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CE: R.R.; ANNSURG-D-16-00125; Total nos of Pages: 7;

ANNSURG-D-16-00125

ORIGINAL ARTICLE

Suicide, Self-harm, and Depression After Gastric Bypass Surgery
A Nationwide Cohort Study
Ylva Trolle Lagerros, MD, PhD, y Lena Brandt, MSc, Jakob Hedberg, MD, PhD,z Magnus Sundbom, MD,
PhD,z and Robert Bode´n, MD, PhD §

Objective: The aim of this study was to examine risk of self-harm, hospitalization for depression and death by suicide after gastric bypass surgery
(GBP).
Summary of Background Data: Concerns regarding severe adverse psychiatric outcomes after GBP have been raised.
Methods: This nationwide, longitudinal, self-matched cohort encompassed
22,539 patients who underwent GBP during 2008 to 2012. They were
identified through the Swedish National Patient Register, the Prescribed Drug
Register, and the Causes of Death Register. Follow-up time was up to 2 years.
Main outcome measures were hazard ratios (HRs) for post-surgery self-harm
or hospitalization for depression in patients with presurgery self-harm and/or
depression compared to patients without this exposure; and standardized
mortality ratio (SMR) for suicide post-surgery.
Results: A diagnosis of self-harm in the 2 years preceding surgery was
associated with an HR of 36.6 (95% confidence interval [CI] 25.5–52.4) for
self-harm during the 2 years of follow up, compared to GBP patients who had
no self-harm diagnosis before surgery. Patients with a diagnosis of depression
preceding GBP surgery had an HR of 52.3 (95% CI 30.6–89.2) for hospitalization owing to depression after GBP, compared to GBP patients without a
previous diagnosis of depression. The SMR for suicide after GBP was
increased among females (n ¼ 13), 4.50 (95% CI 2.50–7.50). The SMR
among males (n ¼ 4), was 1.71 (95% CI 0.54–4.12).
Conclusions: The increased risk of post-surgery self-harm and hospitalization for depression is mainly attributable to patients who have a diagnosis of
self-harm or depression before surgery. Raised awareness is needed to identify
vulnerable patients with history of self-harm or depression, which may be in
need of psychiatric support after GBP.
Keywords: bariatric surgery, depression, epidemiology, obesity, psychiatric
disorders, self-injurious behavior, suicide

profound and sustained weight loss, decreased incidences of stroke,
myocardial infarction, and cancer and the resolution, or the improvement, of a number of other obesity-associated comorbidities, such as
diabetes.1 However, concerns regarding severe adverse psychiatric
outcomes have been raised.
Depression is common among bariatric surgery candidates.2
Although bariatric surgery leads to remission of a number of weightrelated comorbidities and improves quality of life,1,3 the impact on
depressive symptoms remains unclear. Some studies have identified
significant reductions in depression and depressive symptoms after
bariatric surgery,4– 6 but data are equivocal, with several reports
suggesting that improvements are not maintained.2,7,8
Suicide is the most severe complication of depression. In a large
population-based cohort study, depression and obesity were significantly
associated with suicide.9 High BMI has also been linked to suicidal
ideation10 and suicide attempts.11 However, the relationship between
surgically induced weight loss and suicide has recently gained attention.
A systematic review of 28 studies revealed that persons undergoing
bariatric surgery are 4 times more likely to commit suicide than the
general population.12 Recently, a Canadian register-based study also
reported increased risks of self-harm emergencies after bariatric surgery
compared to before.13 The temporal proximity between bariatric surgery
and later self-harm may not be enough to suggest a causal relationship, but
merits further investigation.
To disentangle these matters, the purpose of the present study
was to examine risk of self-harm, hospitalization for depression, and
death by suicide after gastric bypass surgery in a nationwide, selfmatched cohort. We specifically aimed to identify psychiatric risk
factors already present before gastric bypass surgery, such as
previous self-harm and depression.

