Brief Thoughts On Suicidal Ideation Post Weight Loss With Surgery Or Ozempic
Is it a consequence of unmet expectations?
There was some buzz this week about the news that the EU was investigating the possibility that some people taking GLP1 analogues like ozempic saw increased thoughts of suicide.
That significant weight loss associates with increased thoughts of self-harm is not news. We see this with patients who have had bariatric surgery whereby one meta-analysis reported the suicide event rate of 2.7/1000 patients (1.9x that of BMI matched controls) while the suicide/self-harm attempt event rate was 17/1000 patients (3.8x that of BMI matched controls).
As to what could be going on?
The authors of the meta-analysis of the surgical patients state that
several mechanisms may contribute to the increased suicide risk noted in the post-bariatric population, including psychiatric, medical, psychosocial causes,and physiologic changes
and it’s the psychosocial causes consequent to weight loss not meeting expectation that I want to highlight, as my clinical experience would suggest for many, that is the most significant.
While our new generation of medications are closing in on bariatric surgical levels of weight loss, weight losses lesser than hoped for are common even with bariatric surgery. And it’s not just the math of not losing as much as one hopes for that can lead to disappointment - in fact I think this is the minor disappointment - but rather in many cases it’s the unmet expectations around what might change consequent to weight loss (things like body image, interpersonal relationships, mood, pain, chronic disease remissions and more) that are the most devastating.
It’s these disappointments, borne out of internalized weight biases and fueled by societal weight loss hyperbole that I’ve seen lead to severe depression and also at times to the genesis of newly disordered eating.
If I’m right and the primary driver is psychosocial, I expect suicidal ideation and self-harming thoughts will be found to associate with GLP1 analogue derived weight losses just as they have with surgical weight losses.
I don’t have any quick solutions, but this underscores the need for more extensive medical education for prescribers to understand weight bias, and ideally to develop validated means to identify those patients most at risk before their surgeries or pharmaceutical prescriptions, as well as strategies and tools designed to help modify unrealistic expectations.
Have a great weekend!
I agree with Dagny Kight in that the photos look basically the same to me. Her face in the after picture looks slightly thinner, but certainly not what I would expect from a 100-lb weight loss. Regardless, I can certainly see how anyone who all their life has felt, and been told that they are 'less than', a failure, an outsider, because of their body size and finally they're a 'normal' size, would find it very difficult to cope with the complex emotions that go along with that. When you've spent years or potentially decades feeling like your life would be perfect if only you were able to lose weight (even if it's not a conscious thought), reality can be very cruel. I also think our weight is tied in to who we are at a very foundational level. Personally, I'm 9 weeks into Ozempic and having success, yet there's a part of me that's almost grieving for the loss of the person I've been all my life that I might be leaving behind (assuming my success continues long term). Being fat is part of my identity. While it's not one I would have chosen, after so many years it's part of who I am, and it takes some adjusting to think of letting go of it.
The photos look the same to me. She has the same bags under her eyes in each, her hair looks lighter in the after photo, and her expression appears the same. Except for different color tops and photo backgrounds, I'm not seeing the contrast. She does not look that different for having lost 100lbs but it might be more apparent in full-body photos. Please tell me I'm totally missing something obvious!