OBES SURG DOI 10.1007/s11695-014-1281-3
BRIEF COMMUNICATION
Childhood Verbal Abuse: A Risk Factor for Depression in Pre-Bariatric Surgery Psychological Evaluations Jessica K. Salwen & Genna F. Hymowitz & K. Daniel O’Leary & Aurora D. Pryor & Dina Vivian
# Springer Science+Business Media New York 2014
Abstract The present study evaluated the importance of multimodal assessment of childhood verbal abuse (CVA) in prebariatric surgery psychological evaluations, and the role of CVA as a predictor of depression. Data from the psychological evaluations of 184 pre-bariatric surgery patients were retrospectively examined. Using two self-report measures and an interview-based screen, 52.2 % of participants reported experiencing some form of CVA; conversely, assessments of CVA based on only one measure yielded significantly lower prevalence rates. Endorsement of CVA on multiple measures was associated with more severe depressive symptomatology and greater likelihood of mood disorder diagnosis. Based on these data, a self-report measure and interview-based screen for CVA should be included in pre-bariatric psychological evaluations; either of these assessments may be conducted via a single-item screen. Lastly, patients who endorse CVA on multiple measures should be monitored closely for symptoms of depression post-surgery. Keywords Abuse . Childhood maltreatment . Depression . Psychological evaluation
Background Although many individuals experience improvements in quality of life and psychosocial functioning following bariatric
J. K. Salwen (*) : G. F. Hymowitz : K. D. O’Leary : D. Vivian Department of Psychology, Stony Brook University, Stony Brook, NY 11794-2500, USA e-mail: [email protected] G. F. Hymowitz : A. D. Pryor Department of Surgery, Stony Brook Medicine, Stony Brook, NY 11794-8191, USA
surgery, some continue to experience significant psychopathology [1]. Clinical depression is particularly important, as it is associated with sub-optimal weight loss following bariatric surgery [2, 3] and is one of the strongest predictors of suicide attempts [4]. Furthermore, the risk of suicide is 2–4 times higher in a bariatric surgery population than in the general population [5-7]. Thus, it is critical to identify correlates of depression and, thus, potential risk factors for suicide in these patients. Due to the function of pre-surgical psychological evaluations, patients may underreport current levels of psychopathology, thereby creating an obstacle in the diagnosis of depression [8-10]. Additionally, they may report distal psychological stressors more readily than proximal stressors. For example, childhood verbal abuse (CVA) is reported more often than current symptoms of depression [11, 12], and there is a large difference in the rates of CVA in pre-bariatric patients (46.2 %) and community individuals (12 %) [13, 11]. There may also be mediational associations among these variables; CVA is more strongly associated with depression than other forms of child abuse are [14], and this association portends an increased risk for both obesity and suicidal behavior [15-17]. Furthermore, some studies indicate that children with obesity are more likely to experience verbal abuse [18], and prospective studies show that childhood abuse is a risk factor for obesity in adulthood [19]. Regardless of the direction of this relationship, the literature consistently supports the association between obesity and abuse. Additionally, although researchers have suggested that retrospective reports of childhood abuse may be subject to error or influenced by symptoms of depression, inaccuracies in retrospective reports of childhood trauma are more likely to be caused by false negatives than false positives [20], suggesting that these relationships may be even stronger than reported. Furthermore, a recent
OBES SURG
meta-analysis indicated that the association between childhood abuse and obesity did not change significantly based on assessment (retrospective report versus prospective observation) or measurement style (questionnaire, interview, or review of records) [21]. Thus, the relationships among CVA, depression, and obesity appear to be a critical area of investigation. While the literature indicates that mode of assessment impacts self-reports of sensitive information overall [22, 7], to our knowledge, no research has been conducted to evaluate the necessity or use of multi-modal assessment of CVA in bariatric surgery candidates. Accordingly, the authors sought to (1) investigate the necessity of multi-modal assessment of CVA in pre-bariatric surgery psychological evaluations and (2) examine the use of CVA as a predictor of depressive symptomatology and mood disorder diagnosis.
