Evidence-Based Reviews

How to manage depression in overweight or obese patients

Current Psychiatry. 2012 July;11(7):33-40

References

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Cognitive/behavioral approaches

Although large, well-designed studies of OW/OB-D patients are in the planning or pilot phases,^26-28 a substantial database supports incorporating behavioral or cognitive-behavioral therapies when treating these patients.²⁹ Patients in programs that combine behavioral approaches with diet and exercise achieve the greatest weight loss, and frequently show improved depression scores.^30-32

In a randomized trial, 203 obese women with moderate to severe depression showed significant weight loss and decreased depression scores whether they were in a behavioral weight-loss program or one that combined behavioral weigh loss with cognitive-behavioral depression management.³³ This study raises important questions: Did the behavioral weight-loss program effectively treat depression? Did patients’ depressive symptoms improve because of their improved sense of well-being as they lost weight? Did a putative reduction in cytokine production by fat cells improve their mood?

Treatment implications

Mrs. G has TRD, a BMI that borders on obesity, sleep problems, and lab values that suggest she may have metabolic syndrome. To best manage patients such as Mrs. G, consider the following steps:

Select an antidepressant that is unlikely to cause further weight gain, such as bupropion, duloxetine, or fluoxetine.
If necessary, add an augmenting agent that is not associated with weight gain, such as bupropion, aripiprazole, or lamotrigine.
Verify that your patient is getting adequate sleep. Begin by reviewing the principles of sleep hygiene and, if necessary, prescribe a sedative or hypnotic medication.
Although controlled clinical trials are lacking, consider including an anti-inflammatory agent such as aspirin to the pharmacologic armamentarium.
Institute an exercise and diet program at the beginning of treatment. Exercise can begin with 20 to 30 minutes a day of walking. Tell patients that exercising in groups is a good way to address nonadherence and social isolation and reinforce positive lifestyle changes. Recommend that patients combine aerobic exercise to burn calories with resistance training to build muscle. Suggest that patients try to make exercising fun using video games or interactive computer-based programs.
Encourage your patient to keep a journal to record his or her weight, amount and type of exercise, medication taken, and dietary intake. Review this information at every session to reinforce the importance of this integrated exercise and diet program.

Related Resources

Markowitz S, Friedman MA, Arent SM. Understanding the relation between obesity and depression: causal mechanisms and implications for treatment. Clinical Psychology: Science and Practice. 2008:15(1):1-20.
Burke LE, Wang J, Sevick MA. Self-monitoring in weight loss: a systematic review of the literature. J Am Diet Assoc. 2011;111(1):92-102.

Drug Brand Names

Aripiprazole • Abilify
Bupropion • Wellbutrin, Zyban
Celecoxib • Celebrex
Citalopram • Celexa
Clozapine • Clozaril
Divalproex • Depakote
Duloxetine • Cymbalta
Escitalopram • Lexapro
Fluoxetine • Prozac
Imipramine • Tofranil
Lamotrigine • Lamictal
Olanzapine • Zyprexa
Olanzapine/fluoxetine • Symbyax
Paroxetine • Paxil
Quetiapine • Seroquel
Risperidone • Risperdal
Selegiline • Emsam
Sertraline • Zoloft
Trazodone • Desyrel, Oleptro
Ziprasidone • Geodon

Disclosure

Dr. Crayton reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.