Presurgical assessment of bariatric patients with the Patient Health Questionnaire (PHQ)--a screening of the prevalence of psychosocial comorbidity

Prevalence and characteristics of preoperative patients with depression

BACKGROUND

Within the perioperative period, depression-related diagnoses are associated with postoperative complications. We developed a perioperative depression screening programme to assess disease prevalence and feasibility for intervention.

METHODS

Adult patients in multiple surgical departments at a single academic centre were screened for depression via the electronic health record patient portal or preoperative anaesthesia clinic before surgery, using the Patient Health Questionnaire (PHQ)-2 and -8. We utilised a broad method, screening all patients, and a focused method, only screening patients with a history of depression. Logistic regression was used to identify characteristics associated with clinically significant depression (PHQ-8 ≥10). Symptomatic patients were administered a brief psychoeducational intervention and referred for mental health services.

RESULTS

A total of 3735 patients were identified by the broad and focused screens, of whom 2940 (79%) returned PHQ-2 data and were included in analysis. The broad screen (N=1216) found 46 (4%) patients who reported symptoms of moderate or greater severity. The focused screen (N=1724) found 242 (14%) patients with symptoms of moderate or greater severity and over all higher rates of depression across the symptom severity scale. Using the total screened pool, logistic regression identified a history of depression as the strongest associated patient characteristic variable but this did not capture most cases. Finally, we found that 66% of patients who were contacted about mental health services accepted referrals or sought outside care.

CONCLUSIONS

At least 4% of preoperative patients have clinically significant symptoms of depression, most of whom do not have a chart history of depression.

Conventional weight loss therapy in morbid obesity during COVID-19 pandemic: degree of burdens at baseline and treatment efficacy

Introduction

COVID-19 affected global physical and psychological health. The purpose of this study was to explore the pandemics impact on health-related quality of life (HRQoL), mental health (anxiety, depression, and perceived stress) and eating behavior in people with severe obesity participating in a multimodal conservative behavioral weight loss (BWL) program conducted via videoconferencing. Additionally, the efficacy of the six-month BWL program in a virtual video-based setting during the pandemic was examined.

Methods

297 participants of a face-to-face multimodal behavioral weight loss program prior to the pandemic (PrePAN, May 2014-September 2019) and 146 participants of the in terms of content same intervention in a videoconference-based setting during the pandemic (PAN, July 2020-April 2022) were questioned and compared using standardized questionnaires for HRQoL, symptoms of depressive and anxiety disorders, perceived stress, and eating behavior at baseline and at the end of treatment.

Results

Symptoms for anxiety, depression and perceived stress were similar between PrePAN and PAN at baseline. In addition, PAN tended to show lower disinhibition of eating behavior and feelings of hunger than PrePAN. During the pandemic, the BWL intervention resulted in body weight loss (67%) or stabilization (16%) in most of the participants. It also contributed by improving physical HRQoL, lower worries, and improved eating behaviors compared to baseline.

Conclusion

During the COVID-19 pandemic, baseline mental health of people with morbid obesity was not worse than before the pandemic. Additionally, the BWL intervention in the virtual video-based setting stabilized and improved physical and mental health during the COVID-19 pandemic.

Chronic abdominal pain after bariatric surgery: a narrative review

Objective: This paper reviews the prevalence, etiology, risk factors, diagnosis and prevention of chronic abdominal pain after bariatric surgery. Introduction: Chronic pain is a very common and complex problem that has serious consequences on individuals and society. It frequently presents as a result of a disease or an injury. Obesity and obesity-related comorbidities are a major health problem and are dramatically increasing year after year. Dieting and physical exercise show disappointing results in the treatment of obesity. Therefore, bariatric surgery is increasingly widely offered as a weight reducing strategy. In our pain clinic we see a lot of patients who suffer from chronic abdominal pain after bariatric surgery. This review aims to explore the link between chronic abdominal pain and bariatric surgery in this specific type of patients. Method: The review is based on searches in PubMed, Embase and Cochrane databases. Keywords are used in different combinations. We did a cross-reference of the articles included. Results: Chronic abdominal pain after bariatric surgery is very common. Around 30% of the bariatric patients experience persistent abdominal pain. An explanation for the abdominal pain is found in 2/3 of these patients. There is a wide variety of causes including behavioral and nutritional disorders, functional motility disorders, biliary disorders, marginal ulceration and internal hernia. Another, frequently overlooked, cause is abdominal wall pain. Unexplained abdominal pain after bariatric surgery is present in 1/3 of the patients with persistent abdominal pain. More studies are needed on the risk factors and prevention of unexplained abdominal pain in bariatric patients.

