Lagerros depression and suicide after bariatric 2016.pdf
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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
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
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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