OBES SURG (2011) 21:730–737 DOI 10.1007/s11695-010-0146-7 CLINICAL RESEARCH Psychiatric Disorders and Participation in Pre- and Postoperative Counselling Groups in Bariatric Surgery Patients Haldis Ø. Lier & Eva Biringer & Bjarte Stubhaug & Hege R. Eriksen & Tone Tangen Published online: 16 April 2010 # Springer Science+Business Media, LLC 2010 Abstract Background Psychological and behavioural factors seem to influence the results of bariatric surgery and the ability to achieve sustained weight loss and subjective wellbeing after the operation. Adequate pre- and postoperative psychological counselling are suggested to improve the results of surgery. However, some patients are reluctant to participate in pre- and postoperative counselling. The aim of the present study was to investigate the possible influence of psychiatric disorders on willingness to participate in group counselling in patients accepted for bariatric surgery. Methods One hundred and forty-one patients referred to bariatric surgery (F/M: 103/38) with mean body mass index (BMI) of 45.2 kg/m2 (SD=5.3) and mean age of 42.0 years (SD = 10.4) were interviewed with Mini International Neuropsychiatric Interview (M.I.N.I.) and Structured Clinical Interview (SCID-II) preoperatively. Results The overall prevalence of current psychiatric disorders was 49%. Thirty-one percent did not want to participate The study was supported by a grant from the Western Regional Health Authority, Norway. H. Ø. Lier (*) : E. Biringer : B. Stubhaug Section of Mental Health Research, Haugesund Hospital, Helse Fonna HF, P.O. Box 2170, 5504 Haugesund, Norway e-mail: haldis.johanne.oekland.lier@helse-fonna.no H. R. Eriksen HEMIL Research Centre for Health Promotion, Unifob Health, University of Bergen, Bergen, Norway B. Stubhaug : T. Tangen Section of Psychiatry, Institute of Clinical Medicine, University of Bergen, Bergen, Norway in counselling groups. Patients who were unwilling to participate in counselling groups had significantly higher prevalence of social phobia (32%/ 12%, p=0.006) and avoidant personality disorder (27%/ 12%, p=0.029) than patients who agreed to participate. Conclusions Psychiatric disorders are prevalent among candidates for bariatric surgery. Social phobia and avoidant personality disorder seem to influence the willingness to participate in counselling groups. Individual counselling and/or web-based counselling might be recommended for bariatric surgery patients who are reluctant to participate in group counselling. Keywords Bariatric surgery . Psychiatric disorders . Social phobia . Counselling Introduction Bariatric surgery is increasingly recommended as the treatment of choice for patients with severe obesity (BMI >40 or BMI>35 and a serious comorbid somatic condition) [1]. Bariatric surgery effectively reduces obesity and has a positive effect on related comorbid somatic conditions, psychosocial function and quality of life [1, 2]; but a significant proportion of the surgical patients have difficulty maintaining the weight loss after surgery [2, 3]. The prevalence of psychosocial distress is high in patients seeking bariatric surgery [4, 5], and several studies and reviews of studies have explored how psychosocial factors may predict weight loss, mental health and quality of life after surgery [6, 7]. Most studies [8–10], with some exceptions [11, 12], report increased rates of current and lifetime psychiatric disorders in individuals with obesity. Individuals seeking treatment for obesity have higher rates OBES SURG (2011) 21:730–737 of psychiatric comorbidity compared to individuals not seeking treatment [13, 14]. Psychiatric disorders may be associated with rigid patterns of thoughts and behaviour and consequently less ability to make pre- and postoperative lifestyle changes [15]. Patients with more than one presurgical psychiatric disorder are reported to have less weight loss than patients with no or only one psychiatric disorder at follow-up 50 months after surgery [16]. Lifetime psychiatric disorders are found to be associated with less weight loss 6 months after surgery [17]. Contradicting this, several studies found no association between psychiatric disorders and postoperative weight loss after surgery [7, 18]. Eating disorders are some of the most prevalent psychiatric disorders in the bariatric surgery patients [19]. Preoperative binge-eating disorder (BED) is associated with more disturbed eating patterns after surgery and less favourable outcome, including greater weight regain [20– 23] and preoperative emotional eating