The Vicious Cycle
In my private psychotherapy practice, as well as the TMS treatment component, many of my patients struggle to achieve or maintain a healthy body weight. They tell me about their frustrating efforts with the latest weight loss plan or supplement, even though they report that they’ve “tried just about everything”.
Weight Loss is a National Obsession!
The U.S. media has latched on to the weight loss issue to strike an emotional chord in the vast majority of consumers. But even so, Americans weigh more today than ever before. And they are getting heavier every year.
Studies on weight loss and obesity reveal a disturbing trend toward a ‘thinness bias’ – in the media and our public health system. The struggle to be thin is fast becoming the cause of drastic eating disorders and other serious psychological problems among both overweight and non-overweight individuals.
Overweight Conditions – What are the Health Risks?
A woman whose waist measures more than 35 inches and a man whose waist measures more than 40 inches may be at particular risk for developing health problems. Studies indicate that increased abdominal or upper body fat is related to the risk of developing heart disease, diabetes, high blood pressure, gallbladder disease, stroke, and certain cancers; and is associated with overall increases in mortality (likelihood of death).
It is discouraging for my patients to realize that many drugs prescribed for high blood pressure, diabetes and depression – conditions common to individuals with overweight issues – may increase the likelihood of more weight gain, and set in motion a very frustrating circle.
What Conclusions Do Medical Studies Publish?
In this first article, ‘Part 1’, we will discuss a variety of findings within a variety of curated medical studies that offer data, insights and suggestions related to the question…
“Does overweight and obesity increase the risk of developing depression, or does depression increase the risk of developing overweight and obesity?”
(Note: In ‘Part 2’, we will explore and focus more closely on treatment options, with suggestions and hope for breaking this “Vicious Cycle”.)
Now, let’s look at the factors that place us in this position.
The Prevalence of Overweight and Obesity in the U.S.
More than two-thirds of American adults are overweight or obese, according to the Centers for Disease Control and Prevention. A person’s body mass index (BMI) is considered to be the standard for determining body weight classifications:
- 5 – 24.9: Normal
- 0 – 29.9: Overweight
- 0 – 39.9: Obese
- Above 40: Extremely obese
Here’s how to calculate BMI.
The Cycle Involves Medications
Multiple studies confirm that obesity in the U.S. is increasing at an alarming rate. This weight gain is especially troublesome as it also heightens a person’s risk of physical problems, such as diabetes and cardiovascular disease. Additionally, overweight and obese individuals are at risk for numerous psychological and physiological health problems, such as depression and disordered eating.
A 2010 study found that people with depression were at a 58% greater risk of becoming obese (30-39.9 BMI).
“It’s a vicious cycle because patients already at risk for weight-related health conditions often receive medications that can exacerbate their problems,” said Kelly Lee, PharmD, associate professor of clinical pharmacy and associate dean of UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences.
Antidepressants and Average Monthly Weight Gain
Major depressive disorder (MDD) can be a chronic condition involving recurrent episodes throughout a patient’s life. In order to reduce the chance of relapse, long term treatment with antidepressants is often deemed necessary.
Other Studies have found that antidepressants lead to increased body weight, in anywhere between 24-100% of patients. The average weight gain has been documented at 3.02 pounds per month of treatment. So we clearly see how that could easily translate into a weight gain of 72 pounds or more over two years.
Many patients choose to discontinue antidepressant medication due to the long term side effects resulting from these drugs – one of which is consistent weight gain over time.
Weight Gain Linked to Certain Types of Antidepressants
Among the antidepressants most strongly linked to clinically significant weight gain (defined as at least a 7 percent increase in body weight), include older tricyclic antidepressants, such as amitriptyline (Elavil) and nortriptyline (Pamelor), as well as newer medications, such as paroxetine (Paxil) and phenelzine (Nardil).
The antidepressant mirtazapine (Remeron) is so potent at promoting weight gain that it is sometimes prescribed to underweight senior adults and AIDS patients.
Ibupropion (Wellbutrin and Zyban), however, actually promotes weight loss and is used for depression and smoking cessation, Lee said.
