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Depression and other mental disorders in the relatives of morbidly obese patients
Journal of Affecc’kc Disorders, 25 ( 1992) 91-96 0 1992
91
Elsevier Science Publishers B.V. All rights reserved 016%0327/92/$05.00
JAD 00899
epression and other mental disorders in t e relatives of morbidly obese patients Donald W. Black a, RistZB. Goldstein “,Edward E. Mason c, Sue E. BeIl a and Nancee Blum a Deparfments of a Psychiatry and ’ Divbon
of’
Surgery, Unicersiry of Iowa College of Medicine, Iowa City, iowa, USA;
Epidemiology and Biostatistics, Unilrrsiiy
of Massachusetts School of Public Health, Amhurst,
Massachusetts, USA
(Received 16 December 1991) (Revision received 24 January 1992) (Accepted 11 Feb:uary 1992)
Summary The authors systematically interviewed 88 bariatric clinic patients presenting for vertical banded gastroplasty. The typical subject was middle-aged. female and of Iow socioeconomic status as indicated by his or her method of payment, Morbidly obese subjects were more likely than a comparison group to have first-degree relatives with a history of depression, bipolar disorder, antisocial personality, and other psychiatric disorders. These data indicate that relatives of morbidly obese subjects are frequently emotionally disturbed. Reasons for the findings are discussed.
Key wor&
Morbid obesity; Family history; Mental illness; Bariatric; Genetics
Introduction Morbid obesity, defined as weight at Ieast 100% or 100 pounds (45 kg) above ideal body weight, is associated with excessive morbidity and mortality and is an important health problem (Stunkard et al., 1986). Since conventional treatments (e.g., dieting) are .generally ineffective in the morbidly obese, more drastic methods have been devel-
Address for correspondence: Donald W. Black, Medical Education Building, 500 Newton Road, Iowa City, IA 52242, USA.
oped to deal with this potentially life-threatening c_mdition, .including the vertical banded gastroplasty CVBG), a surgical procedure in which the size of the stomach opening is physically iimited (Mason, 1987). Research on morbid obesity has tended to center around its biologic and physiologic underpinnings, while psychological issues have been largely ignored. For example, although obesity (not morbid obesity per se) has been associated with disturbed family interactions (Bruch, 1973), there are almost no investigations about menial illness among first-degree relatives of the morbidly obese. Since the family environment may be
97
influenced by the presence of a mentally ill family member, it seems an appropriate area for investigation, particularly when, as Bruch suggests, a chaotic home life may be at the root of the self-defeating attitudes that obese persons often have about themselves. We recently had the opportunity to assess morbidly obese persons presenting to the University of Iowa Department of Surgery for evaluation for VBG. Some of our findings have already been reported, including the findings of a high prevalence of mood, anxiety and personality disorders, bulimia, and tobacco dependence in morbidly obese subjects (Black et al., 1989. 1992a). In this communication, we report data on mental disorders in their first-degree relatives using the family histoiy method, which is to our knowledge the first such study. negatively
Subjects and Methods Morbidly obese subjects
Eighty-eight patients seen at our university’s surgery clinic for consultation regarding vertical banded gastroplasty were recruited between January 1987 and June 1989. Patients were eligible if they were at least I8 years old and at least 100 percent or 100 pounds (45 kg) ovet their desirable weight according to actuarial tables (Metropolitan Life Insuldncc Co., 1983). We did not include patients with clinically apparent mental retardation or organic brain syndromes, since these disorders complicate the assessment of other forms of psychopathology and would preclude adequate description of a relatives’ illness. Assessments AfZi giving informed consent, morbi4y