Method Participants We conducted a retrospective chart review of 184 patients (37.2 % men and 62.8 % women) who sought pre-bariatric surgery psychological evaluations. Participants were 19 to 69 years old (M=43.98, SD=12.77), and the most common levels of education included completion of a high school degree (27.8 %) and some college education (34.6 %; M= 14.08 years of schooling, SD=2.68). The majority of participants were Caucasian (78.6 %) with 13.2 % Hispanic, 6.0 % African American, and 2.1 % others. BMIs ranged from 29.95 to 67.09 (M=45.85, SD=7.01); 16.8 % of participants fell into the obese range (class I or II obesity; BMI ≥30) and 83.2 % of participants fell into the extremely obese range (class III obesity; BMI ≥40). Procedure All participants underwent a comprehensive psychological evaluation to attain clearance for bariatric surgery, including several self-report measures and a semi-structured clinical interview. All measures used in the current study were administered as part of standard clinical care, and data from these measures were abstracted from patients’ charts. The Human Subjects Institutional Review Board approved a waiver of consent for the use of these data, and patients’ charts from March 2010 to November 2012 were retrospectively examined. Patients who were administered the measures used in the current study were evaluated for inclusion (N=194), and of those patients, 184 had fully completed the measures used in this study.
Materials Childhood Trauma Questionnaire–Short Form (CTQ) [23]. The CTQ is a 28-item self-report measure that assesses physical, sexual, and emotional abuse, and physical and emotional neglect. Items are rated from 1 (never true) to 5 (very often true). For this study, only the 5-item emotional abuse subscale was used (e.g., “people in my family said hurtful or insulting things to me,” and “I felt that someone in my family hated me”); alphas for this subscale across clinical and non-clinical populations range from 0.84 to 0.89 [16]. Scores on this subscale range from 5 to 25, with scores above 9 indicating clinically significant emotional abuse. Participants’ scores were transformed into the presence (1) or absence (0) of clinically significant emotional abuse. Eating Disorder Questionnaire (EDQ) [24]. The EDQ evaluates past and present eating behaviors, dieting methods, medical events, drug and alcohol use, psychological history, and history of adverse experiences (e.g., abuse). One section of this questionnaire assesses the occurrence of adverse events before the age of 18. In this study, the item “someone constantly criticized you and blamed you for minor things,” was used to assess childhood verbal abuse. This item was scored as yes (1) or no (0). Krasner Psychological Center Semi-structured Interview for Bariatric Surgery. In the semi-structured interview, patients are asked about weight loss and diet history, eating patterns, surgery motivation and knowledge, family history, personal functioning, abuse history, psychiatric history, and medical history. Additionally, patients are asked if they experienced “any kind of verbal or emotional abuse as a child, adolescent, or young adult, for example, being intensely criticized or called names by family members”. For the current study, presence (1) or absence (0) of verbal abuse was used. Depression Anxiety Stress Scales-21 (DASS) [25]. The DASS is a 21-item self-report instrument that assesses severity of depression, anxiety, and stress within the previous 2 weeks. For this study, only the depression subscale was used. Scores range from 0 to 42; scores at or above a 9 indicate clinically significant symptomatology. The DASS has been shown to have good internal consistency, reliability, and validity in clinical and non-clinical populations. Mini International Neuropsychiatric Interview (MINI) [26]. The MINI is a structured interview designed to assess Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnoses. The MINI was administered during the semi-structured interview, and individuals who endorsed symptoms consistent with DSM-IV criteria for major depressive disorder, dysthymic disorder, bipolar disorder, and/or depressive disorder not otherwise specified were classified as having a mood disorder diagnosis.
