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What Does Self Harm Tell Us About Bariatric Surgery?

A recent study of self harm after bariatric surgery might be telling us more about how we care for people with obesity than it does about this surgical procedure. A new study in JAMA Surgery found an increased risk of intentional self harm after bariatric surgery. Junaid Bhatti and colleagues followed 8,815 people for three years before and after bariatric surgery. These incidents were seen in 1.3% of people in the study and the risk for such incidents went up by more than 50% after bariatric surgery.

This study is important because incidents of intentional self harm are predictors of suicide risk. The study adds to the understanding of the risk of suicide following bariatric surgery because it follows a large group of people both before and after surgery. The authors conclude:

These findings imply that more work is needed to understand why self-harm behaviors increase in the postoperative period and how these risks might be reduced.

Perhaps these findings will bring some reflection on the systematic constraints in the delivery of care to people who need bariatric surgery. As we have noted before, bariatric surgery is often inappropriately described as a last resort — positioning it as an act of desperation.

Anyone who has been through the process of seeking bariatric surgery will tell you that health plans seem to treat it as a game designed to deny access to needed care. All too often, necessary care before and after surgery must be paid entirely out of pocket by the patient. With reimbursement for follow-up care being so constrained, it is little wonder that patients are often lost to follow-up after the first year post op.

We hope that this will be a signal for more rigorous standards of post-surgical care — including its coverage by health plans — for people who need bariatric surgery.

Click here to read more from LiveScience, here to read the study, and here for more on the nuts and bolts of reimbursement for post-surgical care.

Self Portrait, Pen and Ink by Albrecht Durer / WikiArt

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October 15, 2015

2 Responses to “What Does Self Harm Tell Us About Bariatric Surgery?”

  1. October 15, 2015 at 11:15 am, Alex Brecher said:

    I didn’t find the researchers’ results surprising. That is in large part because I have seen the studies before. Also, although my own personal experience was completely positive, I have seen many others who have struggled post-op.
    Here are some of the possible explanations I have heard of and believe are viable for increased risks of suicide attempts in bariatric surgery patients.
    • An increased ability to commit or attempt suicide, similar to what can happen when depressed patients begin taking anti-depressants. A theory I have heard is that the risk of suicide increases when patients first begin taking anti-depressants, possibly because they now have the energy to think about taking action toward suicide. Maybe weight loss surgery patients gain the energy to think about suicide as they lose weight.
    • Replacement addictions leading to drug overdose. Replacement addictions are common in weight loss surgery patients. They replace our former food addictions and can come in all kinds of forms, whether it is an addiction to alcohol, exercise, or drugs.
    • Loss of use of food as an “outlet” for external stressors. We all handle stress in our own ways. Many of us used food to reduce stress before surgery. After surgery, that outlet is gone. If we do not develop a new healthier outlet, our new outlet may be drugs or alcohol, or we may not have an outlet. The outcome may be a suicide attempt.
    • Realization that a high BMI was not the cause of the patient’s problems and mood. Some patients believe their problems will go away when they lose weight and their obesity-related health concerns diminish. Unfortunately, problems at work, relationship struggles, and self-worth issues do not automatically go away after weight loss surgery, and they may become more devastating because the patient realizes they are not a result of having a high BMI.
    • Increased social pressures. These can begin as soon as the patient begins considering bariatric surgery and feels the need to defend her decision and explain that it is not the “easy out.” The defense can continue for life as friends and family continually make comments, whether positive or negative, about the patient’s weight, eating habits, and other personal matters.
    • Changes in hormone levels. The JAMA researchers noted changes in neurohormones such as neuropeptide YY, which could be linked to depressive symptoms.
    • Realization that it’s a lifelong change. Life is a really, really long time. Some patients may not realize quite how long until they are post-op and feeling the daily grind of their surgery. This may be especially true in malabsorptive or irreversible surgeries like the gastric sleeve.
    A strong support system is absolutely critical to prevent these tragedies! It needs to begin in the earliest pre-op stages, and continue possibly for life. It needs to include the medical side as well as the social side.
    Before approving patients for surgery, bariatric centers need to provide more than a cursory psychological evaluation. They need to really try to figure out whether their potential weight loss surgery patients have risk factors for depression and suicide attempts.
    I have met so many weight loss surgery patients who are on anti-depressants, yet depression is a contraindication for weight loss surgery! The bariatric center team needs to put the best interest of the potential patient first and try to determine whether the need to use anti-depressants is due to obesity-related factors and will go away post-op, or whether the patient has signs of depression unrelated to obesity.
    From approval through surgery, the patient should continue to meet with a qualified mental health professional to prepare themselves for life after surgery – going beyond behavior changes and reaching into likely changes in self-perception and personal and even professional relationships.
    After surgery, mental health support needs to continue. Patients need to have access to a professional should they need one. They should be educated on signs of depression and suicidal tendencies. They also need to be taught to expect certain new stressors, and they need to learn coping strategies to replace food. They should also go to support group sessions, both to receive education and to be able to share stories with and learn from other patients.
    These are all things that “should” happen. Unfortunately, they rarely do. It is not uncommon for the initial psychological evaluation to be the only contact they have with a mental health professional, and even then, the evaluation may be more of a formality than a true investigation into the patient’s mental health and likelihood of being a good candidate for surgery.
    Post-op follow-up is often little to non-existent. Not only might patients not be given the one-on-one attention they may need, but they may not even know which symptoms to look for should they develop depression. They may feel lost, which can be exacerbated if other post-op follow-up such as nutritional support is also lacking.
    In addition, follow-up support in in-person support groups may not be what it should. If meetings even are offered by a certain bariatric center, they may be at inconvenient times, or too far away, or too infrequent, to be of use. Or, patients simply may not attend.
    This is also where online support groups like BariatricPal can come in. I believe they serve many purposes.
    • Let patients know they are not alone. Whatever feelings, situations, and relationship struggles they are facing, countless other weight loss surgery patients have gone through the same things.
    • They can be anonymous. People do not always want to talk about their deepest fears and feelings face to face. An online setting can provide a forum for them to express themselves without fear of consequences.
    • They are available 24/7. Possibly suicidal patients need help RIGHT NOW, not tomorrow, and not at the next available appointment.
    • They are free. There’s no need to worry about whether insurance covers it, or how many minutes they have to work through their problems.
    • They are positive. At least, BariatricPal is. I work very hard to enforce our zero-tolerance policy for rudeness.

  2. October 15, 2015 at 9:47 pm, Ted said:

    Alex, thank you for sharing so much good information here and for all of your good work through BariatricPal. You’re making a big difference for a lot of people. Thank you!