Bariatric Surgery and Suicide Risk in Patients With Obesity.

OBJECTIVE: In a large multisite cohort of Veterans who underwent Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy, we compared the 5-year suicidal ideation and attempt rates with matched nonsurgical controls. BACKGROUND: Bariatric surgery has significant health benefits but has also been associated with adverse mental health outcomes. METHODS: Five-year rates of suicidal ideation and suicide attempts of Veterans who underwent Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy from the fiscal year 2000-2016 to matched nonsurgical controls using sequential stratification using cumulative incidence functions (ideation cohort: n=38,199; attempt cohort: n=38,661 after excluding patients with past-year outcome events). Adjusted differences in suicidal ideation and suicide attempts were estimated using a Cox regression with a robust sandwich variance estimator. RESULTS: In the matched cohorts for suicidal ideation analyses, the mean age was 53.47 years and the majority were males (78.7%) and White (77.7%). Over 40% were treated for depression (41.8%), had a nonrecent depression diagnosis (40.9%), and 4.1% had past suicidal ideation or suicide attempts >1 year before index. Characteristics of the suicide attempt cohort were similar. Regression results found that risk of suicidal ideation was significantly higher for surgical patients (adjusted hazard ratio=1.21, 95% CI: 1.03-1.41), as was risk of suicide attempt (adjusted hazard ratio=1.62, 95% CI: 1.22-2.15). CONCLUSIONS: Bariatric surgery appears to be associated with a greater risk of suicidal ideation and attempts than nonsurgical treatment of patients with severe obesity, suggesting that patients need careful monitoring for suicidal ideation and additional psychological support after bariatric surgery.

The Effect of Bariatric Surgery on Long-term Depression Treatment in Patients With Obesity.

OBJECTIVE: In a large multisite cohort of Veterans who underwent Roux-en-Y gastric bypass (RYGB) or laparoscopic sleeve gastrectomy (LSG), initiation of (ie, incident) and persistence of (ie, continuation of preoperative) depression treatment are compared with matched nonsurgical controls. BACKGROUND: Bariatric surgery has been associated with short-term improvements in depression but less is known about longer term outcomes. METHODS: In a retrospective cohort study, we matched 1713 Veterans with depression treatment who underwent bariatric surgery in Veterans Administration bariatric centers from fiscal year 2001 to 2016 to 15,056 nonsurgical controls using sequential stratification and examined the persistence of depression treatment via generalized estimating equations. Incidence of depression treatment was compared using Cox regression models between 2227 surgical patients and 20,939 matched nonsurgical controls without depression treatment at baseline. RESULTS: In surgical patients with depression treatment at baseline, the use of postsurgical depression treatment declined over time for both surgical procedures, but postsurgical patients had greater use of depression treatment at 5 years [RYGB: odds ratio=1.24, 95% confidence interval (CI): 1.04-1.49; LSG: odds ratio=1.27, 95% CI: 1.04-1.56] compared with controls. Among those without depression treatment at baseline, bariatric surgery was associated with a higher incidence of depression treatment compared with matched controls (RYGB: hazard ratio=1.34, 95% CI: 1.17-1.53; LSG: hazard ratio at 1-5 years=1.27, 95% CI: 1.10-1.47). CONCLUSIONS: Bariatric surgery was associated with a greater risk of postoperative incident depression treatment and greater persistence of postoperative depression treatment. Depression may worsen for some patients after bariatric surgery, so clinicians should carefully monitor their patients for depression postoperatively.

Does Long-Term Post-Bariatric Weight Change Differ Across Antidepressants?

We sought to evaluate whether weight change up to 5 years after bariatric surgery differed by antidepressant class taken before surgery. Background: Bariatric surgery induces significant weight loss, but outcomes are highly variable. The specific type of antidepressant used prior to surgery may be an important factor in long-term weight loss. Methods: This retrospective cohort study from 2000 to 2016 compared the 5-year weight loss of 556 Veterans who were taking antidepressant monotherapy (bupropion, selective serotonin reuptake inhibitors [SSRIs], or serotonin-norepinephrine reuptake inhibitors [SNRIs]) before bariatric surgery (229 sleeve gastrectomy and 327 Roux-en-Y gastric bypass) versus 556 matched nonsurgical controls. Results: Patients taking bupropion before sleeve gastrectomy had greater differential weight loss between surgical patients and matched controls than those taking SSRIs at 1 (8.9 pounds; 95% confidence interval [CI], 1.6-16.3; P = 0.02) and 2 years (17.6 pounds; 95% CI, 5.9-29.3; P = 0.003), but there was no difference at 5 years (11.9 pounds; 95% CI, -8.9 to 32.8; P = 0.26). Findings were similar for gastric bypass patients taking bupropion compared to SSRIs at 1 (9.7 pounds; 95% CI, 2.0-17.4; P = 0.014), 2 (12.0 pounds; 95% CI, -0.5 to 24.5; P = 0.06), and 5 years (4.8 pounds; 95% CI, -16.7 to 26.3; P = 0.66). No significant differences were observed comparing patients taking SNRI versus SSRI medications. Conclusions: Sleeve gastrectomy and gastric bypass patients taking bupropion had greater weight loss than those taking SSRIs, although these differences may wane over time. Bupropion may be the first-line antidepressant of choice among patients with severe obesity considering bariatric surgery.