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Results Data were examined for missing values and normality; none of the participants had missing values on study instruments to an extent that prevented scoring according to test maker instructions. Although the DASS depression subscale was negatively skewed, these data were not altered as the distribution was assumed to be an appropriate approximation of the population. Overall, 36.4 % of participants reported childhood verbal abuse (CVA) on the CTQ, 29.9 % on the EDQ, and 27.7 % in the semi-structured interview. However, all of these rates were significantly lower than the overall CVA rate of 52.2 % (N= 96); X 2 = 9.26 (p = 0.003), 18.88 (p < 0.001), and 22.94 (p0.10). With regard to depression, 13.7 % of participants reported depressive symptomatology above the clinical cutoff on the DASS (M=4.49, SD=6.73). Furthermore, 9 % of participants received some form of mood disorder diagnosis as assessed via the MINI. Endorsing CVA on a greater number of measures (i.e., 0 to 3) was associated with an increased severity of depressive symptomatology, r (181)=0.33, p
BRIEF COMMUNICATION
Childhood Verbal Abuse: A Risk Factor for Depression in Pre-Bariatric Surgery Psychological Evaluations Jessica K. Salwen & Genna F. Hymowitz & K. Daniel O’Leary & Aurora D. Pryor & Dina Vivian
# Springer Science+Business Media New York 2014
Abstract The present study evaluated the importance of multimodal assessment of childhood verbal abuse (CVA) in prebariatric surgery psychological evaluations, and the role of CVA as a predictor of depression. Data from the psychological evaluations of 184 pre-bariatric surgery patients were retrospectively examined. Using two self-report measures and an interview-based screen, 52.2 % of participants reported experiencing some form of CVA; conversely, assessments of CVA based on only one measure yielded significantly lower prevalence rates. Endorsement of CVA on multiple measures was associated with more severe depressive symptomatology and greater likelihood of mood disorder diagnosis. Based on these data, a self-report measure and interview-based screen for CVA should be included in pre-bariatric psychological evaluations; either of these assessments may be conducted via a single-item screen. Lastly, patients who endorse CVA on multiple measures should be monitored closely for symptoms of depression post-surgery. Keywords Abuse . Childhood maltreatment . Depression . Psychological evaluation
Background Although many individuals experience improvements in quality of life and psychosocial functioning following bariatric
J. K. Salwen (*) : G. F. Hymowitz : K. D. O’Leary : D. Vivian Department of Psychology, Stony Brook University, Stony Brook, NY 11794-2500, USA e-mail: [email protected] G. F. Hymowitz : A. D. Pryor Department of Surgery, Stony Brook Medicine, Stony Brook, NY 11794-8191, USA
surgery, some continue to experience significant psychopathology [1]. Clinical depression is particularly important, as it is associated with sub-optimal weight loss following bariatric surgery [2, 3] and is one of the strongest predictors of suicide attempts [4]. Furthermore, the risk of suicide is 2–4 times higher in a bariatric surgery population than in the general population [5-7]. Thus, it is critical to identify correlates of depression and, thus, potential risk factors for suicide in these patients. Due to the function of pre-surgical psychological evaluations, patients may underreport current levels of psychopathology, thereby creating an obstacle in the diagnosis of depression [8-10]. Additionally, they may report distal psychological stressors more readily than proximal stressors. For example, childhood verbal abuse (CVA) is reported more often than current symptoms of depression [11, 12], and there is a large difference in the rates of CVA in pre-bariatric patients (46.2 %) and community individuals (12 %) [13, 11]. There may also be mediational associations among these variables; CVA is more strongly associated with depression than other forms of child abuse are [14], and this association portends an increased risk for both obesity and suicidal behavior [15-17]. Furthermore, some studies indicate that children with obesity are more likely to experience verbal abuse [18], and prospective studies show that childhood abuse is a risk factor for obesity in adulthood [19]. Regardless of the direction of this relationship, the literature consistently supports the association between obesity and abuse. Additionally, although researchers have suggested that retrospective reports of childhood abuse may be subject to error or influenced by symptoms of depression, inaccuracies in retrospective reports of childhood trauma are more likely to be caused by false negatives than false positives [20], suggesting that these relationships may be even stronger than reported. Furthermore, a recent
OBES SURG
meta-analysis indicated that the association between childhood abuse and obesity did not change significantly based on assessment (retrospective report versus prospective observation) or measurement style (questionnaire, interview, or review of records) [21]. Thus, the relationships among CVA, depression, and obesity appear to be a critical area of investigation. While the literature indicates that mode of assessment impacts self-reports of sensitive information overall [22, 7], to our knowledge, no research has been conducted to evaluate the necessity or use of multi-modal assessment of CVA in bariatric surgery candidates. Accordingly, the authors sought to (1) investigate the necessity of multi-modal assessment of CVA in pre-bariatric surgery psychological evaluations and (2) examine the use of CVA as a predictor of depressive symptomatology and mood disorder diagnosis.