(Ann Surg 2016;xx:xxx–xxx)

T

he use of gastric bypass surgery has become a rapidly expanding
management option for the severely obese patients. It results in


From the Department of Medicine, Clinical Epidemiology Unit, Karolinska Institutet,
Stockholm, Sweden; yDepartment of Endocrinology, Metabolism and Diabetes,
Karolinska University Hospital Huddinge, Stockholm, Sweden; zDepartment of
Surgical Sciences, Uppsala University, Uppsala, Sweden; and §Department of
Neuroscience, Psychiatry, Uppsala University, Uppsala, Sweden.
Reprints: Dr. Ylva Trolle Lagerros, MD, PhD, Department of Medicine, Clinical
Epidemiology Unit, Karolinska Institutet, T2, SE 171 76 Stockholm, Sweden.
E-mail: ylva.trolle@ki.se.
This research was funded by the regional agreement on medical training and
clinical research between Stockholm County Council and Karolinska Institutet
(YTL), funding from Serafimerlasarettet (YTL) and unrestricted research
grants from Nasvell Foundation (RB) and Uppsala County Council (RB).
YTL reports receiving consulting fees from Novo Nordisk and JH reports
receiving consulting fees from AstraZeneca. For the remaining authors none
were declared.
The authors report no conflicts of interest.
Copyright ß 2016 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0003-4932/14/26105-0821
DOI: 10.1097/SLA.0000000000001884

Annals of Surgery Volume XX, Number X, Month 2016

METHODS
Registries
The Swedish National Board of Health and Welfare authorized access to 3 Swedish national health and population registries:
Data on dispensed drugs from the Swedish Prescribed Drug Register
coded according to the Anatomical Therapeutic Chemical (ATC)
classification system;14 data on deceased patients from the National
Cause of Death Register15; and data on diagnoses from hospital inand outpatient care from the National Patient Register which covers
>99% of all psychiatric and somatic (including surgery) discharges.
Validation studies with medical charts have shown positive predictive
values around 85% to 95% for the diagnoses in the register.16
Individual record linkages between the registries were possible
through each individual’s unique personal identity number (PIN),
assigned to all Swedish residents at birth or at time of immigration.17

Participants
From the National Patient Register, shown to have a high
accuracy and reliability for obesity surgery registrations, 18 we
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CE: R.R.; ANNSURG-D-16-00125; Total nos of Pages: 7;

ANNSURG-D-16-00125

Lagerros et al

identified all patients with a procedure code indicating a gastric
bypass procedure between 2008 and 2012, and a diagnosis of obesity,
that is, a body mass index 30 kg/m2 (ICD-10 diagnosis: E66). We
excluded gastric banding and gastric sleeve surgery, 1% and 0.2%,
respectively, of all bariatric surgery in Sweden during this period. We
used codes (JDF10, JDF11) from the Swedish version of the
NOMESCO (Nordic Medico-Statistical Committee) classification
of surgical procedures, version 1.9. Follow-up started at discharge
from surgery and ended at first psychiatric hospitalization for selfharm or depression, death, emigration, or 2 years after bariatric
surgery, or end of follow-up (December 31, 2012), whichever
came first.

Psychiatric Comorbidity Before and After Gastric
Bypass Surgery
To identify patients with a psychiatric comorbidity before and
after gastric bypass surgery, we used the patient register and the
prescribed drug register. Self-harm and suicide were identified
through the ICD-diagnoses X60-X84. We also included the ICDdiagnoses Y10-Y34 (event of undetermined intent), commonly
included in suicide research after a number of studies reported a
high number of definite suicides when reevaluating undetermined
causes of death.19–22 Patients with depression were identified based
on ICD-diagnoses F32-F33 from inpatient or specialized psychiatric
outpatient services. However, as many patients with mild depression
in Sweden are treated in primary care, not covered by the National
Patient Register, we chose to consider at least 1 filled prescription of
an antidepressant (ATC-code N06A) prescribed by any physician
(also in primary care) as an indication for depression. Previous
Scandinavian studies validating prescribed drugs found in the Prescribed Drug Register to the diagnosis found in the National Patient
Register have found high positive predictive values.23,24 A filled
prescription is a more sensitive marker for depression, albeit less
specific, as antidepressants can also be used for other indications
such as anxiety disorders. In addition, we identified those with any
psychiatric contact, in inpatient, or specialized psychiatric outpatient
services 2 years before gastric bypass surgery, independent of
diagnosis. Suicides within two years after gastric bypass surgery
were identified in the National Cause of Death register.
Psychiatric diagnoses registered by the surgeon concurrent
with the code for gastric bypass, that is, the very same admission,
were omitted to eliminate the risk that primary care diagnoses of
psychiatric disorders (not in the National Patient Register) given at an
earlier time point were repeated by the surgeon without a proper
psychiatric evaluation and thereby giving a false incidence peak.

