Introduction

Metabolic and bariatric surgery is a safe and medically effective treatment choice for severe obesity. Yet, despite (1) an increase in the number of MBS procedures performed in the United States annually over the past decade and (2) the fact that many people express interest in MBS, voluntarily attend MBS information sessions, and schedule initial MBS appointments, only about 50% of referred or eligible persons for MBS complete the procedure [1]. Furthermore, studies have documented Hispanics and non-Hispanic Blacks (NHB) are significantly less likely than non-Hispanic Whites (NHW) to complete MBS despite having higher rates of both severe obesity and obesity-related comorbidities (e.g., type 2 diabetes and heart disease), yet the underlying causes of MBS completion disparities remain understudied [1]. Barriers including lack of knowledge of MBS health benefits as well as fears of complications and the procedure itself have been identified in studies [2,3,4,5] while others have shown lack of insurance as a plausible barrier [3, 6, 7].

Intrapersonal barriers to MBS completion may include anxiety related disorders, which have been studied among those considering MBS [8, 9]. One study showed that anxiety was a predictor of MBS non-completion while others have shown depression and anxiety are common psychological disorders associated with those with obesity and considering MBS [10,11,12]. Other studies also suggest that mental health may be a predictor of completing MBS [11, 13]. While several previous studies have used the Structured Clinical Interview for DSM Disorders (SCID) to assess mental disorders among MBS patients [14,15,16,17,18,19], including the current team [17] the Mini International Neuropsychiatric Interview (MINI) tool has also been used in previous studies as a standardized, reliable measure to predict weight loss and quality of life post-MBS and to assess past or current psychiatric disorders such as depression and anxiety [20,21,22,23,24,25].

To date, there have been very limited studies examining how the presence of mental health conditions are associated with the decision to complete MBS and especially among racially and ethnically diverse patients. Therefore, the objective of this study was to determine whether a history of depression and anxiety as individual or concurrent conditions were associated with MBS completion using the MINI tool. A secondary aim was to determine if there were sex or ethnic differences in the prevalence of anxiety, depression history, or both among MBS completers versus non-completers. It was hypothesized that those with a history of concurrent anxiety and depression would be less likely to follow through with MBS completion regardless of race, ethnicity, or sex.

Methods

Study Design and Population

This is a prospective cohort study (The Bariatric Health Study) that has recruited patients considering MBS (NIH/NIMHD 5R01MD011686). Patients with obesity were recruited through clinics that specialize in MBS or weight management in the Texas geographical area, as well as through social media due to the COVID-19 pandemic. The recruitment sites for the Bariatric Health Study included Minimally Invasive Surgical Associates, Lee Bariatrics clinic, City Hospital at White Rock, Dallas, TX, and UT Southwestern Medical Center’s Division of Endocrinology’s Wellness Program of Internal Medicine Sub-Specialties Clinic. Eligibility criteria included being at least 18 years of age and eligible for MBS as determined by a medical provider.

This study is currently evaluating socioecological predictors of both MBS completion and post MBS weight loss and cardiometabolic disease resolution. The analysis reported here was only focused on the pre-MBS anxiety and/or depression as possible predictors of the decision to complete MBS, and how this varied by sex and ethnicity.

Study Procedures and Recruitment

Pre-COVID-19 Recruitment

Eligible patients completed a mandatory educational seminar prior to the scheduling of surgery. At these seminars, MBS team members (surgeon, lead clinical coordinator, and dietician) discussed topics regarding obesity and MBS such as eligibility, lifestyle changes before and after MBS, risks, and expected results. Participant recruitment for the study started in August 2019 and ended in October 2022 with 6-month, one-year, and two-year follow-up assessments ongoing. The first MBS procedure among the participants was performed on September 2019. Participants who had MBS after December 2022 were not included in the study. Study coordinators recruited patients to the current study during these seminars by providing detailed information and sign-up sheets. Additionally, clinical recruitment strategies included the use of IRB-approved flyers and brochures that were posted in waiting room areas. Interested participants completed an online consent form to participate in the study. Once the consent was completed, participants completed a structured interview via in person, by phone or web conference that included a battery of validated instruments to assess various socioecological predictors of MBS completion.

