Elsevier

Comprehensive Psychiatry

Volume 55, Issue 2, February 2014, Pages 248-259
Comprehensive Psychiatry

Psychopathology in bariatric surgery candidates: A review of studies using structured diagnostic interviews

https://doi.org/10.1016/j.comppsych.2013.08.021Get rights and content

Abstract

Psychiatric disorders are not uncommon among severely obese patients who present for bariatric surgery. This paper (1) reviews the results of the published studies using the structured interviews to assess psychopathology in bariatric surgery candidates; (2) compares the prevalence rates of psychiatric disorders across these studies with the data from other population samples; and (3) assesses whether sociodemographic variables appear to affect these prevalence rates. We searched online resources, PubMed, PsychINFO and reference lists of all the relevant articles to provide an overview of evidence so far and highlight some details in the assessment and comparisons of different samples in different countries. The prevalence estimates in the non-treatment obese group did not appear to differ substantially from the general population group in the US or the Italian population samples, although they were relatively higher for the German population. However, the rates of psychopathology in the bariatric surgery candidates were considerably higher than the other two population groups in all the samples. Overall, the most common category of lifetime Axis I disorders in all the studies was affective disorders, with anxiety disorders being the most common category of current Axis I disorders. Certain demographic characteristics are also associated with higher rates of psychopathology, such as, female gender, low socioeconomic status, higher BMI. Overall, methodological and sociodemographic differences make these studies difficult to compare and these differences should be taken into account when interpreting the results.

Introduction

In terms of societal impact, psychiatric disorders are among the most burdensome of all classes of diseases owing to their high prevalence, frequent chronicity, early age of onset, and accompanying serious impairment. Morbid obesity is often associated with significant psychiatric co-morbidity. Psychological symptoms, such as depression, anxiety and poor self-esteem, were long believed to be prominent in the etiology of obesity, despite scant empirical support [1]. The current consensus among researchers is that psychological symptomatology are quite common among the obese, but may be best understood as correlates, rather than serving as a primary cause [2], [3], [4].

Assessing psychopathology in extremely obese bariatric surgery candidates has significant clinical implications both preoperatively and postoperatively. A thorough psychological and psychosocial assessment is essential because of the necessity for long-term behavioral changes on the part of the bariatric surgical candidates. The quality of research in the field of psychiatric comorbidity in bariatric surgery candidates has improved considerably in the last few years. The studies assessing psychopathology in large bariatric surgery samples from different countries using structured diagnostic interviews present valuable data. In this review, we will: (1) review the results of the published studies which used structured interviews to assess psychopathology in bariatric surgery candidates; (2) compare the prevalence rates of lifetime and current psychiatric disorders across these studies with the data from general population samples, and with samples of obese individuals in the general population not currently in weight loss treatment; and (3) assess whether sociodemographic variables (sex, age, ethnicity and educational attainment) appear to affect these prevalence rates.

Section snippets

Prevalence of psychopathology among bariatric surgery candidates

Literature suggests a high prevalence of psychopathology among these individuals [5], [6], [7], [8], [9], [10]. However, establishing the prevalence and clinical significance of psychiatric disorders among the severely obese including candidates for weight loss surgery poses complex problems. First is the choice of the population to study. It is well established that obese persons seeking treatment show significantly elevated rates of psychopathology compared to obese persons who are not

Published results of psychiatric disorders in bariatric surgery candidates

Despite fairly consistently elevated rates, the available literature has found widely disparate figures of psychiatric disorders in bariatric surgery candidates. Some of this variability undoubtedly results from the divergent approaches used in assessing such populations. The validity and reliability of psychiatric diagnosis in bariatric surgery candidates have been markedly enhanced in the last few years through the use of structured diagnostic interviews, which are the state-of-the-art method

Comparison of prevalence rates of psychiatric disorders in bariatric surgery candidates with other population groups