is also associated with less weight loss after surgery [24]. However, other studies have reported that patients with binge-eating disorder have the same weight loss as patients without eating disorder after bariatric surgery [25–27], if the patients are able to make lifestyle changes in preparation for surgery [27]. In summary, there is no consistent evidence that psychosocial variables like personality traits or psychiatric disorders predict postsurgical weight loss [28]. However, psychiatric comorbidity can be of predictive value for quality of life and mental and physical wellbeing after surgery [6, 7]. In accordance with this, many authors accept bariatric surgery in patients with psychiatric comorbidity, provided that there is adequate preoperative and postoperative support [18, 28–30]. Several studies emphasise the necessity for life style modification for all bariatric surgery patients [20, 31–33]. Coping skills, like active problem solving [34], healthy eating behaviours [35, 36] and regular exercise [32] are all predictors for weight-loss maintenance. Monitoring eating and exercise habits are recommended in the follow-up period [37]. Combinations of interventions, life style changes, drugs and surgery seems to be the most efficacious treatments to achieve long-term weight loss [38]. A recently published study demonstrates that a multimodal intervention approach, combining bariatric surgery, an intensive programme for lifestyle change, and regular consultations by an obesity specialist resulted in sustained weight loss, including reversing weight regain, improved quality of life and reduced comorbidity [39]. In this study, patient outcome was assessed using the Bariatric Analysis and Reporting Outcome System (BAROS) [40], with 60% of the patients reporting an overall BAROS result of good or higher. They also found a significant association between weight loss and number of consultations [39]. 731 There is a growing body of evidence indicating that effective treatment for severe obesity should include combinations of lifestyle and surgical approaches [38, 39]. The specific impact of preoperative counselling versus postoperative support programmes in improving the effectiveness of surgical obesity treatment still remain inconclusive. However, the beneficial effect of nonsurgical supportive interventions seems clear. A clinical implication of this would be to offer all patients programmes focusing on teaching skills and strategies for lifestyle changes in combination with surgery [34, 41]. There is some evidence that pre- and postoperative group counselling focusing on motivation for life style changes and improving coping skills can be useful also for patients with psychiatric comorbidity [42] and increase motivation and improve compliance with dietary and exercise guidelines [43]. Although one study finds that 40% of the bariatric surgery patients are receiving psychiatric treatment, it seems reasonable to assume that such treatment is focused on psychiatric disorders; weight-control strategies are not necessarily integrated in such treatment [19]. To our knowledge, there are no studies that explore the influence of psychiatric disorders on the willingness to participate in counselling groups for patients with obesity being candidates for bariatric surgery. Aims of the Study The aims of the present study were to examine the prevalence of psychiatric disorders in patients with obesity prior to bariatric surgery, and to investigate whether the presence of comorbid psychiatric disorders influenced their willingness to participate in counselling groups. Method Study Population One hundred and forty-one patients participated in the study. A total of 169 patients with obesity were screened for participation in the study. They were all referred from general practitioners (GPs) to the Department of Surgery at Haugesund Hospital at the West coast of Norway. This region includes both urban and rural areas. Procedures for recruitment, screening and inclusion of participants are shown in Fig. 1. A total of 150 patients had a psychiatric assessment (19 patients were excluded; psychiatric assessment not relevant (n=16), did not meet for psychiatric assessment (n=3)). Two patients refused to participate in the study and three patients retracted their consent. Descriptively, mean age was higher in the patients who refused to participate compared to the study population 732 OBES SURG (2011) 21:730–737 Fig. 1 Flow chart describing procedure and number of participation during referral, screening and inclusion (56.4 vs. 42.0 years), there was no difference in female/ male ratio or in BMI. A total of 141 patients were included. Of these, 122 (87%) filled-in the self-report questionnaires. Two of the 141 patients did not fulfil the general criteria for bariatric surgery of a BMI >40 or BMI >35 with significant somatic comorbidity; they were, however, still accepted for surgery and included in the present study. Exclusion criteria were severe psychopathology (psychotic disorder, severe mood disorder), severe eating disorder, risk of suicidal behaviour, severe substance abuse or severe cognitive dysfunction, all based on clinical judgment. Four patients, three women and one man (with mean age 51.0 years), were excluded from this study due to severe mood disorder and severe eating disorder. The patients were receiving inadequate clinical treatment, and we recommend more adequate treatment for these disorders before surgery. All included patients were invited to participate in preand postoperative counselling groups aiming at improving coping skills to initiate and maintain life-style changes. Ninety-seven patients (69%) accepted to participate in counselling groups (Intervention group). Of these, seven patients did not meet for intervention. These patients are included in the analyses. Forty-four patients (31%) did not want to participate in counselling groups (Reference group). Assessment Psychiatric assessment was required as a part of the preoperative evaluation process for bariatric surgery and was conducted at the hospital approximately 4 months prior to scheduled surgery. The participants had a full psychiatric evaluation by an experienced psychiatrist (HØL), who also is trained to use the structured interviews. The evaluation lasted about 2 h and included structured psychiatric interviews, clinical assessment and assessment of psychosocial factors. The instruments selected are widely used, well validated, with solid psychometric properties, and they are acknowledged as tools in clinical and research contexts. The diagnostic interviews’ standardised method where symptoms are used to generate diagnosis was applied, and there was no use of other diagnostic algorithms. Further, the diagnostic process was discussed in a consensus meeting with members of the research group, comprising one psychologist and two psychiatrists. The mood and anxiety OBES SURG (2011) 21:730–737 diagnoses were supported by self reports of depression and anxiety symptoms. 733 & Instruments Current and lifetime DSM-IV axis I diagnoses (clinical syndromes) [44] were assessed with the MINI International Neuropsychiatric Interview for DSM-IV (M.I.N.I. Norwegian version 5.0.0) [45, 46]. Reliability, sensitivity and validity were explored in a clinical population in a comparison with the Composite International Diagnostic Interview (CIDI) and against the Structured Clinical Interview for DSM-IV (SCID-P) [45, 46]. The performance of the MINI was equivalent to the two others. It has been widely used and is translated to many languages [45]. Axis II personality disorders [44] were assessed with a Norwegian revised and shortened form of the Structured Clinical Interview for DSM-IV axis II disorders (SCID-II) [47]. SCID-II is widely used and has good diagnostic reliability [48]. The assessment of binge-eating disorder was done using a clinical checklist based on the DSM-IV research criteria [49]. The Beck Depression Inventory, Second Edition (BDIII) is a 21-item self-report questionnaire, was used to measure depressive symptoms over the previous 2 weeks. The BDI has well-established psychometric properties, and is considered to be a valid and reliable screening tool for depression [50, 51]. The cut-offs for severity of depression are: normal <10, mild depression 10 to 18, moderate depression 19 to 29, and severe depression >30 [51]. The Beck Anxiety Inventory (BAI) is a 21-item selfreport questionnaire. Each item is descriptive of subjective, somatic or panic-related symptoms of anxiety, and the cutoffs for severity of anxiety are: normal <7, mild anxiety 8 to 15, moderate anxiety 16 to 25, and severe anxiety >26 [52, 53]. Several studies have supported the reliability and validity of this instrument [54]. Group Counselling The counselling consisted of one group session every week for 6 weeks preoperatively, and three postoperative sessions (at 6 months, 1 year and 2 years after surgery). Each session lasted 3 h. Each group had six to ten participants, and a total of five groups went through the programme. In each group, a team comprising