Research report
Anxiety and depression in bariatric surgery patients: A prospective, follow-up study using structured clinical interviews

https://doi.org/10.1016/j.jad.2011.03.025Get rights and content

Abstract

Background

Candidates for bariatric surgery frequently have co-morbid psychiatric problems.

Methods

This study investigated the course and the prognostic significance of preoperative and postoperative anxiety and depressive disorders in 107 extremely obese bariatric surgery patients in a prospective design with face-to-face interviews (SCID) conducted prior to the surgery and postoperatively after 6–12 months and 24–36 months.

Results

The point prevalence of depressive disorders but not of anxiety disorders decreased significantly after surgery. Preoperative depressive disorders predicted depressive disorders 24–36 months but not 6–12 months after surgery, whereas preoperative anxiety significantly predicted postoperative anxiety disorders at both follow-up time points. Preoperative lifetime and current depressive disorders were unrelated to postoperative weight loss whereas preoperative lifetime, but not current anxiety disorders were of negative prognostic value for postoperative weight loss. Patients with both depressive and anxiety disorders at baseline (current and lifetime) lost significantly less weight after surgery. Postoperative anxiety disorder was not associated with the degree of weight loss at any follow-up time-point; however postoperative depressive disorder was negatively associated with weight loss at the 24–36 month follow-up assessment point.

Limitations

Missing data, limited statistical power, self-reported height and weight are the limitations of this study.

Conclusions

As opposed to anxiety disorders, the point prevalence of depressive disorders decreased significantly after bariatric surgery. However, the presence of depressive disorders after bariatric surgery significantly predicted attenuated post-surgical improvements and may signal a need for clinical attention.

Introduction

Several groups have now reported the results of studies using structured diagnostic psychiatric interviews to assess the level of current and lifetime psychiatric disorders prior to bariatric surgery (Mühlhans and de Zwaan, 2008, Mühlhans et al., 2009, Legenbauer and al., 2011, Legenbauer et al., 2009, Kalarchian et al., 2007, Rosenberger et al., 2006, Mauri et al., 2008). Overall, pre-bariatric surgery patients present with high rates of current and lifetime Axis I disorders (APA, DSM IV), with rates of up to 70%. Affective disorders, anxiety disorders, and binge eating disorder are the most prevalent psychiatric disorders found in pre-bariatric surgery patients.

There exist an increasing number of studies on the predictive value of pre-surgery anxiety and depressive disorders on short- and long-term weight loss outcome after bariatric surgery. However, the results are controversial with some studies showing a negative influence of preoperative anxiety and depressive disorders (Legenbauer et al., 2009, Legenbauer and al., 2011, Kalarchian et al., 2008, Semanscin-Doerr et al., 2010) and other studies showing no influence of pre-surgical co-morbidity on postoperative weight loss (Dubovsky et al., 1985, Powers et al., 1997, Guisado et al., 2001, Dixon et al., 2001, Dixon et al., 2003). Virtually nothing is known about the association between postoperative psychiatric co-morbidity and weight loss outcome. The re-occurrence of anxiety and depressive disorders might have a much stronger impact on the course of weight after bariatric surgery than pre-surgery diagnoses (Legenbauer et al., 2011).

There are several longitudinal questionnaire studies assessing the course of anxiety and depressive symptoms after bariatric surgery using instruments such as the Hospital Anxiety and Depression Scale (HADS; Burgmer et al., 2007, Karlsson et al., 2007, Legenbauer et al., 2007, Nickel et al., 2005, Nickel et al., 2007), the Beck Depression Inventory (BDI; Benecke et al., 2000, Dixon et al., 2003, Dymek et al., 2001, Emery et al., 2007, Leombruni et al., 2007, Powers et al., 1992, Sarwer et al., 2008, Schowalter et al., 2008, Velcu et al., 2005), or the SF-36 (Andersen et al., 2010, Hayden et al., 2011). Most studies reported a significant decrease in depression and anxiety rating scores and improvements in quality of life scores. There is usually a positive association between the decrease in depression and anxiety scores and the amount of weight loss (e.g. Karlsson et al., 2007). However, the value of many of these studies is limited by small sample sizes, high drop out rates at the postoperative assessment points, or a retrospective design (Mitchell et al., 2001). In addition, questionnaires are not diagnostic instruments and the mean scores on these instruments do not permit the estimation of the prevalence of psychiatric disorders post-surgery. Symptoms assessed with self-report questionnaires may be more often biased by confounding covariates compared to symptoms confirmed by an interview (Luppino et al., 2010). Finally, some instruments such as the frequently used BDI may not be suitable for an obese population due to the overlap between somatic symptoms of depression and physical symptoms related to obesity (Hayden et al., 2011).

To our knowledge there are no published studies presenting the results of structured clinical interviews assessing psychiatric disorders conducted prior to and after bariatric surgery. Thus the aims of this study were to explore if:

  • 1)

    the prevalence of current anxiety and depressive disorders as assessed with Structured Clinical Interviews (SCID-I) decreased 6–12 months (t 1) and 24–36 months (t 2) after bariatric surgery,

  • 2)

    preoperative current and lifetime anxiety and depressive disorders would predict postoperative anxiety and depressive disorders, and

  • 3)

    weight loss would be a function of preoperative and postoperative anxiety and depressive disorders.

Section snippets

Participants

From the 151 consecutive patients originally included in the follow-up study, 35 were not operated on because they decided against it or were rejected by their health insurance. In addition, 6 patients had the surgery conducted in different areas of Germany and were therefore lost for follow-up. Three patients died after the surgery. Thus, the final sample included 107 (32 male and 75 female) extremely obese patients who underwent gastric banding (n = 76) or gastric bypass (n = 31) surgery at the

Does the point prevalence of anxiety and depressive disorders decrease post-surgery?

Compared to baseline, we found a significant decrease of the point prevalence of depressive disorders at t 1, 6–12 months after surgery (N = 85, p = 0.002) which remained stable at t 2, 24–36 months after surgery (N = 84, p  0.001). The point prevalence of anxiety disorders did not change after surgery compared to baseline, neither at t 1 (N = 85, p = 0.774) nor at t 2 (N = 84, p = 0.332) (Table 2).

The following distribution of current anxiety and depressive disorders at baseline was found: 8 patients with

Discussion

This study investigated the course and the prognostic significance of preoperative and postoperative anxiety and depressive disorders in 107 extremely obese bariatric surgery patients in a prospective design with a face-to-face interview (SCID-I) conducted prior to the surgery and two face-to-face interviews conducted postoperatively at 6–12 months and 24–36 months. The point prevalence of depressive disorders decreased significantly after surgery whereas the point prevalence of anxiety disorders

Role of funding source

The study was supported in part by a grant from the German Federal Ministry of Education and Research (BMBF, 01GI0835) within the German Competence Network of Obesity.

The BMBF had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.

Conflict of interest

All authors declare that they have no conflict of interest.

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