Lagerros depression and suicide after bariatric 2016.pdf


Aperçu du fichier PDF lagerros-depression-and-suicide-after-bariatric-2016.pdf

Page 1 2 3 4 5 6 7




Aperçu texte


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
6 | www.annalsofsurgery.com

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.

REFERENCES
1. Sjostrom L. Review of the key results from the Swedish Obese Subjects (SOS)
trial - a prospective controlled intervention study of bariatric surgery. J Intern
Med. 2013;273:219–234.
2. Booth H, Khan O, Prevost AT, et al. Impact of bariatric surgery on clinical
depression. Interrupted time series study with matched controls. J Affect
Disord. 2015;174:644–649.
3. Raoof M, Naslund I, Rask E, et al. Health-related quality-of-life (HRQoL) on an
average of 12 years after gastric bypass surgery. Obes Surg. 2015;25:1119–1127.
4. de Zwaan M, Enderle J, Wagner S, et al. Anxiety and depression in bariatric
surgery patients: a prospective, follow-up study using structured clinical
interviews. J Affect Disord. 2011;133:61–68.
5. Burgmer R, Petersen I, Burgmer M, et al. Psychological outcome two years
after restrictive bariatric surgery. Obes Surg. 2007;17:785–791.
6. Sarwer DB, Spitzer JC, Wadden TA, et al. Changes in sexual functioning and
sex hormone levels in women following bariatric surgery. JAMA Surg.
2014;149:26–33.
7. van Hout GC, Fortuin FA, Pelle AJ, et al. Psychosocial functioning, personality, and body image following vertical banded gastroplasty. Obes Surg.
2008;18:115–120.
8. Mitchell JE, King WC, Chen JY, et al. Course of depressive symptoms and
treatment in the longitudinal assessment of bariatric surgery (LABS-2) study.
Obesity (Silver Spring). 2014;22:1799–1806.
9. Schneider B, Lukaschek K, Baumert J, et al. Living alone, obesity, and
smoking increase risk for suicide independently of depressive mood findings
from the population-based MONICA/KORA Augsburg cohort study. J Affect
Disord. 2014;416–421. 152-154.
10. Dutton GR, Bodell LP, Smith AR, et al. Examination of the relationship
between obesity and suicidal ideation. Int J Obes (Lond). 2013;37:1282–1286.
11. Wagner B, Klinitzke G, Brahler E, et al. Extreme obesity is associated with
suicidal behavior and suicide attempts in adults: results of a population-based
representative sample. Depress Anxiety. 2013;30:975–981.
12. Peterhansel C, Petroff D, Klinitzke G, et al. Risk of completed suicide after
bariatric surgery: a systematic review. Obes Rev. 2013;14:369–382.
13. Bhatti JA, Nathens AB, Thiruchelvam D, et al. Self-harm emergencies after
bariatric surgery: a population-based cohort study. JAMA Surg. 2015;151:1–7.
14. Wettermark B, Hammar N, Fored CM, et al. The new Swedish Prescribed Drug
Register–opportunities for pharmacoepidemiological research and experience
from the first six months. Pharmacoepidemiol Drug Saf. 2007;16:726–735.
15. Rosen M. National Health Data Registers: a Nordic heritage to public health.
Scand J Public Health. 2002;30:81–85.
16. Ludvigsson JF, Andersson E, Ekbom A, et al. External review and validation
of the Swedish national inpatient register. BMC Public Health. 2011;11:450.
17. Ludvigsson JF, Otterblad-Olausson P, Pettersson BU, et al. The Swedish
personal identity number: possibilities and pitfalls in healthcare and medical
research. Eur J Epidemiol. 2009;24:659–667.
18. Tao W, Holmberg D, Naslund E, et al. Validation of Obesity Surgery Data in
the Swedish National Patient Registry and Scandinavian Obesity Registry
(SOReg). Obes Surg. 2015 [Epub ahead of print].
19. Donaldson AE, Larsen GY, Fullerton-Gleason L, et al. Classifying undetermined poisoning deaths. Inj Prev. 2006;12:338–343.
20. Linsley KR, Schapira K, Kelly TP. Open verdict v. suicide - importance to
research. Br J Psychiatry. 2001;178:465–468.
21. Allebeck P, Allgulander C, Henningsohn L, et al. Causes of death in a cohort of
50,465 young men–validity of recorded suicide as underlying cause of death.
Scand J Soc Med. 1991;19:242–247.
22. Ohberg A, Lonnqvist J. Suicides hidden among undetermined deaths. Acta
Psychiatr Scand. 1998;98:214–218.
23. Ortqvist AK, Lundholm C, Wettermark B, et al. Validation of asthma and
eczema in population-based Swedish drug and patient registers. Pharmacoepidemiol Drug Saf. 2013;22:850–860.
24. Pedersen EG, Hallas J, Hansen K, et al. Identifying patients with
myasthenia for epidemiological research by linkage of automated registers.
Neuroepidemiology. 2011;37:120–128.
ß

2016 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.