Main Outcome Measures
The main outcome measures were hospitalization owing to
self-harm or depression, or death by suicide 2 years after
gastric bypass.

Statistical Analyses
For the baseline characteristics of the cohort, frequencies and
percentages were calculated for categorical data and means and
standard deviations (SD) were used to describe continuous variables.
Cox proportional hazards regression models were fitted using
time from the date of discharge after gastric bypass surgery to first
hospitalization for depression or self-harm, and emigration, death,
and end of follow-up as indicators of censoring. The proportional
hazards assumption was investigated for each covariate by plotting
Schoenfeld residuals.
We determined the hazard ratio (HR) of self-harm and depression in unadjusted and multivariable-adjusted models. We considered
the following covariates as potential confounders: age, sex, and
2 | www.annalsofsurgery.com

Annals of Surgery Volume XX, Number X, Month 2016

calendar year of surgery (to control for time trends in surgery inclusion
criteria). We used Wald’s method to determine 95% confidence intervals
(CIs) around the HR. We plotted incidence rates, (per 100 observed
patients and year and based on number of diagnoses registered in the
Swedish National Patient Register each year) from 10 years before to 2
years post-surgery, with mid-P exact CIs.25,26
As the numbers of patients who committed suicide were too
small to evaluate HRs, we only conducted descriptive statistics.
However, the numbers were sufficient to calculate standardized
mortality ratios (SMRs) for suicide. This was defined as the observed
number of suicides, divided by expected number from age-, calendar
year-, and sex-standardized suicide rates in the general
Swedish population.
All analyses were performed using SAS version 9.4 (SAS
Institute Inc, Cary, NC). All P values were 2-sided, with P 0.05
considered to be statistically significant.
The study was evaluated and approved by the Research Ethical
Review Board in Stockholm in accord with the ethical standards of
the Helsiniki Declaration of 1975.

RESULTS
Descriptive Data
Between 2008 and 2012, a total of 22, 539 subjects underwent
gastric bypass in Sweden. The majority (75.3%) were women. The
average age at surgery was 41.3 years, standard deviation 11.0
years (Table 1).
Diagnosis of self-harm was rather stable in the years before
gastric bypass surgery; 1 to 4 years before surgery, the average rate
was 0.38/100 person-years (95% CI 0.35–0.43/100 person-years). It

TABLE 1. Characteristics of Subjects Who Underwent Gastric
Bypass Surgery in Sweden Between 2008 and 2012
Number

Percentage

Number of subjects
22, 539
Sex
Male (%)
5, 578
Female (%)
16, 961
Age at surgery, y, mean (SD)
41.3
<35 (%)
6, 204
35–44 (%)
7, 465
>44 (%)
8, 870
Type of surgery
Open gastric bypass
1, 565
surgery (%)
Laparoscopic gastric bypass
20, 974
surgery (%)
Days of follow-up post-surgery
Mean (SD)
546.0
Min–Max
2–730
Year of surgery
2008 (%)
2, 270
2009 (%)
3, 609
2010 (%)
4, 742
2011 (%)
6, 420
2012 (%)
5, 498
Psychiatric history during the 2 years before surgery
Diagnosis of self-harm (%)
307
Diagnosis of depression (%)
230
6 023
Anti-depressant medication (%)

Standard
Deviation

24.7
75.3
11.0
27.5
33.1
39.4
6.9
93.1
233.1
10.1
16.0
21.0
28.5
24.4
1.4
1.1
26.7


Filled prescription from the pharmacotherapeutic group N06A (according to the
Anatomical Therapeutic Chemical classification system, ATC).