obese subjects were evaluated by trained raters (SEB, RBG) using the Diagnostic Interview Schedule (5IS; Robins et al., 1981), which has established adequate reliability for diagnosing many of the major mental disorders using DSM-III criteria. A semi-structured instrument developed by the investigators was used to gather data regarding the subjects’ past and present educational and marital status, and on the subjects’ perceptions and reports of their early family life. The Personality Diagnostic Questionnaire (PDQ; Hyler et al.,
1983) v:as used to assess DSM.111 personality disorders, and starting in November of 1987, the Structured Interview for DSM-III Personality Disorders (SIDP; Stangl et al., 1985) was added to provide a more thorough personality assessment. The Family History-Research Diagnostic Criteria (FH-RDC: Andreasen et al., 19771, a structured interview instrument, was added to collect information about mental disorders in first-degree relative;. All family history information was gathered b1.1RBG. Comparison group
roup was recruited in the A comparison course of another _Jy (Black et al., 1992bb. As part of a family Giady of obsessive-compulsive disorder, we idene: ied 33 non-ill subjects who had been screened 4th the Schedule for AffecVertive Disorders and chizophrenia-lifetime sion (Spitzer and Endicott, 1978) to exclude those with major mental disorders. The FH-RDC was administered bv RBG to *gather data regarding their first-degree relatives. The mean (SD) age of subjects in the comparison group was 38.1 (10.1) years and 20 (6 1%) were female. Statistical arlahsis
Categorical data were analyzed by using the chi-square statistic and, when necessary, Fisher’s exact test. Results The sociodemogrr;; hit and clinical profiles of the morbidly obese -ubjects are summarized in Table 1. The morbidI obese subjects are predominantly middle-aged women of low socioecoTABLE
I
Sociodemographic
profile of X8 morbidly obese subjects
Age, mean (SD) Weight, kg, mean !SD)
36.1 (10.3) 141.3 (28.3)
Gender % female
79.5
% male
20.5
Pay Status ?f Public assistance
59. I
‘7c Private insurance
38.7
% Other/unknown
2.3
93 TABLE 2 ifctime
prevalence of mental disorders in morbid obese and control relatives
No. of probands with family history data
Proband group
No. of relatives No. of relatives with FH-RDC diagnosis of: Alcoholism Depression ’ Schizophrenia Bipolar disorder * Organic brain syndrome Drug use disorder Antisocial personality 3 Other psychiatric disorder a > 1 psychiatric disorder ’ No known mental disorder ’
Morbid Obesity 48
Control 33
336
182
29 (8.6) 59 (17.6) 1 (0.3) 11 (3.3) 1 to.31 13 (3.9) 10 (3.0) 26 (7.7) 27 03.0) 218 (64.9)
14 (7.7) 8 (4.4) 1 (0.6) 0 0 4 (2.3) 0 1 (0.6) 5 (2.8) 155 (87.6)
’ x2 = 17.4, df = 1, P < 0.0001; * Fisher’s Exact test, P = 0.009 (one tail); 3 Fisher’s Exact test? P =‘O.Ol (one tail); 4x2 = 12.0, df = 1, P = 0.0005; 5x2= 5.4, df = 1, P = 0.02; ’ x2 = 30.1, df = 1, P < 0.001.
nomic status as indicated by their method of payment for medical care. Frequencies of psychiatric disorders among the relatives of morbidly obese and comparison subjects are presented in Table 2. Significantly more relatives of morbidly obese probands have de-
TABLE 3 Mental disorders in relatives of depressed depressed morbidly obese probands
versus
non-
Proband group
No. of relatives with family history data No. (%) of relatives with: Alcoholism Depression Schizophrenia Bipolar disorder Organic brain syndrome Drug use disorder Antisocial personality Other psychiatric disorder > 1 psychiatric disorder No known mental disorder ’
w,thout MDD (N= 36)
with MDD (N= 12)
252
84
pression, bipolar disorder, antisocial personality, and other psychiatric disorders. There was no difference in the prevalence of alcoholism. Relatives of morbidly obese patients were more likely to have more than one illness, and fewer were free of mental illness than subjects in the comparison group. Table 3 shows the prevalence of mental disorders in the relatives of both depressed and nondepressed obese subjects. There was no significant difference in the prevalence of depression. Only one difference was significant in the tablethe percentage of relatives with no known mental disorder. Discussion
20 (7.9) 39 (15.5) 0 8 (3.2) 1 (3.2) 7 (2.8) 5 (2.0) 17 (6.7) 17 (6.7) 175 (69.4)
9 (10.7) 20 (23.8) 1 (1.2) 3 (3.6) 0 6 (7.1) s (0.0) 9 (10.7) lO(ll.9) 43 (51.2)
1 h 2 = 9.2, df = 1, P = ti.n?2; MDD = major depressive disorder.