Association of Bariatric Surgical Procedures With Changes in Unhealthy Alcohol Use Among US Veterans.

Importance: Bariatric surgical procedures have been associated with increased risk of unhealthy alcohol use, but no previous research has evaluated the long-term alcohol-related risks after laparoscopic sleeve gastrectomy (LSG), currently the most used bariatric procedure. No US-based study has compared long-term alcohol-related outcomes between patients who have undergone Roux-en-Y gastric bypass (RYGB) and those who have not. Objective: To evaluate the changes over time in alcohol use and unhealthy alcohol use from 2 years before to 8 years after a bariatric surgical procedure among individuals with or without preoperative unhealthy alcohol use. Design, Setting, and Participants: This retrospective cohort study analyzed electronic health record (EHR) data on military veterans who underwent a bariatric surgical procedure at any of the bariatric centers in the US Department of Veterans Affairs (VA) health system between October 1, 2008, and September 30, 2016. Surgical patients without unhealthy alcohol use at baseline were matched using sequential stratification to nonsurgical control patients without unhealthy alcohol use at baseline, and surgical patients with unhealthy alcohol use at baseline were matched to nonsurgical patients with unhealthy alcohol use at baseline. Data were analyzed in February 2020. Interventions: LSG (n = 1684) and RYGB (n = 924). Main Outcomes and Measures: Mean alcohol use, unhealthy alcohol use, and no alcohol use were estimated using scores from the validated 3-item Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), which had been documented in the VA EHR. Alcohol outcomes were estimated with mixed-effects models. Results: A total of 2608 surgical patients were included in the final cohort (1964 male [75.3%] and 644 female [24.7%] veterans. Mean (SD) age of surgical patients was 53.0 (9.9) years and 53.6 (9.9) years for the matched nonsurgical patients. Among patients without baseline unhealthy alcohol use, 1539 patients who underwent an LSG were matched to 14 555 nonsurgical control patients and 854 patients who underwent an RYGB were matched to 8038 nonsurgical control patients. In patients without baseline unhealthy alcohol use, the mean AUDIT-C scores and the probability of unhealthy alcohol use both increased significantly 3 to 8 years after an LSG or an RYGB, compared with control patients. Eight years after an LSG, the probability of unhealthy alcohol use was higher in surgical vs control patients (7.9% [95% CI, 6.4-9.5] vs 4.5% [95% CI, 4.1-4.9]; difference, 3.4% [95% CI, 1.8-5.0])). Similarly, 8 years after an RYGB, the probability of unhealthy alcohol use was higher in surgical vs control patients (9.2% [95% CI, 8.0-10.3] vs 4.4% [95% CI, 4.1-4.6]; difference, 4.8% [95% CI, 3.6-5.9]). The probability of no alcohol use also decreased significantly 5 to 8 years after both procedures for surgical vs control patients. Among patients with unhealthy alcohol use at baseline, prevalence of unhealthy alcohol use was higher for patients who underwent an RYGB than matched controls. Conclusions and Relevance: In this multi-site cohort study of predominantly male patients, among those who did not have unhealthy alcohol use in the 2 years before bariatric surgery, the probability of developing unhealthy alcohol use increased significantly 3-8 years after bariatric procedures compared with matched controls during follow-up.

Long-term opioid use after bariatric surgery.

BACKGROUND: Opioid analgesics are often prescribed to manage pain after bariatric surgery, which may develop into chronic prescription opioid use (CPOU) in opioid-naïve patients. Bariatric surgery may affect opioid use in those with or without presurgical CPOU. OBJECTIVE: To compare CPOU persistence and incidence in a large multisite cohort of veterans undergoing bariatric surgery (open Roux-en-Y gastric bypass, laparoscopic RYGB, or laparoscopic sleeve gastrectomy) and matched nonsurgical controls. SETTING: Veterans Administration hospitals. METHODS: In a retrospective cohort study, we matched 1117 surgical patients with baseline CPOU to 9531 nonsurgical controls, and 2822 surgical patients without CPOU at baseline to 26,392 nonsurgical controls using sequential stratification. CPOU persistence in veterans with baseline CPOU was estimated using generalized estimating equations by procedure type. CPOU incidence in veterans without baseline CPOU was estimated in Cox regression models by procedure type because postoperative pain, complications, and absorption may differ by procedure. RESULTS: In veterans with baseline CPOU, postsurgical CPOU declined over time for each surgical procedure; these trends did not differ between surgical patients and nonsurgical controls. In veterans without baseline CPOU, compared with nonsurgical controls, bariatric patients had higher CPOU incidence within 5 years after open Roux-en-Y gastric bypass (hazard ratio = 1.19; 95% confidence interval: 1.06-1.34) or laparoscopic open Roux-en-Y gastric bypass (hazard ratio = 1.22, 95% confidence interval: 1.06-1.41). Veterans undergoing laparoscopic sleeve gastrectomy had higher CPOU incidence 1 to 5 years after surgery (hazard ratio = 1.28; 95% confidence interval: 1.05-1.56) than nonsurgical controls. CONCLUSIONS: Bariatric surgery was associated with greater risk of CPOU incidence in patients without baseline CPOU but was not associated with greater CPOU persistence.