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ANNSURG-D-16-00125

Annals of Surgery Volume XX, Number X, Month 2016

Suicide, Self-harm, and Depression After GBP

FIGURE 1. Rates of depression and hospitalization because of self-harm 10 years
before until 2 years after gastric bypass
surgery. Points are rates per 100
observed patients and year and based
on number of diagnoses registered in
the Swedish National Patient Register
each year. Note that post-surgery data
points represent all post-surgical patients
independent if they had presurgical
depression or self-harm.

Rate /1000 observed pa ents and year

35
G
a
s
t
r
i
c

30
25
20
15
10

b
y
p
a
s
s

Depression
Self harm

Error bars represent 95% confidence intervals

5
0
-10

-9

-8

-7

-6

-5

-4

-3

-2

-1

<-1

<1

1

2

Years before and a er opera on

increased to 0.47/100 person-years (95% CI 0.37–0.59/100 personyears) and 0.59/100 person-years (95% CI 0.44–0.78/100 personyears) the first and second year after surgery.
The rates of depression, diagnosed from inpatient or specialized psychiatric outpatient services, were slightly higher than the
rates for self-harm, both before and after gastric bypass surgery. Two
years before surgery, the rate of depression was 0.60/100 personyears (95% CI 0.50–0.71/100 person-years). One year after surgery,
the rate had increased to 0.75/100 person-years (95% CI 0.62–0.91/
100 person-years), and 2 years after gastric bypass surgery the rate
was 1.15/100 person-years (95% CI 0.94–1.41/100 person-years)
(Figure 1). About half (46 %) of the patients hospitalized with a
depression diagnosis during the first year after surgery had been
hospitalized for depression before, during the last 10 years. At year 2,
this percentage was higher (61%).

Risk Factors for Post Gastric Bypass Self-harm
After adjustment for age, sex, and calendar year of surgery, the
HR for hospitalization for self-harm within 2 years after gastric

bypass was 36.6 (95% CI 25.5–52.4) for patients having received a
diagnosis of self-harm in the 2 years preceding surgery (n ¼ 47),
compared to patients with no such diagnosis (n ¼ 89) (Table 2). Next,
we report hospitalization for self-harm by ICD-codes X60-X84
(intentional self-harm) and Y10-Y34 (event of undetermined intent)
versus hospitalization only because of intentional self-harm. The
HRs are in the same magnitude, potentially even slightly higher when
we do not include events of undetermined intent (Table 3).
We also conducted subanalyses stratified on previous selfharm or not. For patients with a history of psychiatric hospitalization,
but with no previous history of self-harm, the HRs for self-harm after
surgery were higher than in the group with previous psychiatric
hospitalization and a history of self-harm; however, it should be
noted that the rate of self-harm is low in this group 0.31/100 personyears (95% CI: 0.16–0.53/100 person-years) such that the absolute
numbers of post-surgery cases are small and CIs are wide (Table 4).
The risk was higher among younger patients without previous selfharm, HR 2.42 (95% CI 1.28–4.57), for being <25 years’ old
compared to being 45 years and older.

TABLE 2. HR with 95% CI of Self-harm or Depression
Psychiatric
History 2 Years
Preceding Surgery

Total Number
(Person-years)

Number

Rate/100
person-years
(95% CI)

Unadjusted HR
(95% CI)

Adjusted HRy
(95% CI)

Hospitalization for self-harm within 2 years post-surgery
Diagnosis of self-harm
No
Yes

22,232 (33,141)
307 (459)

Diagnosis of depression
No
Yes
Antidepressant medicationz

16,285 (24,192)
230 (324)
6,024 (9,100)

89
0.27 (0.22–0.33)
ref ¼ 1
47
10.24 (7.61–13.50)
38.1 (26.7–54.2)
Hospitalization for depression within 2 years post-surgery

ref ¼ 1
36.6 (25.5–52.4)

ref ¼ 1
52.9 (31.0–90.0)
8.4 (5.7–12.4)

ref ¼ 1
52.3 (30.6–89.2)
8.4 (5.6–12.4)

33
23
105

0.14 (0.09–0.19)
7.10 (4.60–10.50)
1.15 (0.95–1.39)

CI indicates confidence interval; HR, hazard ratio. History of self-harm and depression during the 2 years preceding surgery and HR with 95% CI of self-harm or depression leading
to hospitalization during the 2 years after surgery among subjects who underwent gastric bypass surgery in Sweden between 2008 and 2012.