of a psychiatrist, a psychologist and a physiotherapist performed the intervention. Main components of the treatment were: & & Information about bariatric surgery and appropriate behaviour change; eating and physical exercise Mindfulness training, focusing on stress reduction techniques; breathing and yoga & Introduction of self-monitoring procedures for eating, physical activity, and mindfulness training. Real-time self monitoring of eating behaviour is initiated from the beginning of counselling, and is continued throughout treatment. Problem-solving skills and cognitive restructuring techniques The patients in the Reference group (n=44, 31%) had no intervention (Fig. 1) Statistical Methods SPSS 15.0 for Windows was used for the statistical analyses. Group comparisons between the Intervention and Reference groups with regard to psychiatric disorders and demographic data were performed using Pearson’s Chisquare Test and Student’s t test for independent samples. Tests were two-tailed with α-level 0.05. Ethical Issues All participants provided written informed consent prior to assessment. The study was approved by the Regional Committee for Medical and Health Research Ethics and the Norwegian Social Science Data Services (NSD). The trial was registered at www.clinicaltrials.gov prior to patient inclusion. The study was performed in accordance with The Helsinki Declaration of the World Medical Association Assembly. Results Demographic and clinical characteristics of the entire study population are reported in Table 1. Of the patients, 103 (73%) were females and 38 (27%) males, mean age 42 years (range 22–65, SD=10.4), and mean BMI 45.2 kg/m2 (range 33.4–64.6, SD=5.3). There were no significant differences between the Intervention group and the Reference group with regards to age, gender, BMI, work status or education. Prevalence of Psychiatric Disorders Sixty-one patients (43%) fulfilled the diagnostic criteria for at least one current Axis I disorder (clinical syndromes) and 73 (52%) for at least one lifetime Axis I disorder. Mood-, anxiety- and eating disorders were the most prevalent diagnoses, while substance use disorders were rare (n=2, 1.4%). Twenty-six (18%) patients were diagnosed with social phobia, 24 (18%) with dysthymic disorder, 16 (11%) with agoraphobia without panic disorder, and 16 (11%) with a current eating disorder. Of the patients with a current 734 OBES SURG (2011) 21:730–737 Table 1 Demographic and clinical characteristics of 141 candidates for bariatric surgery Age (years) BMI, kg/m2 Gender, female Education (N=135) <10 years 10-13 years >13 years Work status (N=134) Employed Pensiona Other a Study population (N=141) Intervention group (N=97) Reference group (N=44) Mean SD Range Mean SD Range Mean SD Range 42.0 45.2 10.4 5.3 22–65 33.4–64.6 43.0 45.3 10.1 5.1 23–65 33.4–64.6 39.8 44.8 10.7 5.6 22–60 34.5–60.0 N (%) 103 (73) N (%) 68 (70) N (%) 35 (79.5) 45 (33) 66 (49) 24 (18) 30 (32) 49 (53) 14 (15) 15 (36) 17 (41) 10 (24) 78 (58) 52 (39) 4 (3) 56 (61) 33 (36) 3 (3) 22 (52) 19 (45) 1 (2) Pension includes sick leave, disability pension, social economic support eating disorder, one (1%) fulfilled diagnostic criteria for bulimia nervosa (BN), 10 (7%) fulfilled the DSM-IV diagnostic criteria for binge-eating disorder, and five (4%) fulfilled the Oxford criteria for BED (i.e. requiring one objective bulimic episode per week during the last 3 months; Table 2). Patients with a current mood disorder had a mean BDI-II score of 19.3 (range 3–43, SD=10.9) representing mild to moderate depression, mean BDI-II score in the whole study group was 11.3 (range 0–43, SD= 9.8). Patients with current anxiety disorder had a mean BAI score of 14.2 (range 0–44, SD=13.5) representing mild symptoms of anxiety, mean BAI score in the whole study group was 8.2 (range 0–44, SD=8.2). There were no significant gender differences in the prevalence of psychiatric disorders. Thirty-six patients (26%) met criteria for at least one personality (Axis II) disorder. Avoidant personality disorder was the most prevalent personality disorder (n=24.17%; Table 2). Information regarding lifetime and current psychiatric treatment was obtained from 123 (87%) of the participants. Fourteen patients (11%) reported that they currently received psychiatric treatment, 59 patients (48%) had received psychiatric treatment in the past and 24 patients (21%) used psychiatric medication at the time of assessment. Participation in Group Counselling There were no significant differences in the overall prevalence of current