Psychiatric Risk After Bariatric Surgery: Understanding the Literature

BY: Christine Peat, PhD

DATE: October 24, 2015

In recent weeks, media attention has been focused on several peer-reviewed journal articles that highlight the potential negative psychiatric outcomes following bariatric surgery. These recent articles demonstrate an increased risk for particularly troubling outcomes including alcoholism and suicide attempts. With such headlines, the collective narrative appears to look quite bleak for those who decide to undergo weight loss surgery. However, it is important to consider the context of these findings in an effort to more fully understand the relative risks (and benefits) associated with bariatric surgery. Although the aforementioned risks are certainly serious and warrant close clinical and scientific attention, common misconceptions about bariatric surgery can exaggerate the risks and minimize the benefits of these procedures. So let’s take a careful look at the available evidence:

  • Alcoholism after surgery – Several peer-reviewed manuscripts have demonstrated an increased risk for alcohol abuse after weight loss surgery. In fact, a study (2012) found that the percentage of bariatric patients abusing alcohol rose significantly from 7.6% prior to surgery to 9.6% after surgery. Although this significant increase is cause for concern, it is important to note that alcohol use disorders are estimated at 5% of adults in the general population and thus these estimates are perhaps on par with general risk among adults. Furthermore, current research has not yet identified why this increase in alcohol abuse might exist and no causal relationship between alcoholism and bariatric surgery has been documented. Ongoing studies have postulated that changes in the way dopamine receptors respond to alcohol after surgery might play a role; however, the evidence remains inconclusive. Therefore, prior to surgery patients should be appropriately educated about the risk of post-surgical alcohol abuse and should be closely monitored after surgery, but such risks should also be contextualized with the potential benefits including reduction in Type 2 diabetes mellitus, improvement in hypertension and sleep apnea, and a 40% overall reduction in mortality.
  • Suicide risk after surgery – Recent headlines regarding suicide risk after bariatric surgery include: “Bariatric surgery linked to suicide attempts,” and “Staggering 50% of bariatric surgery candidates commits suicide.” However, a careful read of the recent Canadian study (on which many of these headlines are based) reveals a more subtle interpretation of the numbers. Lead author Bhatti and colleagues followed over 8,000 patients who were treated with gastric bypass surgery over the course of five years. Of those 8,000 patients, 111 reported self-harm emergencies (e.g., overdose) after surgery with the overall rate of these emergencies increasing from 2.33 per 1000 patient-years prior to surgery to 3.63 per 1000 patient-years after (an approximate mean increase of 50%). Importantly, over 90% of those reporting a self-harm emergency occurred in patients with a diagnosed psychiatric disorder prior to surgery – a risk factor not specific to bariatric surgery patients. Thus, mental health experts have generally concluded that having a psychiatric diagnosis should not prevent a person from pursuing surgery. Instead, “It’s really about making sure that people have appropriate support, that their mental health condition is appropriately managed and stable, and most importantly, that they have appropriate access and follow-up for their mental health as they go through their postoperative journey.” (Sanjeev Sockalingam, MD).

Thus it is important to emphasize that while bariatric surgery is not without its risks, those risks should be considered in the context of risk in the general (non-surgery seeking) population and weighed against the potential benefits that surgery might bring. The available evidence also seems to suggest that close mental health follow-up is a crucial part of bariatric surgery so that any mental health concerns or risk factors might be identified and appropriately addressed by professionals. Encouragingly, some places have recognized the importance of this follow-up and Ontario, Canada has even gone so far as to mandate a 5-year follow-up period in bariatric centers throughout the entire province. Such follow-up will play a key role in the scientific investigation of psychiatric risk after bariatric surgery and hopefully allow researchers to identify prognostic indicators to prevent the occurrence of adverse outcomes.