10 Patients from hospitalized care, 13 from specialized outpatient care.
yAdjusted for age, sex, and calendar year of surgery.
zzFilled prescription from the pharmacotherapeutic group N06A (according to the Anatomical Therapeutic Chemical classification system, ATC).

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CE: R.R.; ANNSURG-D-16-00125; Total nos of Pages: 7;

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Annals of Surgery Volume XX, Number X, Month 2016

Lagerros et al

TABLE 3. HR with 95% CI of Self-harm

Hospitalization
Diagnosis of
Self-harm 2 Years
Preceding Surgery

Total Number
(Person-years)

No
X60-X84
Y10-Y34

22,232 (33,141)
195 (319)
112 (140)

No
X60-X84
Y10-Y34

22,232 (33,166)
195 (329)
112 (142)

Rate/100
Person-years
(95% CI)

Number

Unadjusted HR
(95% CI)

Hospitalization (ICD-codes X60-X84 and Y10-Y34)
89
0.27 (0.22–0.33)
ref ¼ 1
27
8.46 (5.69–12.14)
31.3 (20.3–48.2)
20
14.29 (8.97–22.14)
53.9 (33.2–87.5)
Hospitalization (ICD-codes X60-X84)
79
0.24 (0.19–0.30)
ref ¼ 1
24
7.30 (4.78–10.69)
30.1 (19.1–47.6)
19
13.38 (8.30–20.51)
58.9 (35.7–97.2)

Adjusted HR
(95% CI)
ref ¼ 1
30.7 (19.9–47.5)
49.7 (30.2–81.8)
ref ¼ 1
31.1 (19.6–49.2)
54.3 (32.4–90.8)

CI indicates confidence interval; HR, hazard ratio. History of self-harm during the 2 years preceding surgery and HR with 95% CI of self-harm leading to hospitalization during the 2
years after surgery among subjects who underwent gastric bypass surgery in Sweden between 2008 and 2012. Stratified by ICD-coding X60-X84 (intentional self-harm) and Y10-Y34
(event of undetermined intent) vs hospitalization with both intentional self-harm and events of undetermined intent and only intentional self-harm.

Adjusted for age, sex, and calendar year of surgery.

Risk Factors for Post Gastric Bypass Depression
Patients diagnosed with depression in specialized psychiatric
in- or outpatient care in the 2 years preceding surgery were at high
risk for hospitalization for depression after gastric bypass surgery.
The adjusted HR for being hospitalized for depression was 52.3 (95%
CI 30.6–89.2, n ¼ 23) in this group, compared to gastric bypass
patients without previous depression. Even in patients with no
diagnosis of depression from specialized psychiatric services in
the 2 years preceding surgery, but with at least 1 filled prescription
of antidepressants prescribed by any physician (n ¼ 6, 024), the
adjusted HR for hospitalization for depression in the 2 years following surgery was 8.4 (95% CI 5.6–12.4) (Table 2).

Suicide Rate Post Gastric Bypass Compared to the
General Population
Of the 17 subjects (4 men and 13 women) who committed
suicide during the 2 years following gastric bypass surgery, 14

patients had at least 1 filled prescription of antidepressant medication, of which 1 had been diagnosed with depression, and 1 had a
diagnosis of self-harm in the 2 years preceding surgery. The SMR for
suicide was increased among females, 4.50 (95% CI 2.50–7.50), but
the estimate was imprecise among males because of small numbers,
1.71 (95% CI 0.54–4.12) (Table 5).

DISCUSSION
This large population-based prospective investigation
assessed the effects of bariatric surgery on self-harm, as well as
suicide and depression. We found that a history of self-harm was an
important risk factor for subsequent self-harm in the 2 years following gastric bypass surgery. Furthermore, a previous diagnosis of
depression from specialized psychiatric services, or having filled at
least 1 prescription of an antidepressant prescribed by any physician
in the 2 years preceding surgery, was associated with higher risk of
hospitalization for depression in the 2 years following surgery.

