1. BASELINE BMI DOES NOT PREDICT SIX MONTH REMISSION RATE FOR DEPRESSION MANAGED UNDER COLLABORATIVE CARE MANAGEMENT Kurt B. Angstman, MS MD Todd W. Wade, MD Department of Family Medicine Mayo Clinic Rochester, Minnesota, USA European Psychiatric Association April 2013

2. Obesity and Depression: co morbid conditions. Obesity is common in depressed patients Obesity is common in depressed patients At least 25% of depressed women At least 25% of depressed women Simon GE, Von Korff M, Saunders K, et al. Association between obesity and psychiatric disorders in the US adult population. Arch Gen Psychiatry. 2006;63:824-830. Simon GE, Von Korff M, Saunders K, et al. Association between obesity and psychiatric disorders in the US adult population. Arch Gen Psychiatry. 2006;63:824-830. Apparent bi-directional relationship Apparent bi-directional relationship Obesity at baseline increased the risk of onset of depression (unadjusted odds ratio [OR] = 1.55) Obesity at baseline increased the risk of onset of depression (unadjusted odds ratio [OR] = 1.55) Depression at baseline increased the odds for developing obesity (OR = 1.58) Depression at baseline increased the odds for developing obesity (OR = 1.58) Luppino FS, de Wit LM, Bouvy PF, et al. Overweight, obesity, and depression: a systematic review and meta-analysis of longitudinal studies. Arch Gen Psychiatry. 2010;67:220-229. Luppino FS, de Wit LM, Bouvy PF, et al. Overweight, obesity, and depression: a systematic review and meta-analysis of longitudinal studies. Arch Gen Psychiatry. 2010;67:220-229.

3. Collaborative Care Management: Primary Care tool for depression treatment Consists of: Consists of: Disease registry Disease registry Guidelines for evidence based care Guidelines for evidence based care Care manager to coordinate care between the patient, primary care provider and mental health specialist Care manager to coordinate care between the patient, primary care provider and mental health specialist Oversight and management by psychiatrist Oversight and management by psychiatrist Patient care is maintained by primary care Patient care is maintained by primary care Effectiveness demonstrated in meta- analysis of 37 randomized studies. Effectiveness demonstrated in meta- analysis of 37 randomized studies. Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med. 2006; 166:2314-2321. Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med. 2006; 166:2314-2321.

4. Study Design Retrospective chart and database review Retrospective chart and database review 1, 587 adult primary care patients 1, 587 adult primary care patients Diagnosis of Major Depressive Disorder or Dysthymia Diagnosis of Major Depressive Disorder or Dysthymia PHQ-9 score ≥ 10 PHQ-9 score ≥ 10 1,111 patients had complete data with six month follow up PHQ-9 information 1,111 patients had complete data with six month follow up PHQ-9 information Angstman KB, Wade TW, DeJesus RS, Rundell JR, Altrichter PM. Patient BMI does not predict six month clinical outcome of depression managed under collaborative care. Journal of Primary Care and Community Health. 2012 Jul 17. DOI: 10.1177/2150131912454012 Angstman KB, Wade TW, DeJesus RS, Rundell JR, Altrichter PM. Patient BMI does not predict six month clinical outcome of depression managed under collaborative care. Journal of Primary Care and Community Health. 2012 Jul 17. DOI: 10.1177/2150131912454012

5. Hypothesis Impact of baseline BMI at the time of enrollment into CCM on depression outcomes, while controlling for other clinical variables. Impact of baseline BMI at the time of enrollment into CCM on depression outcomes, while controlling for other clinical variables. Our hypothesis was that initial obesity (BMI ≥ 30 kg/m2) and morbid obesity (BMI ≥ 40 kg/m2) would each have negative effects on depression remission rates 6 months after enrollment into CCM. Our hypothesis was that initial obesity (BMI ≥ 30 kg/m2) and morbid obesity (BMI ≥ 40 kg/m2) would each have negative effects on depression remission rates 6 months after enrollment into CCM.

6. Percentage of patients with BMI categories (N=1 587) at diagnosis of depression and enrollment into CCM

7. Depression outcomes at six months, by baseline BMI (p=0.93)

8. Odds ratio for depression remission at six months, by original BMI category (controlling for age, gender, race, marital status, diagnosis, depression severity, GAD-7, AUDIT and MDQ scores.)

9. Conclusions Found that our initial hypothesis was not demonstrated. Found that our initial hypothesis was not demonstrated. The patient’s baseline BMI category was not an independent predictor for depression outcome six months after enrollment in CCM. The patient’s baseline BMI category was not an independent predictor for depression outcome six months after enrollment in CCM. Only 27.4% of our depressed patients had a normal BMI at the time of diagnosis and enrollment into CCM Only 27.4% of our depressed patients had a normal BMI at the time of diagnosis and enrollment into CCM A negative impact of obesity on remission of depressive symptoms would have had significant clinical implications A negative impact of obesity on remission of depressive symptoms would have had significant clinical implications Based on these results, BMI was not independently associated with outcomes at six months. Based on these results, BMI was not independently associated with outcomes at six months.

10. Conclusions Collaborative care management for depression has been shown to be effective for improving depression outcomes Collaborative care management for depression has been shown to be effective for improving depression outcomes Minimal prior research has focused on other clinical comorbidities that might impact outcome in this model. Minimal prior research has focused on other clinical comorbidities that might impact outcome in this model. While obesity was common in our study population While obesity was common in our study population It was reassuring, based on this study that six month depression treatment outcomes do not appear to be significantly impacted by the patient’s baseline BMI. It was reassuring, based on this study that six month depression treatment outcomes do not appear to be significantly impacted by the patient’s baseline BMI.

11. Je vous remercie! angstman.kurt@mayo.edu angstman.kurt@mayo.edu angstman.kurt@mayo.edu wade.todd@mayo.edu wade.todd@mayo.edu wade.todd@mayo.edu