1. Depression and Obesity: An Update Leslie J. Heinberg, Ph.D. Associate Professor, Cleveland Clinic Lerner College of Medicine Director, Behavioral Service Bariatric & Metabolic Institute

2. Overview Depression Depression in Obesity Depression in Bariatric Surgical Candidates Depression and Outcome following Bariatric Surgery – Weight Loss – Reduction in Depression

3. Depression and Obesity

4. Depression 20.9 million American adults or 9% of the population have a mood disorder – Major Depression – depressed/irritable – loss of interest in previously pleasurable activities – problems with eating and sleeping – guilt – low energy – difficulty concentrating – thoughts about death – at least 2 weeks duration Women are twice as likely to have depression than men

5. Depression and Obesity: Cause and/or Effect Direct positive association between obesity and depression in women 1 – 1 in 7 obese women have depression – 37% higher rate than normal-weight women Either negative or no association in men 2 – 1 in 14 obese men have depression Both men and women with BMI≥40 are more likely to have Major Depression 3 – Population-based studies demonstrate 5x as likely to have had depressive episode in last year 1.Fabricatore & Wadden, 2006 2.Allison et al., 2009 3.Onyike et al., 2003

6. Depression and Obesity: Cause and/or Effect In adolescents, baseline depression wasn’t associated with obesity but depressed mood at baseline independently predicted obesity at 1 year follow-up 1 – Baseline obesity didn’t predict depression at follow-up In older adults (≥50), non-obese depressed subjects at baseline were not more likely to become obese over 5 years than non-depressed subjects 2 – However, non-depressed obese subjects were twice as likely to develop depression over the next 5 years Thus, relationship may relate to age 1.Barefoot et al., 1998 2.Heo et al., 2006

7. Depression and Obesity: Cause and/or Effect Depression as a maintaining or exacerbating factor of obesity – Appetite disturbance is key feature – Close association between binge eating disorder and depression (~50%) – Avolition and loss of energy – Majority of mood stabilizers and anti-depressants have weight gain side effects

8. Depression and Obesity: Cause and/or Effect Obesity as a maintaining or exacerbating factor of depression – Body image disturbance – Stigmatization, Discrimination and Prejudice – Medical comorbidities

9. Depression in Bariatric Surgery Candidates

10. Prevalence in Bariatric Populations Most common diagnosis 25-30% of surgical candidates report depression at time of evaluation 1,2 50% report lifetime prevalence of mood disorder or an anxiety disorder 1,2 – 22-24% have lifetime prevalence of a Axis II (personality) disorder 72.5% report a lifetime history of psychotropic medication use (87.7% were anti-depressants) 3 – 47.7% rate of current use 1.Kalarchian et al., 2007 2.Mühlhans et al., 2009 3.Pawlow et al., 2005

11. Depression predicts other co-morbidities (Ali et al., 2009) Poorer quality of life – Physical – Psychological Greater prevalence of certain co-morbidities among depressed patients – Independent of BMI – dyslipidemia, GERD, back pain, joint pain, sleep apnea, stress incontience and hernia

12. Depression as a Contraindication AACE/TOS/ASMBS 2009 Guidelines – “The only contraindications to bariatric surgery are persistent alcohol and drug dependence, uncontrolled severe psychiatric illness such as depression or schizophrenia, or cardiopulmonary disease that would make the risk prohibitive” NIH Consensus Statement on Gastrointestinal Surgery for Severe Obesity (1991) – “Absence of uncontrolled psychotic or depressive disorder”

13. Medication Concerns Pharmacokinetics of psychotropic medication after surgery are not well understood 1 – RYGB typically transitioned from sustained-release formulations – Modeled dissolution rates of anti-depressants are highly divergent (increased, decreased, unchanged) – In vivo studies of serum drug levels are needed Close monitoring of patients is necessary 1. Love et al., 2008

14. Depression and Bariatric Surgery Outcome

15. Depression and Outcome Very inconsistent findings in the literature

16. Impact of antidepressant use post-RYGB and weight loss (Love et al., 2008) BMI

17. Behavioral predictors of weight regain (≥15% from nadir) post-RYGB (Odum et al., 2009) Baseline Depression Score

18. Number of psychiatric disorders and weight loss post LAGB (Kinzl et al., 2006) BMI units lost >30 months

19. Relationship of depression to 6 month RYGB outcomes (Kalarchian et al., 2008) Reduction in BMI

20. Mood Disorders and Weight Loss in LSG (Semanscin- Doerr, Windover, Ashton & Heinberg, in press)

21. Depression and Weight Loss Outcomes Depression does not consistently predict weight loss after WLS – Negative affect that is related to patients’ distress about obesity may facilitate weight loss after surgery – Major depression or other psychopathology independent of body weight may be associated with sub-optimal outcomes. Poorer outcomes may still be markedly positive

22. Effect of RYGB on depression outcomes (Thonney et al., 2010) Depression Severity

23. Effect of RYGB on depression and quality of life (Masheb, 2007)

24. Excess deaths by suicide following WLS

25. Weight Loss and Depression Outcomes Clear positive benefit on depression due to weight loss surgery – Similar findings for psychological quality of life Concerning findings on increased risk of suicide after 1 st year – Depression screening needs to continue at all follow-up appointments – Argues for continued multidisciplinary follow-up

26. Pre-operative AssessmentInpatient post- operative stay 1 month F/U3 month F/UOther post-operative appointments Assessment Objective Testing/ Questionnaire MMPI-2-RF; elevations on the following flagged for evaluation  Demoralization  Low positive emotions  Dysfunctional negative emotions  Helplessness/Hopelessness  Suicide As neededScreening questionnaire given to all post-operative pts. Clinical Interview When any of the following are positive, full diagnostic criteria for mood disorders are assessed  Low or irritable mood  Anhedonia  Past or current mood diagnosis  Past or current outpt. MH treatm.  Past inpt. psychiatric hosp.  Past or current psychotropic medication  Past suicide attempts As neededClinical interview to follow-up on:  Any psychological complications  Failure to return to psychotropic medications  Failure to return to mental health treatment Treatment Current and/or not optimally managed Stabilization or current mood disorders are required prior to clearance  Mild symptoms=referral to PCP for medication  Mod-Severe symptoms=referral to psychiatrist and recommendation for psychotherapy  Reassess and review records prior to surgery  Patient informed and IP staff aware that treating psychologist is available by pager for worsening symptoms  Utilization of C/L psychiatry  Use of NPO formulations Referrals and recommendations analogous to pre-operative plan Follow-up appointment given with BMI Psychology Well-managed Review  Past mental health care records  Time-release formulations of psychotropics and recommend switch to regular formulation prior to surgery Resume psychotropic medication once off of NPO Encourage to adhere with current regimen

27. Thank you Contact: heinbel@ccf.org