The results indicate that first-degree relatives of probands with morbid obesity are significantly more likely to have a mental disorder than relatives of comparison subjects, particularly depression, bipolar disorder, and antisocial personality. There was also a general increase in psychopathology among their relatives. The findings may help to explain why families of obese persons (although not the morbidly obese per se) are thought to be chaotic and disorganized (Bruch, 19331, since they suffer from so much mental illness.
Although no investigators have systematically addressed the issue of family psychiatric history in the morbidly obese. several have reported UK!controlled or anecdotal findings. Emk (1962? reported that 4 ( 135) of 31 subjects studied had a psychotic parent, and a similar number had an alcoholic parent. In another study, Atkinson and Ringuette (1967) reported a history of emotional illness among the parents of 9 of 21 (43%) subjects, and an alcoholic parent was reported by 4 (19%) subjects. Further. these investigators found that nearly 40% of the 39 offspring in the group disturbed.’ Castelnuovowere ‘emotionally Tedesco and Scheibe! (1975) found that of 12 morbidly obese subjects. 2 reported an alcoholic parent. Although all of these investigators identified serious problems in the families of tht: morbidly obese. their observations are uncontrolled and their assessments (e.g., ‘emotional illness’) are non-specific. A parent with a history of alcoholism, depression or other ‘emotional illness’ could contribute to a poor home environment, as a direct result of the illness. Likewise, the ill parent could be transmitting a genetic disorder to the morbidly obese offspring. Our study confirms the link between family history of mental illness and morbid obesity, but we cannot explain the association. Social class could confound the results, since most of our morbidly obese probands had low socioeconomic status. and low social class has long been associated with higher rates of both psychotic and non-ps::chutic mental disorders (Dohrenwend, 1990). We do not have measures of socioeconomic status for comparison subjects and so cannot assess this possibility. Whether the morbid obesity is independently related to disturbed family functioning is less certain. The excess depression in our morbidly obese probands. which was reported earlier (Black et al., 19921, may also c.$nfound the results. Major depression, a familial condition, was found in 19% of the probands and 5% of controls. However, the depression in the relatives of morbidly obese probands is apparently not explained by depression in the proband, since there was no significant difference in the percentage of ill relatives of depressed and nondepressed obese probands. The limitations of our study lleell to be ad-
dre.;sed. First, the sample was relatively small and da-a collection was incomplete. A larger sample size would have provided greater statistical power to help determine differences between cases and controls. Morbidly obese subjects were predominantly white females of low socioeconomic status who presented to a tertiary care facility for VBG. Therefore, our subjects may not be representative of morbidly obese persons in general, or of those who present to other centers. However, the sociuchwglapitic puL$t: of OUL’ study subjects is similar to that reported by other researchers ill a tertiary care setting (Hutzler et al., 19831. Furthermore, subjects used for the comparison of family psychiatric history were not matched to the characteristics of the morbidly obese probands. The way comparison subjects were selected may have helpeti to eliminate mentally ill persons from the pool of relatives, exaggerating differences in the frequency of mental illness in relatives between cases and the comparison group. One might assume that carefully screened subjects would have less mental disorder among relatives than is generally found in the community. In fact, the frequency of major depression among relatives of comparison subjects in our study is comparable to national rates reported in the ECA study (Robins et al., 1984), indicating that this is not a significant problem. Finally, the results are based on family history data obtained from probands, a method considered inferior to the direct interview of relatives, since probands may not be familiar with or able to describe a relative’s psychiatric symptoms (Andreasen et al., 1986). Acknowledgements The authors wish to thank Patrick Monahan and Eva Rodriguez for their assistance. eferences Andrcasen.
N.C.. Endicott.
J.. Spitzer.
R.L. and Winokw.
6.
