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Mrs. G is a 52-year-old mother and teacher with a 20-year history of recurrent depressive episodes for which she has been treated with various antidepressants, including sertraline, fluoxetine, and citalopram. For some of her depressive recurrences, she also received adjunctive second-generation antipsychotics (SGAs), including quetiapine and olanzapine.
She describes feelings of “being defeated,” hopelessness, and boredom and frustration with her teaching. It takes her approximately 30 minutes to go to sleep each night, but she wakes up after 2 to 3 hours, and the remainder of her night’s sleep is markedly disrupted. Because of her hopeless feelings, she has given up on dieting and going to the gym. When feeling down she has donuts and coffee. She has gained 45 lbs over the past 10 years and now weighs 175 lbs. In addition to her disrupted mood, she complains of frequent headaches and sore muscles.
Mrs. G’s psychiatrist refers her to her primary care physician for evaluation of her physical complaints and recommendations regarding her weight gain. Her waistline measures 90 cm and her body mass index (BMI) is 29.1 kg/m2; a BMI of ≥30 is considered obese. Her blood pressure is 145/85 mmHg. Laboratory work reveals a total cholesterol level of 235 mg/dL, low-density lipoprotein of 146 mg/dL, and fasting blood sugar, 135 mg/dL.
Mrs. G’s case illustrates many of the issues psychiatrists face when caring for overweight or obese patients with depression (OW/OB-D). Both conditions can be challenging to manage, and may be especially difficult to treat when they co-occur. When depression and obesity co-occur, their capacity to inflict psychological and physical harm likely is greater than either condition alone. Data point to a “2-way street” of mutually destructive effects of being overweight/obese on depression and vice versa.1
This article summarizes ways that depression and obesity aggravate each other, and highlights research that suggests depression and obesity are manifestations of inflammatory processes. It also suggests a stepwise approach to treating OW/OB-D patients.
Mutually destructive processes
Self-esteem and body image. Lowered self-esteem is a hallmark of depression. In popular culture, “you can’t be too rich or too thin,” and the pressure to be slim is great. Therefore, OW/OB-D patients have 2 reasons to feel a depleted sense of self-worth: their psychiatric illness and their weight. Observant clinicians will recognize these dual sources of self-deprecation and tailor treatment to address both.
Increasing numbers of celebrities, performers, and prominent politicians are overweight or obese. Increased social acceptance of OW/OB individuals in our culture may be legitimizing weight gain and obesity. When OW/OB-D patients justify their weight by pointing to overweight celebrities, clinicians can counter this argument with data on the hazards of obesity on health and well-being, such as premature death, coronary artery disease, diabetes, arthritis, and some forms of cancer.
OW/OB patients tend to interact with other OW/OB individuals. Christakis et al2 reported that adults with obese friends were more likely to become obese than individuals without obese friends. Valente et al3 found that overweight teens were twice as likely to have overweight friends as non-overweight teens. This power of social connectedness can be harnessed when treating OW/OB-D patients, where therapeutic groups can help patients address both depression and weight gain.
Inactivity. OW/OB-D patients with psychomotor retardation or reduced activity may gain weight because they consume more calories than their body requires. Depressed patients may say they “have no energy” to participate in a clinician-recommended exercise program or that “it won’t do any good anyway.”
These tendencies are best dealt with by incorporating an exercise program into the comprehensive plan for OW/OB-D patients from the start of treatment. Several studies suggest that in addition to helping manage weight, exercise may have antidepressant effects. In a large, well-controlled trial of patients with major depressive disorder (MDD), Blumenthal et al4 found that an exercise program was as effective as fluoxetine, 20 mg/d, and the antidepressant effects persisted at 10-month follow-up for patients who continued to exercise.5 In a review of studies of exercise in depressed patients, Helmich et al6 concluded that in most studies exercise was beneficial. However, Mead et al7 found that nearly all trials of exercise and depression had substantial design flaws. Based on the 3 well-designed studies they reviewed, Mead et al concluded that the efficacy of exercise was comparable to that of cognitive therapy.
Although the evidence on exercise for treating depression is inconclusive, an exercise program is essential for OW/OB-D patients because it can help manage weight and improve cardiovascular fitness. Motivation is a key ingredient of successful programs.8 Encourage patients to make exercise enjoyable, perhaps by using video games or other interactive computer-based programs.9