psychiatric disorders between the two groups (Table 3).The prevalence rates of social phobia and avoidant personality disorder were significantly higher Table 2 Current and lifetime Axis I and Axis II psychiatric diagnosis in candidates for bariatric surgery Study population (N=141) Mood disorders Major depressive disorder Dysthymic disorder Lifetime mood disorder Bipolar I or bipolar II lifetime Anxiety disorder Panic disorder Agoraphobia without panic Social phobia OCD PTSD Generalised anxiety disorder Lifetime panic disorder disorder Substance use disorder Eating disorders Personality disorders (Axis II) Paranoid Schizoid Schizotypal Antisocial Borderline Histrionic, narcissistic Avoidant Dependent Obsessive compulsive N % 95 % CI 10 24 65 3 7.1 17.0 46.1 2.1 2.85; 10.82; 37.87; −0.25; 8 16 26 2 2 6 5.7 11.3 18.4 1.4 1.4 4.3 18.5; 9.49 6.11; 16.59 12.04; 24.84 −0.53; 3.37 −0.53; 3.37 0.93; 7.59 17 2 16 12.1 1.4 11.3 6.68; 17.44 −0.3; 3.37 6.11; 16.59 8 1 0 2 5 0 24 1 7 5.7 0.7 0 1.4 3.5 0 17.0 0.7 5.0 1.85; 9.49 −0.68; 2.1 11.33 23.22 54.33 4.51 −0.53; 3.37 0.50; 6.60 10.82; 23.22 −0.68; 2.1 1.38; 8.54 OBES SURG (2011) 21:730–737 735 Table 3 Comparison of comorbid psychiatric diagnosis in the sub-group that did/ did not accept participation in counselling groups Axis I: Mood disorders Major depressive disorder Dysthymic disorder Lifetime mood disorder Anxiety disorders Agoraphobia without panic disorder Social phobia Lifetime panic disorder Eating disorder Binge-eating disorder Axis II: Cluster C Avoidant a Pa Study population N=141 Intervention group N=97 Reference group N=44 N % 95% CI N % 95% CI N % 95% CI 10 24 65 7.1 17.0 46.1 2.85;11.33 10.82;23.22 37.87;54.33 7 17 44 7.2 17.5 45.4 2.07;12.37 9.96;25.10 35.45;55.27 3 7 21 6.8 15.9 47.7 −0.63;14.27 5.10;26.72 32.97;62.49 0.932 0.793 0.936 16 26 17 11.3 18.4 12.1 6.11;16.59 12.04;24.84 6.68;17.44 10 12 14 10.3 12.4 14.4 4.26;16.36 5.82;18.92 7.44;21.42 6 14 3 13.6 31.8 6.8 3.5;23.78 18.06;45.58 −0.63;14.27 0.56 0.006 0.198 10 7.1 2.85;11.33 8 8.2 2.77;13.73 2 4.5 −1.61;10.71 0.428 24 17.0 10.82;23.22 12 12.4 5.82;18.92 12 27.3 14.11;40.43 0.029 Group comparison: Pearson Chi-Square test in the Reference group than in the Intervention group (32/ 12%, p=.006 and 27/12%, p=.029 respectively; Table 3). In the intervention group, nine patients (10%) were currently receiving psychiatric treatment and 17 patients (20%) used psychiatric medication; and in the reference group, four patients (11%) received treatment and ten patients (28%) used psychiatric medication. Discussion In this study, 43% of patients with obesity had a current Axis I psychiatric disorder and 26% an Axis II personality disorder. The most prevalent diagnoses were social phobia, dysthymic disorder, and avoidant personality disorder. About 30% of the bariatric surgery patients refused to participate in a pre- and postoperative counselling group, and the prevalence rates of social phobia and avoidant personality disorder were significantly higher in this group than among the patients willing to participate. The prevalence of psychiatric disorders in this study was high compared to studies based on community samples and epidemiological surveys [55–57] and several other studies of bariatric surgery patients [10, 11, 58]. Compared to a study by Kalarchian et al. [10], our study showed descriptively higher prevalence rates of current mood disorders (24.1% vs. 15.6%) and anxiety disorders (29.8% vs. 24.0%), while the prevalence rates for lifetime mood disorder and personality disorders were similar. Compared to two other studies of bariatric surgery patients [11, 58], our study showed higher prevalence of both lifetime and current Axis I disorders. A total prevalence of eating disorders of 11% in our study is comparable to other studies using interview-based diagnoses (16% [10], 10% [11] and 7% [58]). Studies where psychiatric diagnoses are based on self report and clinical assessment without using structured interview-based diagnoses, typically find higher prevalence rates for psychiatric diagnoses. In a study by Sarwer et al., 62% of the patients received at least one psychiatric diagnosis, 31% a current major depressive disorder, and 28% a current eating disorder [19]. In the present study, patients with a current mood disorder scored descriptively higher on the BDI-II, compared to other studies of both adults and adolescents waiting for bariatric surgery (19.3 vs. 13.2 [59], 10.4 [60], 14.6 [61] and 15.2 [62]). However, the mean BDI-II score of 11.3 in the entire study population was