This study’s principal finding was that, among bariatric surgery candidates determined to have BED, over 40% also were diagnosed with a current mood or anxiety disorder. The rates of these disorders were significantly higher in BED than non-BED participants. The most common current condition was major depressive disorder, diagnosed in 27% of patients with BED. BED participants also were significantly more likely than individuals without BED to have a lifetime history of mood and anxiety disorders. Major depression was again the most common mood disorder, whereas the most frequent anxiety disorders were panic disorder (without agoraphobia), post-traumatic stress disorder, social phobia, and specific phobia.
The present findings of increased psychopathology in the presence of BED, obtained using criteria for BED proposed for DSM-5, are consistent with studies of volunteers in community samples [10
], as well as of overweight and obese individuals assessed in clinical settings [12
]. Our findings also agree with those of Rosenberger et al [7
], who evaluated Axis I disorders in 174 consecutive bariatric surgery candidates. In the 24 patients (13.8%) diagnosed with an eating disorder, 66.7% met criteria for a current Axis I diagnosis, compared with only 26.7% of those who were free of an eating disorder. Our results suggest that prior studies that failed to observe greater depression and anxiety in severely obese individuals with BED were either underpowered (potentially because of small sample sizes) or used suboptimal methods (e.g., self-report questionnaires) to diagnose BED and other psychopathology [3
]. Severe obesity (i.e., class III) clearly is associated with a greater risk of major depression and other psychopathology than are lesser degrees of adiposity [39
]. The presence of BED, however, appears to be associated with a further increase in this elevated risk.
The present findings do not address the question of whether BED is associated with suboptimal short- or long-term weight loss following bariatric surgery [40
] or whether surgery candidates should receive treatment (e.g., cognitive behavioral therapy) prior to surgery to reduce problem eating [42
]. These are critical issues that require further study. Our results, however, confirm that BED is a marker of depression, anxiety, and other psychosocial problems [27
]. The pre-surgical psychosocial assessment provides mental health professionals an opportunity to identify and facilitate the treatment of psychiatric conditions in bariatric surgery candidates [45
]. The amelioration of patient suffering - from depression, anxiety, and other conditions - is a critical objective in itself, regardless of whether the preoperative amelioration of psychopathology improves the outcome of bariatric surgery [46
We had expected surgical candidates with BED, compared to those without, to report greater dissatisfaction with their weight, shape, and overall appearance. However, the two groups did not differ significantly on these measures, potentially because of a floor effect. Both groups reported the greatest possible dissatisfaction with their weight and shape, with average scores of 1.1 and 1.3, measured on a scale of 1 to 7, on which 1 represents very dissatisfied. This finding suggests that all surgery candidates who have a BMI of approximately 50 kg/m2
are likely to be very dissatisfied with their weight, regardless of their overall psychological functioning. There also were no significant differences between BED and non-BED groups in the amount of weight they desired to lose with surgery. Both groups wished to lose about 55 kg from a starting weight of 140 kg, equal to about a 40% reduction in initial weight. A weight loss of this magnitude only modestly exceeds the 35% mean loss that is produced by Roux-en-Y gastric bypass 18 to 24 months postoperatively [47
]. Both BED and non-BED participants also appeared to realize that they would remain obese after surgery. If they obtained their desired post-surgical losses, both groups were calculated to have a BMI of 30 kg/m2
. These data suggest that extremely obese patients who seek gastric bypass surgery have generally reasonable weight loss goals. These goals, however, must be tempered in individuals who seek laparoscopic adjustable banding, which produces a mean loss of approximately 20% of initial weight at 2 years post-surgery [48
This study’s strengths included its use of rigorous measures to identify groups of patients with and without BED, who then completed a SCID. Limitations included the inability to determine whether participants who were diagnosed with BED, but failed to complete the SCID, differed in psychopathology from those who completed the interview. In addition, the investigation may have been vulnerable to participants’ selectively underreporting some aspects of their psychiatric status because they were aware that their psychosocial fitness for bariatric surgery was being evaluated. Thus, for example, few participants reported a current substance use disorder. Fabricatore et al have described the potential for such “impression management” in bariatric surgery candidates [50
]. The study also would have been strengthened by examining Axis II disorders.
In summary, this study underscores the benefit of assessing BED in patients with extreme obesity who seek bariatric surgery. This disorder can be evaluated in a non-threatening, conversational manner while inquiring about patients’ eating habits. The presence of BED would appear to signal the need for more thorough assessment of psychiatric status and the likelihood of a clinically significant mood or anxiety disorder that could be ameliorated with psychiatric care. Weight reduction alone cannot be expected to fully alleviate the suffering associated with mental health disorders.