0.1% than others, and alcoholics with dysphoria more often negative tests even if the suicide generally was associated with previous drinking. Concerning the blood alcohol level alcoholics with peptic ulcer did not differ from the others. Alcoholics with initial depression had more often previous suicide attempts. Twenty (36%) of the alcoholics had experienced a personal loss during the year preceding the suicide. The possible implications of the findings for suicide prevention strategies is discussed.

Suicide in the medical patient

According to the statistical abstract of the United States for 1982-1983, there were 1,913,800 deaths in the United States in 1979. Twenty-seven thousand, or 1.4 percent of those deaths were by suicide, yielding a suicide rate of 11.9/100,000/year. The rate was highest (39.2/100,000) for white males sixty-five years and over and lowest (0.1/100,000) for black females between five and fourteen years. It is generally accepted that physical illness is a risk factor for suicide. If this is true, then in caring for persons with significant physical illness, physicians are dealing with a population at increased risk of suicide. In its opening section, this article will review the evidence that points to a positive correlation between suicide and physical illness. Next the association between specific illnesses, such as peptic ulcer and cancer, and suicide will be examined. Third, risk factors associated with the occurrence of suicide in medical-surgical hospitals will be reviewed. Fourth, the occurrence of suicide in relationship to medical procedures will be discussed. Fifth, the evaluation and management of suicidal patients in medical settings will be briefly considered. This review will not consider the relationship between physical illness and attempted suicide.

Suicide in male alcoholics with peptic ulcers

Eighty-seven male alcoholics with peptic ulcers and 913 without peptic ulcers were first admitted to the Department of Psychiatry of Lund, Sweden during the period 1956-1969. In the initial ratings rigidity/perfectionism, strain/tenseness, sleep disturbances, the asthenic syndrome, and heredity for alcoholism/personality disturbances/suicide were more frequent in the peptic ulcer group than in the others. Patients with peptic ulcers were more often married and less often unmarried or showed antisocial/criminal indications of antisociality/criminality. A follow-up by records was performed on January 1, 1981. Seventeen percent in the peptic ulcer group and 6% in the other group had committed suicide (p less than 0.001). Mortality (suicides excluded) was similar in the two groups as was the social adjustment among the survivors. Within the peptic ulcer group strain/tenseness was significantly related to future suicide, while operation, heredity, and rigidity/perfectionism were not.

Suicide methods in British Columbian adolescents

All suicides or suspect suicides involving persons under 20 years of age in the Province of British Columbia in 1978 and 1979 were studied. Coroner's files were used to identify 122 cases, of which 11% involved persons under the age of 15 years. Males 15-19 years of age accounted for 80 cases and 52% used a rifle as the means of death; females 15-19 years of age used alcohol and drugs in 54% of all cases. Suicides involving adolescents 15-19 years of age were analyzed by sex, ethnicity, and residence. Native Indians and nonmetropolitan residents were disproportionately represented and were more likely to use a rifle. Females and metropolitan residents were more likely to use methods other than firearms. Alcohol consumption was a feature in 45% of cases, but there was no significant difference between groups based on sex, ethnicity, or residence. Antecedent problems were not identified or recorded in 39% of the male and 31% of the female cases.