Association Between Bariatric Surgery and Long-term Health Care Expenditures Among Veterans With Severe Obesity.

Importance: Bariatric surgery has been associated with improvements in health in patients with severe obesity; however, it is unclear whether these health benefits translate into lower health care expenditures. Objective: To examine 10-year health care expenditures in a large, multisite retrospective cohort study of veterans with severe obesity who did and did not undergo bariatric surgery. Design, Setting, and Participants: A total of 9954 veterans with severe obesity between January 1, 2000, and September 30, 2011, were identified from veterans affairs (VA) electronic health records. Of those, 2498 veterans who underwent bariatric surgery were allocated to the surgery cohort. Sequential stratification was used to match each patient in the surgery cohort with up to 3 patients who had not undergone bariatric surgery but were of the same sex, race/ethnicity, diabetes status, and VA regional network and were closest in age, body mass index (calculated as weight in kilograms divided by height in meters squared), and comorbidities. A total of 7456 patients were identified and allocated to the nonsurgery (control) cohort. The VA health care expenditures among the surgery and nonsurgery cohorts were estimated using regression models. Data were analyzed from July to August 2018 and in April 2019. Interventions: The bariatric surgical procedures (n = 2498) included in this study were Roux-en-Y gastric bypass (1842 [73.7%]), sleeve gastrectomy (381 [15.3%]), adjustable gastric banding (249 [10.0%]), and other procedures (26 [1.0%]). Main Outcomes and Measures: The study measured total, outpatient, inpatient, and outpatient pharmacy expenditures from 3 years before surgery to 10 years after surgery, excluding expenditures associated with the initial bariatric surgical procedure. Results: Among 9954 veterans with severe obesity, 7387 (74.2%) were men; the mean (SD) age was 52.3 (8.8) years for the surgery cohort and 52.5 (8.7) years for the nonsurgery cohort. Mean total expenditures for the surgery cohort were $5093 (95% CI, $4811-$5391) at 7 to 12 months before surgery, which increased to $7448 (95% CI, $6989-$7936) at 6 months after surgery. Postsurgical expenditures decreased to $6692 (95% CI, $6197-$7226) at 5 years after surgery, followed by a gradual increase to $8495 (95% CI, $7609-$9484) at 10 years after surgery. Total expenditures were higher in the surgery cohort than in the nonsurgery cohort during the 3 years before surgery and in the first 2 years after surgery. The expenditures of the 2 cohorts converged 5 to 10 years after surgery. Outpatient pharmacy expenditures were significantly lower among the surgery cohort in all years of follow-up ($509 lower at 3 years before surgery and $461 lower at 7 to 12 months before surgery), but these cost reductions were offset by higher inpatient and outpatient (nonpharmacy) expenditures. Conclusions and Relevance: In this cohort study of 9954 predominantly older male veterans with severe obesity, total health care expenditures increased immediately after patients underwent bariatric surgery but converged with those of patients who had not undergone surgery at 10 years after surgery. This finding suggests that the value of bariatric surgery lies primarily in its associations with improvements in health and not in its potential to decrease health care costs.

Geographic Variation in Obesity, Behavioral Treatment, and Bariatric Surgery for Veterans.

OBJECTIVE: This study aims to describe geographic variation in veterans' prevalence of obesity, participation in Veterans Health Administration's behavioral weight management program (MOVE!), and receipt of bariatric surgery in fiscal year (FY) 2016. METHODS: In this retrospective cohort study of veterans with obesity who received Veterans Health Administration care in FY2016, electronic health record data were obtained on weight, height, outpatient visits to the MOVE! program, and bariatric surgeries. For each Veterans Integrated Service Network (VISN) region, the prevalence rate of veterans with obesity (BMI ≥ 30 kg/m2 ), MOVE! participation rates, and bariatric surgery rates are presented. RESULTS: The prevalence of obesity in veterans ranged from 30.5% to 40.5% across VISNs in FY2016. MOVE! participation among veterans with obesity was low (2.8%-6.9%) across all VISNs, but veterans with class II and III obesity (BMI ≥ 35) had higher MOVE! participation rates (4.3%-10.8%) than veterans with class I obesity. There was 20-fold variation across VISNs in receipt of bariatric surgery among veterans with BMI ≥ 35, ranging from 0.01% to 0.2%. Among veterans with BMI ≥ 35 participating in MOVE!, there was 46-fold variation in bariatric surgery provision, ranging from 0.07% to 3.27%. CONCLUSIONS: Despite veterans' high prevalence of obesity, behavioral and surgical weight management participation is low and varies across regions.