(19771 The family history method using diagnostic criteria: reliability and validity. Arch. Gen. Psychiat. 34. 1229-1235. Andreasen.
NC..
Rice. J., Endicott.
J., Reich. T. and Coryell,
W. (1986) The family history approach to diagnosis. How useful is it? Arch. Gen. Psychiat. 43, 421-429. Atkinson.
R.M.
graphical
and Ringuette,
and psychological
ness. Psychosomatic Med.
E.L. (1967) A survey of bioftatures
in extraordinary
29, 121-133.
fat-
9s
Black. D.W., Goldstein, R.B. and Mason, E.E. (1992a) ?he prevalence of mental disorder in 88 morbidly obese gastropla
Hj!er. S.E.. Reider, R.O. and Spitzer, R.L. (1983) Personality Diagnostic Questionnaire (PDQ). New York State Psychiatric Instttuie, New York. Mason, E.E. (1987) Morbid obesity: Use of vertical banded gastroplasty. Surg. Clin. N. Am. 67, 521-537. Metropolitan Life Insurance Company. (1983) Revised weight standards for men and women, New York. Robins, L.N.. Helzer, J.E., Croughan, J. and Ratcliff, K.S. (1981) The NIMH Diagnostic Interview Schedule, its history, characteristics, and validity. Arch. Gen. Psychiat. 38, 381-389. Robins, L.N., Helzer. J.E.. Weissman, M.M., Orvaschel, H., Gruenburg, E.. Eurke, J.D. and Regier DA. (1984) Lifetime prevalence of specific psychiatric disorders in three sites. Arch. Gen. Psychiat. 41. 949-958. Spitzer, R.L. and Endicott. J. (1978) Schedule for affective disorders and schizophrenia. Biometrics Research Division. New York State Psychiatric Institute. Stangl, D.. Pfohl. B. and Zimmerman, M. (1985) A structured interview for DSM-III personality disorders. Arch. Gen. Psychiat. 42. 591-596. Stunkard, A.J., Stinnett, J.L., Smoller. J.W. (1986) Psychological and social aspects of the surgical treatment of obesity. Am J Psychiat. 143, 417-429.
91
Elsevier Science Publishers B.V. All rights reserved 016%0327/92/$05.00
JAD 00899
epression and other mental disorders in t e relatives of morbidly obese patients Donald W. Black a, RistZB. Goldstein “,Edward E. Mason c, Sue E. BeIl a and Nancee Blum a Deparfments of a Psychiatry and ’ Divbon
of’
Surgery, Unicersiry of Iowa College of Medicine, Iowa City, iowa, USA;
Epidemiology and Biostatistics, Unilrrsiiy
of Massachusetts School of Public Health, Amhurst,
Massachusetts, USA
(Received 16 December 1991) (Revision received 24 January 1992) (Accepted 11 Feb:uary 1992)
Summary The authors systematically interviewed 88 bariatric clinic patients presenting for vertical banded gastroplasty. The typical subject was middle-aged. female and of Iow socioeconomic status as indicated by his or her method of payment, Morbidly obese subjects were more likely than a comparison group to have first-degree relatives with a history of depression, bipolar disorder, antisocial personality, and other psychiatric disorders. These data indicate that relatives of morbidly obese subjects are frequently emotionally disturbed. Reasons for the findings are discussed.
Key wor&
Morbid obesity; Family history; Mental illness; Bariatric; Genetics
Introduction Morbid obesity, defined as weight at Ieast 100% or 100 pounds (45 kg) above ideal body weight, is associated with excessive morbidity and mortality and is an important health problem (Stunkard et al., 1986). Since conventional treatments (e.g., dieting) are .generally ineffective in the morbidly obese, more drastic methods have been devel-
Address for correspondence: Donald W. Black, Medical Education Building, 500 Newton Road, Iowa City, IA 52242, USA.