The results of the above studies suggest that the rates of psychopathology are substantial in bariatric surgery candidates. However, it is also important to compare these rates to the rates in other populations. We compared the lifetime and current prevalence rates of psychiatric disorders among several groups: general population, obese individuals not seeking treatment data, and obese individuals considering bariatric surgery data (Table 2, Table 3). Data for the general population estimate in

Methodological issues and studies of psychiatric disorders in bariatric cases

The evaluation instrument used in all the studies on bariatric surgery candidates was the English, Italian or the German version of the SCID Interview. Four studies [28], [30], [31], [32] conducted face-to-face interviews, while that of Kalarchian et al. [29] conducted interviews by telephone. However, previous research has suggested that telephone administration of the SCID yields comparable results as face-to-face administration [26], [48], [49], [50], [51], [52].

In the studies of Kalarchian

Effects of demographic variables on prevalence of psychopathology

Sociodemographic factors such as gender, age, education, socioeconomic status and ethnicity may moderate the relationship between obesity and psychiatric disorders [3]. Bariatric surgery candidates are predominantly female which was true in the five studies discussed here, with >70% of their samples being female (Table 4). In the general population, women are known to present with higher rates of Axis I psychiatric disorders than men, especially anxiety and affective disorders [44], [55], [56].

The association of eating disorders in obese patients and Axis I and Axis II psychopathology

Obese patients with comorbid BED have significantly higher rates of Axis I and Axis II psychiatric disorders compared to obese patients without BED [64], [65], [66], [67], [68], [69]. These findings seem to hold true among bariatric surgery candidates as well. Among the studies reviewed, three [28], [30], [31] examined comorbidity between eating disorders and Axis I psychiatric disorders in bariatric surgery candidates. Consistent with previous studies [7], [70], [71], all observed a higher

Prevalence of Axis II psychopathology in bariatric surgery candidates

The studies of Kalarchian et al. [29] and Mauri et al. [31] provided an examination of comorbid personality disorders in addition to other Axis I psychiatric disturbances in bariatric surgery candidates. These studies used the Structured Clinical Interview for DSM-IV Axis II disorders (SCID II). In the study of Kalarchian et al. [29], 28.5% of the cohort met diagnostic criteria for an Axis II disorder. That 28.5% included 25% of the participants had both an Axis I and II diagnosis, and 3.5% had

Quality of life and functional impairment

Health Related Quality of Life (HRQOL) in bariatric surgery candidates has been studied extensively and found to be poorer among those subjects than among normative samples [76], [77]. Morbidly obese individuals are faced with multiple obstacles in their daily living that can have a devastating effect on functional health status [70]. Various scales are available to assess HRQOL and functional impairment. For example, the Medical Outcomes Study 36-item Short Form Health Survey (SF-36), a widely

Strengths and limitations of the studies on bariatric surgery candidates

The studies reviewed [28], [29], [30], [31], [32] assessed the prevalence rates of psychopathology in bariatric surgery candidates avoiding many key methodological flaws. A notable strength of all the studies is the relatively large sample size, providing better estimates than previous studies with generally smaller samples. Other strengths include the fact that the assessments were conducted across several clinical sites, the use of carefully trained assessors, and the use of Structured

Impact of psychopathology on outcomes of bariatric surgery

Assessment of prevalence of psychopathology in bariatric surgery candidates is important, due to the possibility of significant effects of these disorders on various outcomes of bariatric surgery, particularly weight loss [90]. However the literature here is limited. Patients with psychiatric disorders are thought to have greater risk for somatic and psychological complications after bariatric surgery. However, various studies provide conflicting results and no clear predictors [91], [92]. Some

Summary

Given the increasing population of bariatric surgery patients, evaluation of patients’ preoperative psychiatric status may play an important role in maximizing successful postoperative outcomes. Systematic diagnostic assessment can be done using a structured diagnostic interview (SCID) for determining the full spectrum of Axis I disorders. Although obesity surgery is not contraindicated based on most psychiatric disorders, adequate preoperative treatment and postoperative psychological support

Acknowledgment

This research was partially supported by a grant from the National Institutes of Health (DK 84979).

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