Screening for depressive symptoms in postbariatric surgery patients using a validated Arabic version of Patient Health Questionnaire

BACKGROUND

The prevalence of depressive symptoms in obese patients is higher than nonobese patients. Evidence shows an improvement of depressive symptoms after bariatric surgery, but this improvement fluctuates 3-4 years after surgery. Some studies report a worsening of depressive symptoms, but that the type of surgery and surgical complications contribute to the high depression rate. Our objective was to assess depressive symptoms in postbariatric surgery patients using an Arabic version of Patient Health Questionnaire-9 (PHQ-9).

MATERIALS AND METHODS

A cross-sectional study was conducted in a tertiary care hospital in Riyadh from January to December 2019 using a validated Arabic version of PHQ-9. The questionnaires sent through Google Survey link to patient phone numbers were registered in an electronic record system. Data analysis was analyzed using SPSS version 23. Frequency and percentages were computed for the categorical variables and mean and standard deviation were calculated for the continuous variables. Chi-square test performed to test for the association between categorical variables and depression and logistic regression analysis were performed to determine the risk factors for development of depression after bariatric surgery.

RESULTS

A total of 152 patients were included in the study. Fifty percent patients did not have depression, 26.3% had mild depression, 15.8% had moderate depression, 7.2% had moderately severe depression, and only one patient (0.7%) had severe depression. Only marital status was significantly associated with depression after bariatric surgery (P = 0.019). Gender, education, marital status, and income when used in the multivariate logistic regression could not predict the incidence of depression.

CONCLUSION

Using a score of 10 in PHQ-9 as a cutoff, the prevalence of depressive disorder in postbariatric surgery patients was 23.7%, which is similar to the prevalence of nonobese general Saudi population of 20%.

General Practitioner's Knowledge about Bariatric Surgery Is Associated with Referral Practice to Bariatric Surgery Centers

(1) Background: Patients seeking treatment for obesity and related diseases often contact general practitioners (GPs) first. The aim of this study was to evaluate GPs’ knowledge about weight loss surgery (WLS) and potential stereotypes towards obese patients. (2) Methods: For this prospective cohort study, 204 GPs in the region of the bariatric surgery center at the University Hospital Aachen were included. The participants filled out a questionnaire comprising general treatment of obese patients, stigmatization towards obese patients (1–5 points) as well as knowledge regarding WLS (1–5 points). (3) Results: The mean age of the GPs was 54 years; 41% were female. Mean score for self-reported knowledge was 3.6 points out of 5. For stigma-related items, the mean score was 3.3 points out of 5. A total of 60% of the participants recognized bariatric surgery as being useful. Knowledge about bariatric surgery significantly correlated with the number of referrals to bariatric surgery centers (p < 0.001). No significant correlation was found between stigma and referral to surgery (p = 0.057). (4) Conclusions: The more GPs subjectively know about bariatric surgery, the more often they refer patients to bariatric surgery specialists—regardless of potentially present stereotypes. Therefore, GPs should be well informed about indications and opportunities of WLS.

Attitude Matters! How Attitude towards Bariatric Surgery Influences the Effects of Behavioural Weight Loss Treatment

INTRODUCTION

Multidisciplinary obesity services at university hospitals usually treat patients with more complex and severe obesity. In addition, patients with Class 3 obesity, in particular, have different attitudes regarding the choices of therapy.

METHODS

This explorative study investigated the effect of patient attitudes towards bariatric surgery on body weight change (primary outcome) and psychological improvement (secondary outcomes: quality of life, depression, anxiety, and eating behaviour) in a 6-month moderate behavioural weight loss (BWL) programme in a university outpatient setting.

