Childhood Verbal Abuse: A Risk Factor for Depression in Pre-Bariatric Surgery Psychological Evaluations

See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/262607700 Childhood Verbal Abuse: A Risk Factor for Depression in Pre-Bariatric Surgery Psychological Evaluations Article in Obesity Surgery · May 2014 DOI: 10.1007/s11695-014-1281-3 · Source: PubMed CITATIONS READS 2 78 5 authors, including: Jessica K Salwen K. Daniel O'Leary 15 PUBLICATIONS 26 CITATIONS 317 PUBLICATIONS 14,296 CITATIONS Johns Hopkins School of Medicine, Baltimore… SEE PROFILE Stony Brook University SEE PROFILE Aurora D Pryor Dina Vivian 128 PUBLICATIONS 1,028 CITATIONS 42 PUBLICATIONS 1,928 CITATIONS Stony Brook University SEE PROFILE Stony Brook University SEE PROFILE All content following this page was uploaded by K. Daniel O'Leary on 14 July 2014. The user has requested enhancement of the downloaded file. All in-text references underlined in blue are added to the original document and are linked to publications on ResearchGate, letting you access and read them immediately. 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: jessica.salwen@stonybrook.edu 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. OBES SURG 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 (p<0.001), respectively. Of the participants who reported CVA (N=96), 43.8 % reported it on only one measure, 32.3 % on two measures, and 24.0 % on all three measures. For participants who reported CVA on only one of the three measures, the likelihood of reporting it was not significantly different across measures, X2 (1, N=40)=0.98, p= 0.77; 37.5 % reported CVA only on the CTQ, 27.5 % on the EDQ, and 35 % in the semi-structured interview. As results suggested that using just one measure would not sufficiently identify all cases of CVA, we evaluated the effectiveness of using two out of the three measures. When both the CTQ and semi-structured interview were used to assess CVA, 46.2 % of patients (88.5 % of the initial 96 participants) reported CVA, as compared to 43.5 % who reported it on the CTQ/EDQ (83.3 % of the initial 96 participants), and 44 % who reported it on the EDQ/interview (84.3 % of the initial 96 participants). Based on chi-square tests for independence, none of these endorsement rates were significantly different from the overall CVA rate of 52.2 % (all ps >0.10). 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<0.001. To analyze these data further, we performed a stepwise hierarchical linear regression with depressive symptomatology as the outcome variable. Initially, the model with presence/ absence of any CVA predicting DASS depressive symptomatology was significant, F (1, 180)=10.60, p=0.001 (beta= 0.24). However, when the number of measures on which an individuals reported CVA was added to the model (0 to 3 measures), the strength of the model increased significantly, Fchange (1, 179)=11.95, p=0.001 (beta=0.45). Additionally, the overall model with presence/absence of CVA and number of measures predicting DASS depressive symptomatology was significant, F (2, 179)=11.60, p<0.001. Once the number of measures variable was entered into the model, presence/ absence of CVA was no longer statistically significant, t (179)=−1.12, p=0.26 (beta=−0.15). Lastly, we examined the likelihood of being diagnosed with a mood disorder based on the number of measures on which CVA was reported. As compared to not reporting any CVA, reporting CVA on any of the three measures was not associated with a significant increase in likelihood of diagnosis. However, reporting CVA on all three measures, as compared to not reporting any CVA, was associated with a significant increase in likelihood of a mood disorder diagnosis, odds ratio (OR)=4.5, Z=2.20, p= 0.03. Similarly, reporting CVA on either two or three measures as compared to not reporting any CVA was also associated with a significant increase in the likelihood of mood disorder diagnosis, OR=2.25, p=0.02. Conclusions Overall, these findings suggest that endorsement of childhood verbal abuse across multiple modes of assessment is associated with more severe depressive symptomatology, and a greater likelihood of having a mood disorder diagnosis. Furthermore, these data highlight the importance of multi-modal assessment of childhood verbal abuse in pre-bariatric patients for several reasons. Primarily, the likelihood of reporting abuse across measures was very similar, but lower than the overall endorsement rate, suggesting no differential sensitivity among the measures. Additionally, using at least two of the three measures led to an increase in prediction of depressive symptomatology above and beyond merely knowing whether the history was positive or negative for verbal abuse. Finally, the use of multi-modal assessment can help practitioners identify individuals with a high risk for depressive symptomatology, and thus, suicide. In clinical practice, it is likely unnecessary to evaluate childhood verbal abuse using more than two assessment strategies. If a practitioner does choose to evaluate maltreatment with two measures, the assessment may be most thorough if one of these measures is interview based, while another is a self-report questionnaire. While multiple measures of childhood abuse exist, we recommend using either the Childhood Trauma Questionnaire, which we use in our bariatric surgery program, or the Adverse Childhood Experiences Survey. However, if practitioners do not wish to use a formal selfreport measure of childhood abuse, these results suggest that a single item may be sufficient for each form of abuse (i.e., verbal, physical, and sexual). In this case, the Eating Disorders Questionnaire and Weight and Lifestyle Inventory, both commonly used in pre-surgical assessment, contain brief screeners for childhood abuse. For patients who report childhood verbal abuse, depressive symptomatology, or both, practitioners may want to assess OBES SURG symptoms of depression at post-surgical visits. Assessment of depression may also be improved through a multi-method approach, such as giving patients self-report questionnaires in addition to having a practitioner ask about current functioning. Commonly used self-report measures include the Patient Health Questionnaire, Beck Depression Inventory, and the Quick Inventory of Depressive Symptomatology. Overall, the identification of childhood verbal abuse as a significant correlate of depression is especially important in this population, as social desirability may lead bariatric patients to underreport current psychological symptoms. Postsurgical patients should be monitored closely in order to most successfully improve both physical and mental health. Furthermore, as the main aim of this study was to evaluate the necessity of multi-modal assessment of CVA in patients presenting for bariatric surgery, we were not interested in determining whether or not the relationships among CVA, depression, and obesity were causal. However, future studies should evaluate these connections using a prospective study design, in an effort to delineate temporal associations, and, thus, aid in preventive efforts. 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