OBES SURG DOI 10.1007/s11695-014-1226-x

ORIGINAL CONTRIBUTIONS

Psychological Outcome 4 Years after Restrictive Bariatric Surgery Ramona Burgmer & Tanja Legenbauer & Astrid Müller & Martina de Zwaan & Charlotte Fischer & Stephan Herpertz

# Springer Science+Business Media New York 2014

Abstract Extreme obesity is associated with severe psychiatric and somatic comorbidity and impairment of psychosocial functioning. Bariatric surgery is the most effective treatment not only with regard to weight loss but also with obesityassociated illnesses. Health-related psychological and psychosocial variables have been increasingly considered as important outcome variables of bariatric surgery. However, the longterm impact of bariatric surgery on psychological and psychosocial functioning is largely unclear. The aim of this study was to evaluate the relationship between the course of weight and psychological variables including depression, anxiety, healthrelated quality of life (HRQOL), and self-esteem up to 4 years after obesity surgery.By standardized questionnaires prior to (T1) and 1 year (T2), 2 years (T3), and 4 years (T4) after R. Burgmer (*) : C. Fischer : S. Herpertz Department of Psychosomatic Medicine and Psychotherapy, LWL-University Hospital, Ruhr University Bochum, Alexandrinenstraße 1-3, 44791 Bochum, Germany e-mail: [email protected]

surgery, 148 patients (47 males (31.8 %), 101 females (68.2 %), mean age 38.8±10.2 years) were assessed.On average, participants lost 24.6 % of their initial weight 1 year after surgery, 25.1 % after 2 years, and 22.3 % after 4 years. Statistical analysis revealed significant improvements in depressive symptoms, physical dimension of quality of life, and self-esteem with peak improvements 1 year after surgery. These improvements were largely maintained. Significant correlations between weight loss and improvements in depression, physical aspects of HRQOL (T2, T3, and T4), and selfesteem (T3) were observed.Corresponding to the considerable weight loss after bariatric surgery, important aspects of mental health improved significantly during the 4-year follow-up period. However, parallel to weight regain, psychological improvements showed a slow but not significant decline over time. Keywords Bariatric surgery . Quality of life . Depression . Self-esteem . Weight loss

C. Fischer e-mail: [email protected] S. Herpertz e-mail: [email protected] T. Legenbauer LWL-University Hospital Hamm for Child and Adolescent Psychiatry, Ruhr University Bochum, Heithofer Allee 64, 59071 Hamm, Germany e-mail: [email protected] A. Müller : M. de Zwaan Department of Psychosomatic Medicine and Psychotherapy, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany A. Müller e-mail: [email protected] M. de Zwaan e-mail: [email protected]

Introduction Bariatric surgery seems to be the most effective method for the treatment of extreme obesity (BMI ≥40 kg/m2) and related diseases [1–3]. Physicians have traditionally focused on weight loss and improvements in obesity-related comorbidities as the main outcome measures following bariatric surgery. However, in the past decades, health-related quality of life (HRQOL) and psychological functioning have been increasingly considered as outcome variables [4]. Several studies and reviews considering HRQOL, anxiety, or depressive symptoms after bariatric surgery have been published showing divergent findings [4–6]. Some studies report marked improvements of HRQOL [7, 8] and depressive symptoms [9–11]. Aasprang et al. [12] examined 50 patients 5 years after

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biliopancreatic diversion with duodenal switch and found improved mental and physical quality of life. Physical quality of life scores were comparable to the population norm. Depression but not anxiety significantly improved after 5 years. Other studies report some postoperative improvements; however, impairments in quality of life and affective states are still present in comparison to reference groups [13, 14]. Some studies suggest that improvements in HRQOL aspects deteriorate in the long run [15, 16], while other studies show no significant changes in HRQOL [17] and depressive symptoms at all [18]. Sarwer et al. [19] found that different aspects of quality of life after gastric bypass improved within the first months after surgery. These changes were still detectable 2 years after surgery except the mental aspects of HRQOL, which were no longer significantly different from baseline. Various studies report a relationship between weight loss and psychosocial functioning [20, 21], but again, findings are not consistent. Larsen et al. [22] reported low correlations between quality of life and weight outcome 2 years after gastric banding; however, these correlations became stronger in the long run. The Swedish Obese Subjects (SOS) intervention trial [23] found that different aspects of HRQOL correspond to the course of weight with peak HRQOL improvements during the first year and a gradual decline in the years following surgery. Correlations between improvements in all HRQOL domains and weight loss were significant at 2- and 6year follow-up. Kolotkin et al. [24] compared gastric bypass patients with obese individuals without surgical weight loss treatment and found significant improvements in most aspects of HRQOL in the surgical group. These changes showed small decreases after 6 years corresponding to subjects’ weight gain. In summary, these inconsistencies of results may be due to different sample sizes, different surgical techniques, and, in many cases, short follow-up times. The current report describes a prospective longitudinal 4-year follow-up study of restrictive bariatric surgery patients. The objectives of this study were (1) to evaluate the course of weight; (2) to evaluate the change in depression, anxiety, HRQOL, and self-esteem; and (3) to investigate the relationship between the course of weight and changes in depression, anxiety, HRQOL, and self-esteem.