RESULTS

297 patients with mostly Class 3 obesity participated in the programme. The patients did not yet have any indications for bariatric surgery. Of the participants, 37% had a positive attitude towards bariatric surgery (POS), whereas 38% had a negative attitude (NEG). The drop-out rate was 8%. NEG participants lost significantly more body weight than the POS participants (intention-to-treat population: 4.5 [SD: 6.3] kg versus 0.4 [SD: 5.8] kg; p < 0.001). In both subgroups, anxiety, depression, the mental score for quality of life, and eating behaviour improved.

CONCLUSION

A BWL treatment in a clinical setting identified 2 distinct groups with different attitudes towards bariatric surgery that were associated with different body weight change outcomes. These groups may require differently targeted programmes to achieve the best body weight loss results.

[Quality of indications in bariatric surgery]

Bariatric and metabolic surgery is increasingly being utilized in Germany and also worldwide. Due to the increased perioperative risk compared to non-obese patients, a detailed and accurate preoperative assessment of the patient is pivotal to improve postoperative and long-term outcomes. The indications for bariatric surgery have shifted in recent years from a certain body mass index (BMI) to comorbidity-based indications. In 2018 the German S3 guidelines for metabolic surgery defined the indications for bariatric surgery as well as the preoperative assessment. The indications for bariatric metabolic operations should be assessed by an interdisciplinary team consisting of surgeons, internists, diabetologists, psychologists and dietitians. It is paramount that surgeon and patient define realistic goals of these operations. Also, the different types of bariatric operation and their long-term consequences should be discussed. Additionally, a thorough endocrinological assessment by an internist or diabetologist with respect to relevant comorbidities of obesity as well as the adjustment of existing therapies are important. An assessment by a mental health professional is also mandatory; however, psychological comorbidities are not a contraindication as long as the patient is being treated and the disease is controlled. A preoperative short-term high-protein and low-carbohydrate fluid nutrition helps to reduce the risk of postoperative complications, especially for patients with a high BMI. A preoperative weight loss in the sense of a mandatory loss of a defined proportion of the body weight is not useful.

Psychological Well-Being as an Independent Predictor of Exercise Capacity in Cardiac Rehabilitation Patients With Obesity

Objective: Exercise capacity (EC) is a well-established predictor of cardiovascular health. It is notoriously influenced by several factors, but the independent effect of psychological well-being (PWB) on EC has not yet been explored. The present study aims to investigate (1) whether PWB is an independent predictor of EC over and above selected demographic, behavioral, and biomedical parameters in a sample of CR patients with obesity and (2) whether PWB is a stronger predictor of EC than the other variables.

Methods: Data from 1968 patients were collected at the time of their inclusion in a cardiac rehabilitation (CR) program and retrospectively analyzed in a cross-sectional study. Since cardiorespiratory parameters defined in normal weight populations differ from those of their obese counterparts, an ad hoc validated formula taking body mass index (BMI) into consideration was used to predict EC.

Results: A multiple regression analysis revealed left ventricular eject fraction (LVEF) to be the strongest predictor of EC, followed by PWB, type 2 diabetes (DM), smoking status, atrial fibrillation (AF), and education. Bayesian evaluation of informative hypotheses corroborated LVEF as the best predictor of EC, and confirmed the superiority of PWB over and above DM and smoking status in influencing EC.

Conclusion: These findings strengthen the link between psychological and physical health, suggesting a better PWB is associated with greater EC. Prompt screening of a patient’s mood and readiness to perform an active lifestyle would therefore enhance the long-term health benefits of CR.

Agreement of screening tools with established questionnaires used in psychological assessment of bariatric patients

Background:

Depression and binge eating contributes to less weight loss after bariatric surgery. The lack of standardized assessment of depression and binge eating in bariatric patients makes it hard to identify and provide treatment to relevant patients. This study aimed to enhance the accuracy of identifying binge eating and depression in bariatric patients before surgery. We determined the agreement of brief screening tools for depression, binge eating and quality of life with established questionnaires used in psychological assessment of bariatric patients.