comparable to the results in the studies mentioned. In the study by Sarwer et al., patients with a psychiatric disorder scored 19.5 on BDI [19]. There are no obvious differences in methods, study population or diagnostic procedures that can explain the higher prevalence of Axis I disorders in the present study compared to the three studies using interview-based diagnoses [10, 11, 58]. However, there may be a selection bias of patients in our study. Bariatric surgery is a new treatment option in the area where the study was conducted, and the availability for surgery is limited. Patients with obesity and psychiatric comorbidity more often seek treatment for their obesity compared to patients without psychiatric comorbidity [13, 14]. Consequently, referral to bariatric surgery might be more common in patients with psychiatric disorders. 736 The prevalence rates of social phobia and avoidant personality disorder were significantly higher in the group of patients who refused to participate in a pre- and postoperative counselling group compared to those who were willing to participate. In a study of patients with social phobia comparing individual therapy to group therapy, about 16% of the participants allocated to group treatment refused to participate, because they found it too stressful to expose themselves to group settings [63]. The finding in the present study may indicate a need for individually adapted weight- management interventions for those with social phobia and avoidant personality disorder. For these patients, individual counselling or web-based counselling programmes may be more suitable and acceptable. Alternatively, the patients with social phobia may be offered treatment for their anxiety disorder before the group counselling programme. Social phobia and avoidant personality disorder should not be considered as a contraindication to bariatric surgery, but the pre- and postoperative counselling offered to these patients should be adjusted to their special needs. In a review paper published in 2009, Allison et al. pointed out that there are few studies that have tested or adapted weight-control strategies for those with mental disorders [64]. One study found that more than a half of the patients with comorbid psychiatric disorders, waiting for bariatric surgery, were receiving some form of psychiatric treatment. However, the psychiatric treatment was not always optimal and many patients were in need for additional preoperative psychiatric treatment [19]. Another implication of the main finding in our study, that subgroups of patients tend to avoid parts of a clinical programme, should lead to caution in interpreting results of combined interventions, due to selection bias. Conclusion There was a high prevalence of comorbid psychiatric disorders in patients referred to bariatric surgery. Patients who refused to participate in pre- and postoperative counselling groups showed higher prevalence of social phobia and avoidant personality disorder compared to patients who accepted to participate in such groups. Further research in this field should examine the influence of psychosocial factors as predictors of long-term outcome after bariatric surgery and the impact of psychological counselling and lifestyle programmes in enhancing effectiveness of surgical treatment. Acknowledgement The authors thank Oddbjørn Hove (PhD) at Section of Mental Health Research, Haugesund Hospital for help with preparing the manuscript. OBES SURG (2011) 21:730–737 Conflict of interest statement The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper. References 1. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292:1724–37. 2. Karlsson J, Taft C, Ryder A, et al. Ten-year trends in health-related quality of life after surgical and conventional treatment for severe obesity: the SOS intervention study. Int J Obes. 2007;31:1248–61. 3. Benotti PN, Forse RA. The role of gastric surgery in the multidisciplinary management of severe obesity. Am J Surg. 1995;169:361–7. 4. de Zwaan M, Lancaster KL, Mitchell JE, et al. Health-related quality of life in morbidly obese patients: effect of gastric bypass surgery. Obes Surg. 2002;12:773–80. 5. Clark MM, Balsiger BM, Sletten CD, et al. Psychosocial factors and 2-year outcome following bariatric surgery for weight loss. Obes Surg. 2003;13:739–45. 6. van Hout GCM, Hagendoren CAJ, Verschure SKM, et al. Psychosocial predictors of success after vertical banded gastroplasty. Obes Surg. 2009;19:701–7. 