oped to deal with this potentially life-threatening c_mdition, .including the vertical banded gastroplasty CVBG), a surgical procedure in which the size of the stomach opening is physically iimited (Mason, 1987). Research on morbid obesity has tended to center around its biologic and physiologic underpinnings, while psychological issues have been largely ignored. For example, although obesity (not morbid obesity per se) has been associated with disturbed family interactions (Bruch, 1973), there are almost no investigations about menial illness among first-degree relatives of the morbidly obese. Since the family environment may be
97
influenced by the presence of a mentally ill family member, it seems an appropriate area for investigation, particularly when, as Bruch suggests, a chaotic home life may be at the root of the self-defeating attitudes that obese persons often have about themselves. We recently had the opportunity to assess morbidly obese persons presenting to the University of Iowa Department of Surgery for evaluation for VBG. Some of our findings have already been reported, including the findings of a high prevalence of mood, anxiety and personality disorders, bulimia, and tobacco dependence in morbidly obese subjects (Black et al., 1989. 1992a). In this communication, we report data on mental disorders in their first-degree relatives using the family histoiy method, which is to our knowledge the first such study. negatively
Subjects and Methods Morbidly obese subjects
Eighty-eight patients seen at our university’s surgery clinic for consultation regarding vertical banded gastroplasty were recruited between January 1987 and June 1989. Patients were eligible if they were at least I8 years old and at least 100 percent or 100 pounds (45 kg) ovet their desirable weight according to actuarial tables (Metropolitan Life Insuldncc Co., 1983). We did not include patients with clinically apparent mental retardation or organic brain syndromes, since these disorders complicate the assessment of other forms of psychopathology and would preclude adequate description of a relatives’ illness. Assessments AfZi giving informed consent, morbi4y
obese subjects were evaluated by trained raters (SEB, RBG) using the Diagnostic Interview Schedule (5IS; Robins et al., 1981), which has established adequate reliability for diagnosing many of the major mental disorders using DSM-III criteria. A semi-structured instrument developed by the investigators was used to gather data regarding the subjects’ past and present educational and marital status, and on the subjects’ perceptions and reports of their early family life. The Personality Diagnostic Questionnaire (PDQ; Hyler et al.,
1983) v:as used to assess DSM.111 personality disorders, and starting in November of 1987, the Structured Interview for DSM-III Personality Disorders (SIDP; Stangl et al., 1985) was added to provide a more thorough personality assessment. The Family History-Research Diagnostic Criteria (FH-RDC: Andreasen et al., 19771, a structured interview instrument, was added to collect information about mental disorders in first-degree relative;. All family history information was gathered b1.1RBG. Comparison group
roup was recruited in the A comparison course of another _Jy (Black et al., 1992bb. As part of a family Giady of obsessive-compulsive disorder, we idene: ied 33 non-ill subjects who had been screened 4th the Schedule for AffecVertive Disorders and chizophrenia-lifetime sion (Spitzer and Endicott, 1978) to exclude those with major mental disorders. The FH-RDC was administered bv RBG to *gather data regarding their first-degree relatives. The mean (SD) age of subjects in the comparison group was 38.1 (10.1) years and 20 (6 1%) were female. Statistical arlahsis
Categorical data were analyzed by using the chi-square statistic and, when necessary, Fisher’s exact test. Results The sociodemogrr;; hit and clinical profiles of the morbidly obese -ubjects are summarized in Table 1. The morbidI obese subjects are predominantly middle-aged women of low socioecoTABLE
I
Sociodemographic
profile of X8 morbidly obese subjects
Age, mean (SD) Weight, kg, mean !SD)
36.1 (10.3) 141.3 (28.3)
Gender % female
79.5
% male
20.5
Pay Status ?f Public assistance
59. I
‘7c Private insurance
38.7
% Other/unknown
2.3
93 TABLE 2 ifctime
prevalence of mental disorders in morbid obese and control relatives
No. of probands with family history data
Proband group
No. of relatives No. of relatives with FH-RDC diagnosis of: Alcoholism Depression ’ Schizophrenia Bipolar disorder * Organic brain syndrome Drug use disorder Antisocial personality 3 Other psychiatric disorder a > 1 psychiatric disorder ’ No known mental disorder ’
Morbid Obesity 48
Control 33
336
182
29 (8.6) 59 (17.6) 1 (0.3) 11 (3.3) 1 to.31 13 (3.9) 10 (3.0) 26 (7.7) 27 03.0) 218 (64.9)
14 (7.7) 8 (4.4) 1 (0.6) 0 0 4 (2.3) 0 1 (0.6) 5 (2.8) 155 (87.6)
’ x2 = 17.4, df = 1, P < 0.0001; * Fisher’s Exact test, P = 0.009 (one tail); 3 Fisher’s Exact test? P =‘O.Ol (one tail); 4x2 = 12.0, df = 1, P = 0.0005; 5x2= 5.4, df = 1, P = 0.02; ’ x2 = 30.1, df = 1, P < 0.001.