Antipsychotics and Other Psychotropic Drugs
Second-generation antipsychotic drugs, such as olanzapine (Zyprexa) and Clozapine (clozaril), can induce a triad of symptoms – dramatic weight gain, diabetes and elevated blood cholesterol levels – that are associated with metabolic syndrome.
Results from the 2005–2010 surveys show that 34.6% of U.S. adults aged 20 and over were obese and 7.2% had depression. Other studies have shown higher rates of obesity in persons with depression. This relationship may vary by sex, with women outranking men. Almost 11% of adults take antidepressant medications, including persons who are responding well and persons who still have moderate to severe symptoms of depression.
Additional study outcomes related to depression and obesity include:
- 43% of adults with depression were obese.
- Adults with depression were more likely to be obese than adults without depression.
- In every age group, women with depression were more likely to be obese than women without depression.
- The proportion of adults with obesity rose as the severity of depressive symptoms increased.
- Fifty-five percent of adults who were taking antidepressant medication, but still reported moderate to severe depressive symptoms, were obese.
Antidepressant Usage and Obesity
Understanding the relationship between depression (defined by moderate to severe symptoms) and antidepressant usage and obesity may indicate treatment and prevention strategies for both conditions.
More than one-half of adults with moderate to severe depressive symptoms, who were also taking antidepressant medication, were obese.
- Among adults who took antidepressant medication, of those with moderate or severe depressive symptoms, 55% were obese while 38% with mild or no depressive symptoms were obese (Figure 5).
- Among adults not taking antidepressant medication, 39% of adults with moderate or severe depressive symptoms were obese compared with 33% of adults with mild or no depressive symptoms.
Adults who took antidepressant medication were more likely to be obese than those not taking antidepressants.
While the physical health costs of obesity have become increasingly clear, the existence and nature of a relationship between obesity and mental health in the general population has been less clear.
Cause or Effect – or Both?
It is quite interesting to review the first meta-analysis of: 1.) whether overweight and obesity increase the risk of developing depression and 2.) whether depression increases the risk of developing overweight and obesity.
In summary, there are bi-directional associations between depression and obesity:
- obese persons had a 55% increased risk of developing depression over time, whereas
- depressed persons had a 58% increased risk of becoming obese.
Time Possibly Plays a Role in Depression and Obesity
The unfavorable effect of depression on development of obesity, and the effect of obesity on development of depression, may be reinforced by time. The earlier-described cross-sectional association was only present in women. However, a longitudinal meta-analysis confirms a reciprocal association between obesity and depression in both men and women.
Biological Link Between Overweight, Obesity, and Depression
Although evidence of a biological link between overweight, obesity, and depression remains complex and not definitive, it seems relevant to describe the possibility of biological pathways:
Obesity can be seen as an inflammatory state, as weight gain has been shown to activate inflammatory pathways and inflammation in turn has been associated with depression. Because inflammation plays a role in both obesity and depression, inflammation could be the mediator of the association.
- HPA AXIS
Also, the hypothalamic-pituitary-adrenal axis (HPA axis) might play a role, because obesity might involve HPA-axis dysregulation and HPA-axis dysregulation is well known to be involved in depression. Through HPA-axis dysregulation, obesity might cause development of depression.
- INCREASED INSULIN RESISTANCE
Finally, obesity involves increased risks of diabetes mellitus and increased insulin resistance, which could induce alterations in the brain and increase the risk of depression.
In addition to biological mechanisms, psychological pathways should be mentioned. They include:
- BODY DISSATISFACTION
Being overweight and the perception of overweight increases psychological distress. In both the United States and Europe, thinness is considered a beauty ideal, and partly because of social acceptance and sociocultural factors, obesity may increase body dissatisfaction and decrease self-esteem, which are risk factors for depression.
- EATING DISORDERS
Disturbed eating patterns and eating disorders, as well as experiencing physical pain as a direct consequence of obesity, are also known to increase the risk of depression.
These data lead to the conclusion that depression and obesity interact reciprocally.
In Part 2 we will consider these findings, and discuss ‘Implications for Patient Treatment’. Our goal is to offer patients alternative treatment options that break this Vicious Cycle. With TMS, we can start them on the path to improved health, both physically and psychologically.