7. Herpertz S, Kielman R, Wolf AM, et al. Do psychosocial variables predict weight loss or mental health after obesity surgery? a systematic review. Obes Res. 2004;12:1554–69. 8. Heo M, Pietrobelli A, Fontaine K, et al. Depressive mood and obesity in US adults: comparison and moderation by sex, age, and race. Int J Obes. 2006;30:513–9. 9. Scott KM, McGee MA, Wells JE, et al. Obesity and mental disorders in the adult general population. J Psychosom Res. 2008;64:97–105. 10. Kalarchian MA, Marcus MD, Levine MD, et al. Psychiatric disorders among bariatric surgery candidates: relationship to obesity and functional health status. Am J Psychiatry. 2007;164:328–34. 11. Rosenberger P, Henderson KE, Grilo CM. Psychiatric disorder comorbidity and association with eating disorders in bariatric surgery patients: a cross -sectional study using structured interview-based diagnosis. J Clin Psychiatry. 2006;67:1080–5. 12. Stunkard AJ, Wadden TA. Psychological aspects of severe obesity. Am J Clin Nutr. 1992;55(2 Suppl):524S–32S. 13. Fitzgibbon ML, Stolley MR, Kirschenbaum DS. Obese people who seek treatment have different characteristics than those who do not seek treatment. Health Psychol. 1993;12:342–5. 14. Higgs ML, Wade T, Cesato M, et al. Differences between treatment seekers in an obese population: medical intervention vs. dietary restriction. J Behav Med. 1997;20:391–405. 15. Guisado JA, Vaz FJ. Personality profiles of the morbidly obese after vertical banded gastroplasty. Obes Surg. 2003;13:394–8. 16. Kinzl JF, Schrattenecker M, Traweger C, et al. Psychosocial predictors of weight loss after bariatric surgery. Obes Surg. 2006;16: 1609–14. 17. Kalarchian MA, Marcus MD, Levine MD, et al. Relationship of psychiatric disorders to 6-month outcomes after gastric bypass. Surg Obes Relat Dis. 2008;4:544–9. 18. Black DW, Goldstein RB, Mason EE, et al. Psychiatric diagnosis and weight loss following gastric surgery for obesity. Obes Surg. 2003;13:746–51. 19. Sarwer DB, Cohn NI, Gibbons LM, et al. Psychiatric diagnoses and psychiatric treatment among bariatric surgery candidates. Obes Surg. 2004;14:1148–56. 20. Colles SL, Dixon JB, O’Brien PE, et al. Grazing and loss of control related to eating: two high-risk factors following bariatric surgery. Obesity. 2008;16:615–22. OBES SURG (2011) 21:730–737 21. Niego SH, Kofman MD, Weiss JJ, et al. Binge eating in the bariatric surgery population: a review of the literature. Int J Eat Disord. 2007;40:349–59. 22. Saunders R. “Grazing”: a high-risk behavior. Obes Surg. 2004;14: 98–102. 23. de Zwaan M, Hilbert A, Swan-Kremeier L, et al. Comprehensive interview assessment of eating behavior 18-35 months after gastric bypass surgery for morbid obesity. Surg Obes Relat Diseas. 2009 Sep 3 [Epub ahead of print]. 24. Canetti L, Berry EM, Elizur Y. Psychosocial predictors of weight loss and psychological adjustment following bariatric surgery and a weight-loss program: the mediating role of emotional eating. Int J Eat Disord. 2009;42:109–17. 25. Busetto L, Segato G, De Luca M, et al. Weight loss and postoperative complications in morbidly obese patients with binge eating disorder treated by laparoscopic adjustable gastric banding. Obes Surg. 2005;15:195–201. 26. Kalarchian MA, Wilson GT, Brolin RE, et al. Effects of bariatric surgery on binge eating and related psychopathology. Eat Weight Disord. 1999;4:1–5. 27. Alger-Mayer S, Rosati C, Polimeni JM, et al. Preoperative binge eating status and gastric bypass surgery: a long-term outcome study. Obes Surg. 2009;19:139–45. 28. van Hout GCM, Verschure SKM, van Heck GL. Psychosocial predictors of success following bariatric surgery. Obes Surg. 2005;15:552–60. 29. Buddeberg-Fischer B, Klaghofer R, Sigrist S, et al. Impact of psychosocial stress and symptoms on indication for bariatric surgery and outcome in morbidly obese patients. Obes Surg. 2004;14:361–9. 30. Dziurowicz-Kozlowska AH, Wierzbicki Z, Lisik W, et al. The objective of psychological evaluation in the process of qualifying candidates for bariatric surgery. Obes Surg. 2006;16:196–202. 31. Welch G, Wesolovski C, Piepul B, et al. Physical activity predicts weight loss following gastric bypass surgery: findings from a support group survey. Obes Surg. 2008;18:517–24. 32. Silver HJ, Torquati A, Jensen GL, et al. Weight, dietary and physical activity behaviors two years after gastric bypass. Obes Surg. 2006;16:859–64. 33. Dixon JB, Laurie CP, Anderson ML, et al. Motivation, readiness to change, and weight loss following adjustable gastric band surgery. Obesity. 2009;17:698–705. 34. Lanyon RI, Maxwell BM, Kraft AJ, et al. Prediction of long-term outcome after gastric bypass surgery. Obes Surg. 2009;19:439–45. 