Reply to the Comments on “Stress,Anxiety,and Depression Before and 12 Months After Bariatric Surgery: Repeated Cross-Sectional study”

Dear commentators:

We interviewed each patient and administered the Depression Anxiety Stress Scale-21 (DASS-21), as mentioned in the “Procedure” section. The instrument used in our research was the DASS-21, standardized in Egypt.^2,3 This scale has been validated for use in the Egyptian population and has demonstrated reliability and validity in measuring levels of depression, anxiety, and stress. The data collected from administering this instrument provided valuable insights into the mental health status of our participants. We formed our conclusions after interviewing each patient and administering the DASS-21, as mentioned in the “Procedure” section.

The clinical psychologist Dr. Amani ElBarazi conducted the clinical interviews. He assessed and evaluated each patient comprehensively, considering their medical history, symptoms, and personal background. Dr. ElBarazi tried to gain a holistic understanding of each patient’s mental health needs.

You pointed out that the baseline assessments may have been biased by anxieties related to the expectations of the surgery; however, if this is the case, how can we explain the participants’ increased anxiety following bariatric surgery? Anxiety experienced after surgery may be caused by a variety of circumstances, including changes in body image, the recovery process, or adjusting to new lifestyle choices. Further examination into these potential variables may shed further light on the individuals’ growing anxiety levels. However, future research might look at the possible impact of anxiety on baseline assessments in surgical settings to better understand its impact on outcomes. This might give useful information for enhancing preoperative treatment and patient outcomes.

You indicated that the endpoint assessments were carried out differently in different situations. That is correct. However, the same scale was utilized to compare it to the baseline evaluation. The change in the assessment environment does not imply a bias in the outcomes as long as the evaluation criteria and methods are consistent.

Regarding the follow-up assessment, the author confirmed that the patients who responded to the email were the same as those who completed the baseline evaluation in the clinic at assessment 1. This was accomplished by calling the patients (phone calls) after they had submitted the emails to confirm their replies to the DASS-21 items. This strategy was adopted to guarantee that the study’s data were accurate and consistent.

We chose generalized estimating equations (GEEs) because they extend the generalized linear model, process repeat measurement data, require no parametric distribution assumption, provide robust inference for an incorrect description of subject internal correlation, and provide good within-subject correlations. Several important studies employed (GEEs) to analyze their data. ⁴

The incidence rate ratio refers to the ratio of two different rates of anxiety, stress, and depression incidence regarding bariatric surgery. We calculated the incidence rate ratios using GEEs for two-time assessments. This statistical method allows for a more accurate estimation of the incidence rate ratios over time in the context of bariatric surgery.

The event being measured here is the ratio of anxiety, stress, and depression at time 1 compared to time 2.

We defined incidence of anxiety as anything more than 8 on the anxiety subscale, depression as anything more than 10 on the depression subscale, and stress as anything more than 15 on the stress subscale. Those cutoff scores for depression, anxiety, and stress were based on the study by SH Lovibond and PF Lovibond. ⁵

In the “Findings” section, we presented the incidence rate ratios for anxiety, stress, and depression related to bariatric surgery. We decided not to write about all findings in the “Results” section but to show our data in tables.

Table 2 accurately describes the results since we reported the means and SDs of the time 1 and time 2 assessments and the estimate of GEEs. A temporal within-subject autoregressive correlation matrix was utilized. Models were developed in response to the distributions of outcome measures. DASS-21 scores were estimated using identity link functions for normal distributions. Also, it is unnecessary to use paired t-tests or mean differences. Additionally, using GEE allowed the analysis of correlated data over time, providing a more accurate representation of the results. This method is particularly useful when dealing with repeated measures and longitudinal data.

Further studies could examine other covariates, including the success of the surgery, complications of the surgery, restrictions related to the surgery, comorbid conditions, the presence of psychosocial support, interventions received, and a host of other confounds present at baseline or developing during follow-up. These additional factors could provide a more comprehensive understanding of the impact of surgery on patient outcomes and overall quality of life. Additionally, exploring how these variables interact could help tailor interventions and support for patients undergoing similar procedures in the future.