TABLE 4. Risk Factors of Post-surgery Hospitalization for Self-harm
No History of Self-harm During the 2 Years Preceding Surgery
(n ¼ 22,232 and 33,141 Person-years)

History of Self-harm During the 2 Years Preceding Surgery
(n ¼ 307 and 459 Person-years)

Number of
Rate/100
Unadjusted HR Adjusted HR
(95% CI)
Self-harm Events Person-years
(95% CI)

Number of
Rate/100
Unadjusted HR Adjusted HR
Self-harm events person-years
(95% CI)
(95% CI)

Psychiatric hospitalization during the 2 years preceding surgery
No
78
0.24
ref ¼ 1
Yes
11
3.06
13.00
(6.90 -24.37)
Sex
Female
67
0.27
ref ¼ 1
Male
22
0.27
1.00
(0.62–1.62)
Age, y
<25
14
0.58
2.56
(1.36–4.82)
35–44
45
0.25
1.10
(0.69–1.74)
45
30
0.23
ref ¼ 1

ref ¼ 1
12.57
(6.68–23.68)

28
19

7.93
17.51

ref ¼ 1
2.17
(1.21 -3.90)

ref ¼ 1
2.03
(1.12–3.67)

ref ¼ 1
1.07
(0.66–1.73)

39
8

11.43
6.80

ref ¼ 1
0.60
(0.28–1.28)

ref ¼ 1
0.70
(0.32–1.53)

2.42
(1.28–4.57)
1.07
(0.67–1.70)
ref ¼ 1

6

8.58

29

11.56

12

8.68

0.93
(0.44–2.00)
1.74
(0.84–3.59)
ref ¼ 1

0.87
(0.33–2.36)
1.18
(0.60–2.32)
ref ¼ 1

CI indicates confidence interval; HR, hazard ratio. HRs with 95% CIs for risk factors of post-surgery hospitalization for self-harm stratified by history of self-harm during the 2 years
preceding surgery in patients who underwent gastric bypass surgery in Sweden between 2008 and 2012.

Adjusted for other variables in the table.

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Annals of Surgery Volume XX, Number X, Month 2016

Suicide, Self-harm, and Depression After GBP

TABLE 5. Standardized Mortality Ratio with 95% CI of Suicide Rate After Gastric Bypass Surgery Compared to the General
Swedish Population

All
Women
Men

Observed Number
of Suicides

Rate/100, 000
Person years (95% CI)

Expected Number
of Suicides

Standardized Mortality
Ratio (95% CI)

17y
13
4

50.4 (30.4–79.1)
51.3 (28.5–85.4)
47.9 (15.2–115.5)

5.23
2.89
2.34

3.25 (95% CI 1.96–5.10)
4.50 (95% CI 2.50–7.50)
1.71 (95% CI 0.54–4.12)

CI indicates confidence interval.

Standardized for age, sex , and calendar year.
yFourteen patients had at least 1 filled prescription of an antidepressant, of which 1 had been diagnosed with depression, and 1 had a diagnosis of self-harm in the 2 years preceding
gastric bypass surgery.