Post COVID-19 Recruitment

Due to the COVID-19 pandemic, in March 2022, participant recruitment changed to virtual recruitment where clinics sent to research coordinator participants’ information who had completed MBS seminars. All interviews were conducted virtually, as in-person interviews were not permitted. Additionally, the pre-pandemic clinic recruitment flyers were shared via social media. The study was approved by the University of Texas Health System Institutional review board (IRB# HSC-SPH-18-0850).

Measures

Study Interview

The first component of the interview consisted of the Mini International Neuropsychiatric Interview (MINI) [25], a standardized validated measure designed to assess major psychiatric disorders through dichotomous questions with follow-up structured interviews for positive responses. Study coordinators were trained by a faculty psychiatrist on MINI implementation. The MINI interview questions mostly include ‘yes’ or ‘no’ responses. Examples are provided to participants to further describe the questions. Once all questions are asked for each psychiatric disorder, the number of yes or no responses are counted to determine the disorder that aligns with the responses provided by participant. For this study, the following psychiatric disorders were assessed: major depressive episode (current, past, and recurrent), PTSD, agoraphobia, social anxiety, general anxiety, and panic disorder. The MINI interview is a standardized validated measure that has been shown to be accurate in diagnosing psychiatric conditions in primary care and psychiatric care settings as well as other studies [25,26,27,28,29,30,31,32]. After the MINI interview was completed, the participants completed an online self-administered battery that consisted of several other standardized, validated questionnaires. Once the initial/pre-MBS interview and self-administered battery were completed, participants were compensated with a $50 Amazon or Walmart e-gift card for participation. Study data was collected and managed using Research Electronic Data Capture (REDCap), a secure, HIPAA compliant, web-based software platform. The study was approved by the Committee for Protection of Human Subjects.

Main Outcome

MBS completion was self-reported by participants (yes/no) and validated by the clinical teams.

Main Exposures

History of depression and/or anxiety were assessed with MINI questions as described above [25]. After the initial interview was completed, the research coordinator selected the appropriate category (if any) of disorder based on the responses provided by the participants. If a participant stated that they had experienced a current, past, or recurrent major depressive episode during the MINI interview they were classified as positive for history of depression. If none of the conditions were selected (current, past, and recurrent) then participants were classified as not having history of depression. This was similar for history of anxiety; any participant that stated they had experienced social anxiety, general anxiety, PTSD, agoraphobia, or panic disorder were classified as positive for the condition. Conversely, those who answered not having experienced any of these conditions were considered negative.

Covariates

Covariates included age, sex, ethnicity, and BMI.

Statistical Analysis

Analysis of all descriptive variables including sex, age, ethnicity (non-Hispanic Black (NHB), non-Hispanic white (NHW), Hispanic, and other), MBS completion status (Y/N), and history of depression or anxiety included categorical and continuous variables. Associations between MBS completion status, and sex and history depression, anxiety, or both was performed using Pearson–Chi-squared tests. Crude odds ratios were calculated for history of depression, anxiety, or both in relation to ethnicity using univariable logistic regression models. Multivariable logistic regression models adjusting for ethnicity, age, sex, and BMI were also performed to calculate adjusted odds ratios of MBS completion by history of depression, anxiety, or both. An interaction term of depression*anxiety was also added in the multiple regression model. There was < 3% missingness for demographic variables (age, sex, and ethnicity), and there was no missing data for the outcome variable. All analyses were performed using STATA v.16.1 (Stata Corp LP, College Station, TX, USA). A p value of less than 5% was considered statistically significant.

Results

The final analytical sample consisted of 413 participants, mean age 47.52 years (SD 11.58 years), mean BMI 45.66 kg/m2 (SD 10.31 kg/m2), 87.10% female, 39.50% NHW, 38.75% NHB, 17.5% Hispanic, and 4.25% other. About a third of the sample (33.41%) completed MBS. (Table 1).

Table 1 Participant descriptive characteristics and metabolic and bariatric surgery status (N = 413)
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Table 2 shows the bivariate analysis between those who reported a history of depression and/or anxiety among MBS completers and non-completers by ethnicity and sex. Overall, there was no association between completers and non-completers and depression (p value = 0.803), history of anxiety (p value = 0.087) or both (p value = 0.303). Among MBS completers, 30% reported a history of depression, 20% reported a history of anxiety, and 35% reported a history of both. Among MBS non-completers, 31% reported depression, 27% reported anxiety, and 40% reported a history of both. There were no significant differences by ethnicity for history of depression (p value = 0.598), anxiety (p value = 0.633), or both (p value = 0.716) and MBS completion status. In terms of sex differences, there was no significance between history of depression (p value = 0.493), anxiety (p value = 0.221), or both (p value = 0.461) among MBS completers versus non-completers. Also, there was no association between current body mass index and MBS completion for those with history of depression (p value = 0.102), anxiety (p value = 0.672), or both (p value = 0.166).