Materials and Methods The results presented in this paper are part of the larger multicenter, prospective Essen-Bochum Obesity Treatment Study (EBOTS), initiated in 2000 (for more details, see [25, 26]. Psychological outcome of this sample after 2 years has already been published [10]. The initial cross-sectional assessment comprised 153 obesity surgery patients. Recruitment took place in six surgery departments in Germany and Austria between 2000 and 2001. Exclusion criteria were age

below 18 and above 65, a diagnosis of psychotic disorder or dementia, women who had given birth within the past year and were continuing to lactate, and difficulties in understanding the German language. At follow-up, patients were contacted 1 year (T2), 2 years (T3), and 4 years (T4) after surgery. They were assessed by means of a multiple-step procedure that included a letter of invitation, three attempts to contact them by telephone, a reminder letter, and an incentive of 25 EUR. The average follow-up period at T2 was 13.6 months (±2.2); at T3, 25.1 months (±2.9); and at T4, 50.1 months (±7.7). At the first assessment point (T1), weight and height were measured in light clothing without shoes in the cooperating surgery departments. Further weight assessments took place either at the patients’ homes or in local offices of general practitioners. We certify that all applicable institutional and governmental regulations concerning the ethical use of human volunteers were followed during this research. The study protocol was approved by the Ethics Committee of the University of Essen. All participants provided written informed consent. Participants Preoperatively (T1), 153 patients were investigated; 149 (97 %) received restrictive obesity surgery procedures (97 vertical gastroplasty and 51 gastric banding). Four patients (3 %) underwent a malabsorptive or combined procedure (biliopancreatic diversion or gastric bypass). These four patients were excluded from further analysis because of putative differences in the effects of the surgical methods. One patient had to be excluded from analysis because of difficulties with the German language. The sample of 148 patients consisted of 101 women (68.2 %) and 47 men (31.8 %). Mean age at T1 was 38.8 years (±10.2) (range 19–64 years). Mean BMI (T1) was 50.7 kg/m2 (±8) (range 35.4–74.1 kg/m2). At T2, 118 (79.7 %); at T3, 102 (68.9 %); and at T4, 101 (68.2 %) patients of the original sample could be assessed. Figure 1 shows the number of patients with missing data at the different time points. There were no significant differences between the study participants and those with missing data at T2, T3, and T4 with regard to gender, age, initial weight, initial BMI, anxiety and depression scores (HADS), HRQOL (SF-36), and selfesteem at baseline (all p values >0.1). Instruments Depressive and anxiety symptoms were assessed with the Hospital Anxiety and Depression Scale (HADS-D) [27] (original: [28]). The HADS is a widely used instrument for the screening of anxiety and depression in somatically ill patients. The two subscales provide separate scores with possible ranges from 0 to 21. The validity and reliability have been

OBES SURG Fig. 1 Flowchart showing the number of patients who completed and who dropped out at different follow-up assessment points

Baseline T1 N = 153 5 patients were excluded: 4 patients with malabsorptive procedures, 1 patient in retrospective did not meet the inclusion criteria

Inclusion for analysis n = 148 Data of 30 patients missing: 1 deceased, 1 ill, 1 pregnant, 13 not available, 3 no time/no interest to participate, 11 no information

Measurement T2 13.6 + 2.2 months n = 118

Data of 46 patients missing: 2 deceased, 2 ill, 20 not available, 3 no time to participate, 19 no information

Measurement T3 25.1 + 2.9 months n = 102 Data of 47 patients missing: 2 deceased, 3 ill, 25 not available, 17 no time/no interest to participate

Measurement T4 55.2 + 7.7 months n = 101

documented extensively for in- and outpatients in many countries and medical settings. In this study, we found a Cronbach’s alpha for the anxiety scale of 0.8 and for the depression scale of 0.76. There is no generally accepted cutoff score for clinical relevance [29]. Zigmond and Snaith [28] recommended a scale score 10 indicating a probable case of anxiety or depressive disorder. Herrmann and colleagues [27] proposed in the German version different cutoff scores for anxiety (≥10) and depression (≥8). HRQOL was measured with the Short-Form Health Survey (SF-36) [30]. The SF-36 is the short version of an instrument used in the Medical Outcome Study (MOS) [31] evaluating HRQOL on eight dimensions. For our analyses, we used norm-based, T-standardized physical (PCS) and mental (MCS) component scores that aggregate the weighted mental and physical components from the eight dimensions. The SF36 has been validated internationally for health surveys [31]

and also in obesity research [32]. In our study, Cronbach’s alpha for the subscales ranged from 0.7 to 0.93. Self-esteem was assessed with the Rosenberg Self-Esteem Scale (RSE) [33, 34]. The RSE was originally developed to measure global feelings of self-worth; it includes ten face valid items. A sum score gives a measure for global selfesteem. There are adaptations in many languages; reliability and validity have been well evaluated [35]. In this study, it was found to be a highly reliable measure (Cronbach’s alpha= 0.87). Statistical Analyses All analyses were performed using SPSS for Windows 20.0. Data are presented as means with standard deviation or numbers of cases and percentages. Chi-square and t tests for independent groups were used to compare completers and non-completers. To analyze BMI, HRQOL, depression, anxiety, and selfesteem over time, a linear mixed model [36] was used, with

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the outcome measures as dependent variables. For each outcome variable, a separate model was conducted adjusted for gender, age, and BMI at baseline. Based on estimated marginal means, pairwise comparisons were performed to evaluate the changes with the 95 % confidence interval within the four time points. Exploratory data analyses were conducted using univariate analysis of variance to explore the influence of changes in depression scores (depression scores

Psychological outcome 4 years after restrictive bariatric surgery.

Extreme obesity is associated with severe psychiatric and somatic comorbidity and impairment of psychosocial functioning. Bariatric surgery is the mos...
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