nomic status as indicated by their method of payment for medical care. Frequencies of psychiatric disorders among the relatives of morbidly obese and comparison subjects are presented in Table 2. Significantly more relatives of morbidly obese probands have de-
TABLE 3 Mental disorders in relatives of depressed depressed morbidly obese probands
versus
non-
Proband group
No. of relatives with family history data No. (%) of relatives with: Alcoholism Depression Schizophrenia Bipolar disorder Organic brain syndrome Drug use disorder Antisocial personality Other psychiatric disorder > 1 psychiatric disorder No known mental disorder ’
w,thout MDD (N= 36)
with MDD (N= 12)
252
84
pression, bipolar disorder, antisocial personality, and other psychiatric disorders. There was no difference in the prevalence of alcoholism. Relatives of morbidly obese patients were more likely to have more than one illness, and fewer were free of mental illness than subjects in the comparison group. Table 3 shows the prevalence of mental disorders in the relatives of both depressed and nondepressed obese subjects. There was no significant difference in the prevalence of depression. Only one difference was significant in the tablethe percentage of relatives with no known mental disorder. Discussion
20 (7.9) 39 (15.5) 0 8 (3.2) 1 (3.2) 7 (2.8) 5 (2.0) 17 (6.7) 17 (6.7) 175 (69.4)
9 (10.7) 20 (23.8) 1 (1.2) 3 (3.6) 0 6 (7.1) s (0.0) 9 (10.7) lO(ll.9) 43 (51.2)
1 h 2 = 9.2, df = 1, P = ti.n?2; MDD = major depressive disorder.
The results indicate that first-degree relatives of probands with morbid obesity are significantly more likely to have a mental disorder than relatives of comparison subjects, particularly depression, bipolar disorder, and antisocial personality. There was also a general increase in psychopathology among their relatives. The findings may help to explain why families of obese persons (although not the morbidly obese per se) are thought to be chaotic and disorganized (Bruch, 19331, since they suffer from so much mental illness.
Although no investigators have systematically addressed the issue of family psychiatric history in the morbidly obese. several have reported UK!controlled or anecdotal findings. Emk (1962? reported that 4 ( 135) of 31 subjects studied had a psychotic parent, and a similar number had an alcoholic parent. In another study, Atkinson and Ringuette (1967) reported a history of emotional illness among the parents of 9 of 21 (43%) subjects, and an alcoholic parent was reported by 4 (19%) subjects. Further. these investigators found that nearly 40% of the 39 offspring in the group disturbed.’ Castelnuovowere ‘emotionally Tedesco and Scheibe! (1975) found that of 12 morbidly obese subjects. 2 reported an alcoholic parent. Although all of these investigators identified serious problems in the families of tht: morbidly obese. their observations are uncontrolled and their assessments (e.g., ‘emotional illness’) are non-specific. A parent with a history of alcoholism, depression or other ‘emotional illness’ could contribute to a poor home environment, as a direct result of the illness. Likewise, the ill parent could be transmitting a genetic disorder to the morbidly obese offspring. Our study confirms the link between family history of mental illness and morbid obesity, but we cannot explain the association. Social class could confound the results, since most of our morbidly obese probands had low socioeconomic status. and low social class has long been associated with higher rates of both psychotic and non-ps::chutic mental disorders (Dohrenwend, 1990). We do not have measures of socioeconomic status for comparison subjects and so cannot assess this possibility. Whether the morbid obesity is independently related to disturbed family functioning is less certain. The excess depression in our morbidly obese probands. which was reported earlier (Black et al., 19921, may also c.$nfound the results. Major depression, a familial condition, was found in 19% of the probands and 5% of controls. However, the depression in the relatives of morbidly obese probands is apparently not explained by depression in the proband, since there was no significant difference in the percentage of ill relatives of depressed and nondepressed obese probands. The limitations of our study lleell to be ad-