Table 2 Distribution of history of depression and/or anxiety among metabolic and bariatric surgery completers and non-completers
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Table 3 shows bivariate analysis of those with and without a history of depression, anxiety, or both by ethnicity, sex, and BMI. A history of depression was reported by 31% of the sample, a history of anxiety in 25%, and both in 38% of the sample. There were significant differences found between sex and history of depression (p value = 0.021), anxiety (p value = 0.002), and both (p value = 0.002). Of those with depression, 93% were women, 42% NHW, 30% NHB, 23% Hispanic, and 5% others. Among those with anxiety, 96% were women, 43% NHW, 38% NHB, 14% Hispanic, and 4% others. Of those with both depression and anxiety 94% were women, 42% NHW, 34% NHB, 18% Hispanic, and 5% others. However, there was no association by ethnicity for those with history of depression (p value = 0.080), history of anxiety (p value = 0.710), or both (p value = 0.576). Additionally, there was no significant association between BMI and history of depression (p value = 0.140), history of anxiety (p value = 0.119), or both (p value = 0.171).

Table 3 Distribution of history of depression and anxiety status by race/ethnicity and sex
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Table 4 shows the results of the logistic regression model to examine the association between history of depression and anxiety by ethnicity and sex. NHB were less likely to report history of depression compared to NHW (aOR = 0.54, 95% CI: 0.31–0.97, p value = 0.038). Females were over five and a half times more likely to report a history of anxiety than males (aOR = 5.65, 95% CI = 1.64–19.49, p value = 0.006). Additionally, females were three times more likely to report a history of depression and anxiety than males (aOR = 3.07, 95% CI = 1.39–6.79, p value = 0.005).

Table 4 Crude and adjusted odds of depression and/or anxiety by sex and race/ethnicity
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Table 5 includes the logistic regression results to examine the association between history of depression or anxiety and MBS completion adjusted for age, sex, ethnicity, and BMI. Adjusted models showed that those participants who reported anxiety are 0.52 times less likely to complete MBS compared to those without anxiety (aOR = 0.52,95% CI = 0.30–0.90, p value = 0.020). However, depression (aOR = 0.88, 95% CI = 0.53–1.45, p value = 0.619), or both depression and anxiety (aOR = 0.71, 95% CI = 0.44–1.15, p value = 0.161) were not associated with MBS completion. There was no significance between the interaction term of anxiety*depression and MBS completion (p value = 0.774).

Table 5 Crude and adjusted odds of MBS completion by history of depression and/or anxiety
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Discussion

The aim of this study was to determine whether a history depression, anxiety, individually or concurrently were predictors of MBS completion and whether ethnicity or sex differences were present in those with a history of depression, anxiety, or both. The results show that those with anxiety were 48% less likely to complete MBS compared to those without anxiety, after adjusting for age, sex, and ethnicity. Females were more likely to report a history of anxiety and simultaneous anxiety and depression, while NHB were less likely to report a history of depression. These findings can inform pre-MBS programs and interventions targeting strategies to improve MBS completion rates among ethnically diverse patients.

This present study adds to the literature by reporting the assessment of pre-operative history of depression, anxiety, or both and the association with MBS completion in an ethnically diverse population as a primary observation . The findings revealed 31% of MBS candidates reported history of depression, 25% had a history of anxiety, and 38% had a history of both. This is consistent with another study, which showed that, beyond dealing with the physical health challenges associated with obesity, MBS patient groups may also have prevalence of depression and anxiety [33]. That study also discussed the fact that psychiatric conditions can be barriers for pursuing MBS [33]. Other studies have shown that anxiety, including agoraphobia, social anxiety, and panic disorder, are linked to social isolation [34]. Therefore, there may be an association between social isolation and not completing MBS, especially given that the majority of data collection for this study took place during the COVID-19 pandemic.