Methods:

In total, 120 patients completed both screening tools and established questionnaires before surgery during their psychological assessment sessions. Cohen’s kappa was conducted to determine whether Patient Health Questionnaire-2 agreed with the Beck Depression Inventory II in identifying depression; and if Patient Health Questionnaire-Binge agreed with the Binge Eating Scale in identifying binge eating. To investigate the degree of agreeableness between the RAND 36-Item Health Survey and Moorehead–Ardelt Quality of Life Questionnaire II on quality of life, Bland Altman analysis was performed.

Results:

Our results show that agreement between Patient Health Questionnaire-2 and Beck Depression Inventory II ( k=0.35) was fair. We found that agreement between Patient Health Questionnaire-Binge and Binge Eating Scale ( k=0.41) was moderate.

Conclusions:

These results indicate that the respective brief instruments’ identification of depression and binge eating is comparable to established questionnaires. Our results play a role in offering brief screening tools to be included at different points of assessment, together with established questionnaires and clinical interviews for a more accurate and comprehensive assessment.

Gender-based differences in host behavior and gut microbiota composition in response to high fat diet and stress in a mouse model

Obesity is associated with a high prevalence of mood disorders such as anxiety and depression. Both stress and high fat diet can alter the gut microbiota and contribute to obesity. To examine the interrelationships between obesity, stress, gut microbiota and mood disorders, obesity was induced in mice using a high fat diet, and the mice were subsequently stressed using a chronic unpredictable mild stress protocol. During the experiment, the composition of the gut microbiota was analyzed by 16 S rRNA gene high-throughput sequencing, and anxiety-like behaviors were measured. The results revealed distinct gender differences in the impacts of obesity and stress on anxiety-like behaviors, activity levels, and composition of the gut microbiota. Male mice were more vulnerable to the anxiogenic effects of the high fat diet, and obese male mice showed decreased locomotion activity in response to stress whereas obese female mice did not. In females, stress caused the gut microbiota of lean mice to more closely resemble that of obese mice. Taken together, these results suggest the importance of considering gender as a biological variable in studies on the role of gut microbiota in obesity-related mood disorders.

Sustained effects of a psychoeducational group intervention following bariatric surgery: follow-up of the randomized controlled BaSE study

BACKGROUND

Evidence regarding the efficacy of psychosocial interventions after bariatric surgery is rare and shows conflicting results.

OBJECTIVES

The Bariatric Surgery and Education (BaSE) study aimed to assess the efficacy of a psychoeducational group intervention in patients after bariatric surgery.

SETTING

The BaSE study was a randomized, controlled, multicenter clinical trial involving 117 patients who underwent bariatric surgery. Patients received either conventional postsurgical visits or, in addition, a 1-year psychoeducational group program. The present study evaluated the sustained effects of the intervention program. Mean follow-up duration was 37.9 months (standard deviation [SD] 8.2 months) after surgery.

METHODS

Outcome measures were as follows: body mass index (BMI), weight loss, self-efficacy, depression severity, and health-related quality of life (HRQOL). Groups were compared using an intention-to-treat approach with a mixed model for repeated measurements.

RESULTS

A total of 74 patients (63.2%) completed the follow-up (T5) assessment. Mean weight loss for all patients was 43 kg (SD 15.5 kg) at T5 (mean BMI 35.1 kg/m²). Mean excess weight loss was 60.4%. The effects of the surgery during the first postsurgical year were reflected, on average, by both decreasing weight and psychosocial burden. At the T5 time point, patients had slowly started to regain weight and to deteriorate regarding psychosocial aspects. However, at T5, patients who had participated in the intervention program (n = 39) showed significantly lower depression severity scores (p = .03) and significantly higher self-efficacy (p = .03) compared to the control group (n = 35). The 2 groups did not differ regarding weight loss and quality of life.

CONCLUSION

Psychoeducational intervention shows sustained effects on both depression severity scores and self-efficacy.

Psychological Impact of Severe Obesity

The causes of severe obesity are multifactorial and include metabolic, dietary, physical, and psychological aspects. Additionally, the impact of severe obesity affects more than one's physical health. This article attempts to explore the psychological impact of severe obesity specifically in the areas of mood, eating disorders, sleep disturbance, chronic pain, and quality of life. Additionally, obesity treatment options of lifestyle modification and bariatric surgery that include psychological assessment and/or cognitive behavioral intervention are discussed.