Bariatric surgery has proven to be the only treatment modality
with sustained weight results,27 alleviation of comorbidities, and
increased longevity for the severe obese patient.1,28 However, concerns about psychiatric side effects have been raised.12,29 In the study
by Bhatti et al,13 93% of the bariatric surgery patients seeking
emergency for self-harm had a diagnosis of mental health disorder
before surgery. We linked a diagnosis of self-harm before surgery to
psychiatric outcomes after surgery, and found more than a 30-fold
higher risk of self-harm in this patient group, compared to patients
with no previous self-harm diagnosis. Contrary to Bhatti et al, who
reported more self-harm emergencies among patients older than 35
years, we found that young patients below the age of 25 had a higher
risk of self-harm after surgery than middle-aged and older patients.
Of note is that there are differences in the baseline populations. For
example, our population had a higher proportion of young patients.
From our data, we cannot disentangle how much of this risk is
because of the individuals’ susceptibility owing to mental illness
before surgery, or how much of this risk is because of the effects of
bariatric surgery, although the rates of self-harm seem to be rather
stable during many years before surgery, and then suddenly increase
in the 2 years after surgery. Two epidemiological studies based on
Pennsylvania registers have reported an increased suicide rate among
bariatric surgery patients.30,31 Contrary to our findings, they report
higher suicide rates among men, than among women (13.7 vs 5.2 per
10, 000). Interestingly, only 30% (n ¼ 9) of the Pennsylvanian
suicides occurred within 2 years following surgery, 70% (n ¼ 21)
within 3 years, indicating that a longer follow-up than the 2 years
presented in this study is warranted.
A review of the growing literature of robust, prospective
population based-studies suggests that BMI is inversely associated
with completed suicides, irrespective of sex and region of origin.32
The number of suicides in our population was not sufficient for risk
analyses in depth, but presented as SMR. This is a preferred statistical
technique to analyze small numbers, but should nonetheless be
interpreted with caution considering the few events. Furthermore,
since we used the total Swedish population to calculate SMRs, and
not just other obese individuals in the society, our SMR is probably
an underestimation. Nevertheless, high SMRs for suicide should not
automatically be attributed to the gastric bypass surgery in itself, as
the subpopulation of obese persons seeking bariatric surgery may
differ in patterns of suicidal behavior from the total population of
obese persons. This possible interpretation is supported by reports of
prevalence of past suicide attempts among patients seeking bariatric
surgery being as high as 10%.33 Suicidal ideation (defined as
thinking about, considering, or planning for suicide) has also been
found to be higher in individuals seeking bariatric surgery than in
other surgery or community samples.34 There are also several other
candidate factors that could mediate or moderate the suicide risk
among gastric bypass patients, such as changes in disinhibition
because of increased sensitivity to alcohol, increase in alcohol use
ß

2016 Wolters Kluwer Health, Inc. All rights reserved.

disorders, dissatisfaction with amount of weight loss, weight regain,
reduced absorption of ingested medications, and neuroendocrine
changes following surgery.29,35 Several peptides have been suggested
as potential links between neurobiological processes and psychopathology. Grehlin is one example, an orexigenic (appetite stimulating)
hormone that affects a number of neuroendocrinological systems
from metabolism physiology to stress regulation with antidepressant
and possibly anxiolytic-like effects.36 Changed levels may lead to
depression. Another peptide in the gut–brain axis is peptide YY
(PYY), which stimulates satiety. Post-prandial PYY levels rise after
bariatric surgery,37 but are also found to be higher in patients with
major depression.38 Many studies have also linked neuropeptide Y
(NPY) to depression and suicidal behavior,39 but it has not been
convincingly documented that there is a link between bariatric
surgery, changes in peptide signaling systems, and suicides.
Our findings are in agreement with, and extend results from
previous studies suggesting that depressive symptoms may persist
after surgery. Two-thirds of those receiving treatment for depression
3 years after bariatric surgery reported treatment for depression at
baseline and at all follow-up visits in a large American multicenter
study.8 De Zwaan et al4 followed 107 extremely obese bariatric
surgery patients and found that presence of a presurgery depressive
disorder was predictive of depressive disorder 24 to 36 months
after surgery.
A meta-analysis summarizing the literature on obesity and
depression found a reciprocal relation; obesity increased the odds of
depression by 1.55, whereas depression increased the odds of
developing obesity by 1.58.40 In light of these figures, it is hardly
surprising that patients presenting in bariatric surgery clinics often
report symptoms of depression. In a preoperative evaluation of 288
subjects seeking bariatric surgery, 42% had a lifetime history of
major depressive disorder.41 In a review, Wadden et al42 estimate the
prevalence of depression to be 25% to 30% in bariatric surgery
patients. This corresponds closely with our figure; 26.7% of the
patients in our study had fulfilled at least 1 prescription of antidepressant in the 2 years preceding surgery. However, antidepressants can also be used for anxiety syndromes, obsessive compulsive
disorder, and off-label in binge eating disorder.
Although a majority of surgery programs use some kind of
psychological evaluation of bariatric surgery candidates,43 there is no
clear consensus on how to determine suitability of a patient seeking
bariatric surgery. Only 53% of the programs answering a survey
about common contraindications indicated that current symptoms of
depression were a definite contraindication to surgery and only 60%
considered suicide attempt within in the past year as a definite
contraindication.43
Some studies have even shown that depressed individuals lose
more weight than nondepressed counterparts after bariatric
surgery.44,45 However, a number of studies have described an
improvement in mental and physical health related to quality of life
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CE: R.R.; ANNSURG-D-16-00125; Total nos of Pages: 7;