Other studies showed that a baseline history of anxiety disorders, such as agoraphobia and social anxiety, has been associated with significantly attenuated weight loss after MBS compared to those without anxiety [35, 36]. The results here in combination with previous studies suggest that pre-MBS mental health screening and resources may improve MBS completion rates.

The initial hypothesis for this current study, that a history of depression or anxiety were predictors of MBS non-completion, was partially supported. A negative association between a history of anxiety and MBS completion was found; however, there was not an association between a history of depression or both and MBS completion in this study. Previous studies have shown that the presence of other psychological factors, such as disordered eating and internalized weight bias, impact MBS completion [37,38,39]. Those studies showed that greater severity of these conditions reduced the likelihood of pursuing MBS [38]. Disordered eating or internalized weight bias are examples of barriers that inhibit pre-bariatric patients from implementing the behavioral changes needed to achieve and maintain weight loss [37, 38]. There may be a connection between safety concerns due to complication of MBS as other studies have shown this to be a driver for underutilization for MBS as only 20.3% thought positively about bariatric surgery and only 14.3 % perceived the procedure as safe [40]. In another study, 51% of participants reported a fear of surgery due to complications [41]. Another study reported that among those with obesity, there was a fear of MBS due to the invasiveness of the procedure [42]. Perhaps the current study’s finding of those with a history of anxiety being less likely to complete MBS is driven by similar fears, and thus, pre-MBS education efforts to create confidence of the value of MBS and the strong potential of resolution of metabolic diseases should be emphasized.

This study sample consisted of a highly ethnically diverse population, which is representative of people in the US. The results showed that NHB were 46% less likely to have a history of depression compared to NHW. However, depression was not a significant predictor of MBS completion, and thus, this ethnic difference may not play a role in whether NHB complete MBS. In addition, no ethnic differences were observed in those with a history of anxiety or both depression and anxiety. This is consistent with previous research showing no significant differences in anxiety between the NHB and NHW groups. Nonetheless, the study also showed no significant ethnic differences for depression [43]. More research is needed to clarify the potential association between ethnic disparities and history of depression or anxiety with MBS completion as the current studies are conflicting [44, 45]. Other studies have reported race or ethnicity as predictors of MBS completion [46], yet this current study’s results did not find similar results.

Another key finding of this present study is that there were sex differences in those with a history of anxiety and both history of anxiety and depression, thus confirming a previous study that showed sex differences among people with depression and anxiety [47]. This current study’s adjusted model showed female participants were over five and a half times more likely to have anxiety compared to men and 3 times more likely to have both depression and anxiety compared to men. Moreover, the participants in this study are either considering MBS or have already completed MBS. Thus, this finding is consistent with another study that has shown that among those who pursue MBS completion, women are more likely to have anxiety or both depression and anxiety [48, 49]. However, unlike previous research, this current study did not observe sex differences for history of depression only [48]. Yet, depression and anxiety have also been reported as factors that contribute to MBS hesitancy [49]. This suggests that a history of anxiety could be a barrier among women for completing MBS. Therefore, more comprehensive mental health evaluations and treatments are needed when evaluating female candidates for MBS to ensure that they either complete MBS or receive other evidence-based treatment for obesity to maximize weight loss[50].

Strengths and Limitations

This current study has several strengths, which include recruitment of an ethnically diverse population that is representative of the US population. Also, the large study sample provided power to the study. However, the study also has limitations that need to be considered when interpreting the results. The majority of the participants were recruited from clinics in Texas; thus, the results may not be generalizable to all patients considering MBS. Also, history of depression and/or anxiety was self-reported, but this is standard in the field (e.g., there is no definitive biomarker criteria to diagnose either condition). This current study did not include participants who reported substance misuse due to the small sample size (n = 10), resulting in low power to detect group differences. Additionally, the MINI’s scoring guidance and criteria does not capture the total number or frequency of anxiety or depression symptoms reported that would generate a continuous independent variable and may introduce range restriction as a result.

Conclusion

Among a sample of ethnically diverse participants with severe obesity, this current study’s results show anxiety is inversely associated with MBS completion and women were more than five times as likely to report anxiety and more than three times as likely to report depression and anxiety compared to men. Conversely, NHBs were less likely to report a history of depression. More comprehensive mental health diagnostic and treatments services targeting anxiety, and among females in particular, may improve MBS completion rates.