dre.;sed. First, the sample was relatively small and da-a collection was incomplete. A larger sample size would have provided greater statistical power to help determine differences between cases and controls. Morbidly obese subjects were predominantly white females of low socioeconomic status who presented to a tertiary care facility for VBG. Therefore, our subjects may not be representative of morbidly obese persons in general, or of those who present to other centers. However, the sociuchwglapitic puL$t: of OUL’ study subjects is similar to that reported by other researchers ill a tertiary care setting (Hutzler et al., 19831. Furthermore, subjects used for the comparison of family psychiatric history were not matched to the characteristics of the morbidly obese probands. The way comparison subjects were selected may have helpeti to eliminate mentally ill persons from the pool of relatives, exaggerating differences in the frequency of mental illness in relatives between cases and the comparison group. One might assume that carefully screened subjects would have less mental disorder among relatives than is generally found in the community. In fact, the frequency of major depression among relatives of comparison subjects in our study is comparable to national rates reported in the ECA study (Robins et al., 1984), indicating that this is not a significant problem. Finally, the results are based on family history data obtained from probands, a method considered inferior to the direct interview of relatives, since probands may not be familiar with or able to describe a relative’s psychiatric symptoms (Andreasen et al., 1986). Acknowledgements The authors wish to thank Patrick Monahan and Eva Rodriguez for their assistance. eferences Andrcasen.
N.C.. Endicott.
J.. Spitzer.
R.L. and Winokw.
6.
(19771 The family history method using diagnostic criteria: reliability and validity. Arch. Gen. Psychiat. 34. 1229-1235. Andreasen.
NC..
Rice. J., Endicott.
J., Reich. T. and Coryell,
W. (1986) The family history approach to diagnosis. How useful is it? Arch. Gen. Psychiat. 43, 421-429. Atkinson.
R.M.
graphical
and Ringuette,
and psychological
ness. Psychosomatic Med.
E.L. (1967) A survey of bioftatures
in extraordinary
29, 121-133.
fat-
9s
Black. D.W., Goldstein, R.B. and Mason, E.E. (1992a) ?he prevalence of mental disorder in 88 morbidly obese gastropla
Hj!er. S.E.. Reider, R.O. and Spitzer, R.L. (1983) Personality Diagnostic Questionnaire (PDQ). New York State Psychiatric Instttuie, New York. Mason, E.E. (1987) Morbid obesity: Use of vertical banded gastroplasty. Surg. Clin. N. Am. 67, 521-537. Metropolitan Life Insurance Company. (1983) Revised weight standards for men and women, New York. Robins, L.N.. Helzer, J.E., Croughan, J. and Ratcliff, K.S. (1981) The NIMH Diagnostic Interview Schedule, its history, characteristics, and validity. Arch. Gen. Psychiat. 38, 381-389. Robins, L.N., Helzer. J.E.. Weissman, M.M., Orvaschel, H., Gruenburg, E.. Eurke, J.D. and Regier DA. (1984) Lifetime prevalence of specific psychiatric disorders in three sites. Arch. Gen. Psychiat. 41. 949-958. Spitzer, R.L. and Endicott. J. (1978) Schedule for affective disorders and schizophrenia. Biometrics Research Division. New York State Psychiatric Institute. Stangl, D.. Pfohl. B. and Zimmerman, M. (1985) A structured interview for DSM-III personality disorders. Arch. Gen. Psychiat. 42. 591-596. Stunkard, A.J., Stinnett, J.L., Smoller. J.W. (1986) Psychological and social aspects of the surgical treatment of obesity. Am J Psychiat. 143, 417-429.