35. Faria SL, Kelly EO, Faria OP, et al. Snack-eating patients experience lesser weight loss after Roux-en-Y gastric bypass surgery. Obes Surg. 2009;19:1293–6. 36. Faria SL, Faria OP, Lopes TC, et al. Relation between carbohydrate intake and weight loss after bariatric surgery. Obes Surg. 2009;19:708–16. 37. Marcus MD, Kalarchian MA, Courcoulas AP, et al. Psychiatric evaluation and follow-up of bariatric surgery patients. Am J Psychiatry. 2009;166:285–91. 38. Powell LH, Calcin JE, Calcin JE Jr, et al. Effective obesity treatments. Am Psychol. 2007;62:234–46. 39. Steffen R, Potoczna N, Bieri N, et al. Successful multiintervention treatment of severe obesity: a 7-year prospective study with 96% follow-up. Obes Surg. 2009;19:3–12. 40. Oria HE, Moorehead MK. Bariatric analysis and reporting outcome system (BAROS). Obes Surg. 1998;8:487–99. 41. Batsis JA, Clark MM, Grothe K, et al. Self-efficacy after bariatric surgery for obesity. A population-based cohort study. Appetite. 2009;52:637–45. 42. Wild B, Herzog W, Wesche D, et al. Development of a group therapy to enhance treatment motivation and decision making in View publication stats 737 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. severely obese patients with a comorbid mental disorder. Obes Surg. 2009 Dec 1 [Epub ahead of print]. Kreft JS, Montebelo J, Fogaca KC, et al. Gastric bypass: postoperative complications in individuals with and without preoperative dietary guidance. J Eval Clin Pract. 2008;14:169–71. American Psychiatric Assosiation. Diagnostic and statistical manual of mental disorders. Washington DC: American Psychiatric Association; 1994. Author. Lecrubier Y, Sheehan D, Hergueta T, et al. The mini international neuropsychiatric interview. Eur Psychiatr. 1998;13:198s. Sheehan DV, Lecrubier Y, Harnett-Sheehan K, et al. The Mini International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview. J Clin Psychiatr. 1998;59:22–33. First MB, Gibbon M, Spitzer RL, et al. Structured clinical interview for DSM-IV axis II personality. Biometrics research. New York, NY: New York State Psychiatric Institute; 1997. First MB, Gibbon M, Spitzer RL, et al. User’s guide for the structured clinical interview for DSM-IV Axis II personality disorders [SCID-II]. American Psychiatric Press; 1997. Nangle DW, Johnson WG, Carr-Nangle RE, et al. Binge eating disorder and the proposed DSM-IV criteria: psychometric analysis of the Questionnaire of Eating and Weight Patterns. Int J Eat Disord. 1994;16:147–57. Beck AT, Steer RA, Brown GK. Manual for Beck Depression Inventory—II. San Antonio, TX: Psychological Corp; 1996. Dozois DJA, Dobson KS, Ahnberg JL. A psychometric evaluation of the Beck Depression Inventory-II. Psychol Assess. 1998;10:83–9. Beck AT, Epstein N, Brown G, et al. An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol. 1988;56:893–7. Beck AT, Steer RA. Beck Anxiety Inventory Manual. San Antonio: The Psychology Corporation, Harcourt Brace; 1993. Fydrich T, Dowdall D, Chambless DL. Reliability and validity of the Beck Anxiety Inventory. J Anxiety Disord. 1992;6:55–61. Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62: 617–27. Kringlen E, Torgersen S, Cramer V. A Norwegian psychiatric epidemiological study. Am J Psychiatry. 2001;158:1091–8. Kringlen E, Torgersen S, Cramer V. Mental illness in a rural area: a Norwegian psychiatric epidemiological study. Soc Psychiatry Psychiatr Epidemiol. 2006;41:713–9. Mauri M, Rucci P, Calderone A, et al. Axis I and II disorders and quality of life in bariatric surgery candidates. J Clin Psychiatry. 2008;69:295–301. Wadden TA, Butryn ML, Sarwer DB, et al. Comparison of psychosocial status in treatment-seeking women with class III vs. class I–II obesity. Obesity. 2006;14 Suppl 2:90S–8S. Kim RJ, Langer JM, Baker AW, et al. Psychosocial status in adolescents undergoing bariatric surgery. Obes Surg. 2008;18:27– 33. Zeller MH, Roehrig HR, Modi AC, et al. Health-related quality of life and depressive symptoms in adolescents with extreme obesity presenting for bariatric surgery. Pediatrics. 2006;117:1155–61. Zeller MH, Modi AC, Noll JG, et al. Psychosocial functioning improves following adolescent bariatric surgery. Obesity. 2009; 17:985–90. Stangier U, Heidenreich T, Peitz M, et al. Cognitive therapy for social phobia: individual versus group treatment. Behav Res Ther. 2003;41:991–1007. Allison DB, Newcomer JW, Dunn AL, et al. Obesity among those with mental disorders: a National Institute of Mental Health meeting report. Am J Prev Med. 2009;36:341–50.