Method Participants We conducted a retrospective chart review of 184 patients (37.2 % men and 62.8 % women) who sought pre-bariatric surgery psychological evaluations. Participants were 19 to 69 years old (M=43.98, SD=12.77), and the most common levels of education included completion of a high school degree (27.8 %) and some college education (34.6 %; M= 14.08 years of schooling, SD=2.68). The majority of participants were Caucasian (78.6 %) with 13.2 % Hispanic, 6.0 % African American, and 2.1 % others. BMIs ranged from 29.95 to 67.09 (M=45.85, SD=7.01); 16.8 % of participants fell into the obese range (class I or II obesity; BMI ≥30) and 83.2 % of participants fell into the extremely obese range (class III obesity; BMI ≥40). Procedure All participants underwent a comprehensive psychological evaluation to attain clearance for bariatric surgery, including several self-report measures and a semi-structured clinical interview. All measures used in the current study were administered as part of standard clinical care, and data from these measures were abstracted from patients’ charts. The Human Subjects Institutional Review Board approved a waiver of consent for the use of these data, and patients’ charts from March 2010 to November 2012 were retrospectively examined. Patients who were administered the measures used in the current study were evaluated for inclusion (N=194), and of those patients, 184 had fully completed the measures used in this study.
Materials Childhood Trauma Questionnaire–Short Form (CTQ) [23]. The CTQ is a 28-item self-report measure that assesses physical, sexual, and emotional abuse, and physical and emotional neglect. Items are rated from 1 (never true) to 5 (very often true). For this study, only the 5-item emotional abuse subscale was used (e.g., “people in my family said hurtful or insulting things to me,” and “I felt that someone in my family hated me”); alphas for this subscale across clinical and non-clinical populations range from 0.84 to 0.89 [16]. Scores on this subscale range from 5 to 25, with scores above 9 indicating clinically significant emotional abuse. Participants’ scores were transformed into the presence (1) or absence (0) of clinically significant emotional abuse. Eating Disorder Questionnaire (EDQ) [24]. The EDQ evaluates past and present eating behaviors, dieting methods, medical events, drug and alcohol use, psychological history, and history of adverse experiences (e.g., abuse). One section of this questionnaire assesses the occurrence of adverse events before the age of 18. In this study, the item “someone constantly criticized you and blamed you for minor things,” was used to assess childhood verbal abuse. This item was scored as yes (1) or no (0). Krasner Psychological Center Semi-structured Interview for Bariatric Surgery. In the semi-structured interview, patients are asked about weight loss and diet history, eating patterns, surgery motivation and knowledge, family history, personal functioning, abuse history, psychiatric history, and medical history. Additionally, patients are asked if they experienced “any kind of verbal or emotional abuse as a child, adolescent, or young adult, for example, being intensely criticized or called names by family members”. For the current study, presence (1) or absence (0) of verbal abuse was used. Depression Anxiety Stress Scales-21 (DASS) [25]. The DASS is a 21-item self-report instrument that assesses severity of depression, anxiety, and stress within the previous 2 weeks. For this study, only the depression subscale was used. Scores range from 0 to 42; scores at or above a 9 indicate clinically significant symptomatology. The DASS has been shown to have good internal consistency, reliability, and validity in clinical and non-clinical populations. Mini International Neuropsychiatric Interview (MINI) [26]. The MINI is a structured interview designed to assess Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnoses. The MINI was administered during the semi-structured interview, and individuals who endorsed symptoms consistent with DSM-IV criteria for major depressive disorder, dysthymic disorder, bipolar disorder, and/or depressive disorder not otherwise specified were classified as having a mood disorder diagnosis.
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Results Data were examined for missing values and normality; none of the participants had missing values on study instruments to an extent that prevented scoring according to test maker instructions. Although the DASS depression subscale was negatively skewed, these data were not altered as the distribution was assumed to be an appropriate approximation of the population. Overall, 36.4 % of participants reported childhood verbal abuse (CVA) on the CTQ, 29.9 % on the EDQ, and 27.7 % in the semi-structured interview. However, all of these rates were significantly lower than the overall CVA rate of 52.2 % (N= 96); X 2 = 9.26 (p = 0.003), 18.88 (p < 0.001), and 22.94 (p0.10). With regard to depression, 13.7 % of participants reported depressive symptomatology above the clinical cutoff on the DASS (M=4.49, SD=6.73). Furthermore, 9 % of participants received some form of mood disorder diagnosis as assessed via the MINI. Endorsing CVA on a greater number of measures (i.e., 0 to 3) was associated with an increased severity of depressive symptomatology, r (181)=0.33, p