ANNSURG-D-16-00125

Lagerros et al

during the first year after surgery; this has recently been reported in a
meta-analysis of 21 studies.46 Although depression scores and
quality of life scores improve in the year following bariatric surgery,
they tend to decline after that.8,47 This decline may in part be
associated with weight regain.8 Unfortunately, we do not have
information about weight change in our registries and can thus
not evaluate whether weight loss or gain was associated with
aggravated depression. Nonetheless, with a 50-fold higher risk of
depression severe enough for hospitalization among patients with a
history of depression, compared to those without previous depression, weight regain may not be the only factor of importance,
although we cannot separate what is due to the effects of
bariatric surgery.
The strengths and limitations of the present study are related to
the registry-based design. The Swedish National Patient Register, the
Prescribed Drug Register, and the Causes of Death Register gave us
access to nationwide prospectively collected information and an
opportunity to follow a large sample of patients during a number
of years with a minimal loss to follow-up. We minimized misclassification of the exposures and outcome through exact linkages to
essentially complete high-quality national registries using the individually unique personal identity number. The sample size was large
enough to gain insights, although some CIs are wide.
Among the limitations are that, although we controlled for a
number of covariates, we cannot exclude the risk of residual confounding owing to unmeasured confounders. Furthermore, we were
restricted to use variables available in population-based registries;
thereby, we were unable to study unrecorded factors such as adherence to medication, social support, or suicidal ideation. We did not
have any information on weight pre- or post-surgery. Therefore, it
was not possible to disentangle whether there was an association
between psychiatric outcome and discontent with post-surgery
weight result (low weight loss or early weight regain). We only
studied gastric bypass surgery; we do not know whether the results
are generalizable to other types of procedures. We were also
restricted to diagnoses given by hospital inpatient and outpatient
care, caring for the most severe mentally ill patients. Diagnoses by
other caregivers such as primary care physicians were not captured
by the National Patient Register. This may have led to an underestimation of the number of patients that were at risk before surgery,
although this ought to have been negligible given that a fulfilled
prescription also was a way to identify patients at risk. Nonetheless,
we report a lower percentage of antidepressant use before bariatric
surgery, compared to Mitchell et al8 who report 40.4% based on selfreport with the Beck Inventory. This may be because of differences in
methods to assess antidepressant use, but could also be because of the
fact that antidepressant utilization is lower in Sweden than in the
United States. According to Statistics Sweden, 5.4% of the women
and 2.8% of the men older than 16 years use antidepressants, whereas
the highest usage is found among women aged 45 to 54 years, that is
6.8%.48 The Centers for Disease Control and Prevention, CDC in the
United States, report that 11% of the Americans older than 12 years
use antidepressants, while, also here, the highest use, 23% is found
among women aged 40 to 59 years.49
Notwithstanding the beneficial long-term effects of bariatric
surgery, our findings highlight the importance of recognizing psychiatric comorbidity before surgery. If a careful risk–benefit analysis
is performed before surgery, the decision may be to proceed with
gastric bypass as long as the patient is carefully monitored for
psychiatric deterioration after surgery. Future guidelines may want
to recommend screening for depression and suicidal ideation in this
patient group.
In conclusion, this nationwide population-based cohort study
showed that patients with depression or a diagnosis of self-harm in
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Annals of Surgery Volume XX, Number X, Month 2016

the 2 years preceding gastric bypass surgery are at higher risk for
depression and self-harm behavior including suicide, following the
surgery. Contrary to previous research showing decreased depression
scores post-surgery, our study suggests that patients with previous
psychiatric comorbidity should be considered at higher risk for
severe psychiatric outcomes after bariatric surgery.

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