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Obesity and Depression

by David Engstrom, PhD

Spring 2007

What researchers know, and most people assume, is that individuals with excess weight often suffer from depression. What is less clear is which comes first. Could the effects of being seriously overweight directly lead to depression, or does depression itself cause excess weight gain in the first place? Probably, the answers are “yes” and “yes,” and it may not matter in any practical sense. Depression and weight gain go hand-in-hand.

Certainly, increased appetite, reduced activity and weight gain can be symptoms of depression, and people with depression are more likely to binge eat and less likely to exercise regularly. Both depression and obesity have strong genetic links, so children of people with either or both problems are more predisposed to have them as well. In addition, many prescribed antidepressant medications cause weight gain as side effects.

One recent study found that overall, individuals affected by obesity have a 20 percent elevated risk of depression, and specifically for Caucasian college-educated people with obesity, the depression risk rises to as high as 44 percent. Although females with obesity have previously been found to suffer more depression, this study showed that there were no differences between sexes.

Obesity Defined

One standard measure of obesity is weighing more than 20 percent greater than the ideal body weight for a given height. Another definition is having a body mass index (BMI) of more than 30. According to recent findings, approximately one third of the U.S. population is affected by obesity.

What is Depression?

Defining depression has always been a puzzle. Many people are depressed but don’t know it. Others may seem depressed to friends but really aren’t. It seems that we all have stereotypes of what depression is, but they aren’t always accurate in reality.

One way to understand depression is to see it as consisting of two factors, or primary components. They are the psychological or “cognitive” component which affects mood, and the physical or “somatic” component which influences areas such as sleep and appetite. Viewing depression in this way sometimes helps to determine the primary cause of the problem.

A recent World Health Organization (WHO) report identified depression as “the number one cause of disability in the United States and the third largest, behind heart disease and stroke, in Europe.”

How to Measure Depression

One of the most commonly-used and respected instruments to measure depression is the Beck Depression Inventory (BDI).

The cognitive subscale contains eight items:

  • Pessimism
  • Past failures
  • Guilty feelings
  • Punishment feelings
  • Self-dislike
  • Self-criticalness
  • Suicidal thoughts or wishes
  • Worthlessness

The somatic subscale has 13 items:

  • Sadness
  • Loss of pleasure
  • Crying
  • Agitation
  • Loss of interest
  • Indecisiveness
  • Loss of energy
  • Change in sleep patterns
  • Irritability
  • Change in appetite
  • Concentration difficulties
  • Tiredness and/or fatigue
  • Loss of interest in sex
What Could the Connection Be?

Stop and think about all the possibilities for depression to accompany obesity. To begin with, childhood obesity frequently leads to painful ridicule and exclusion from peer activities. Problems with body image, social isolation and self-esteem might easily follow. Being seriously overweight at any age is a major source of dissatisfaction, sadness and frustration. Extra pounds often cause chronic joint and extremity pain, making individuals less able to get around, enjoy life or exercise.

Serious illness such as diabetes, hypertension and sleep apnea can threaten or shorten life. People with excess weight are often stereotyped and discriminated against by airlines, department stores, insurance companies and even doctors.

Depression after Weight-Loss

Several recent studies have found significant improvements in depression following major weight-loss. This finding has been reported in a large group of patients after gastric restrictive procedures. Younger patients, women and those with greater excess body weight loss after surgery had the greatest improvement on their BDIscores.

What Happens after Bariatric Surgery?

In a study of depression in our own bariatric surgical population at Scottsdale Bariatric Center, approximately 2,005 consecutive patients were evaluated for depression before and after surgery, as well as post-surgical weight loss. We defined improvement of depression in three areas:

  • Cognitive (reduced thoughts of worthlessness, hopelessness and personal failure)
  • Affective (reduced feelings of sadness, frequent crying and   mood swings)
  • Physiological (increased energy level and better sleep habits)

It was found that 24 percent of those patients were diagnosed with depression prior to surgery, a finding very consistent with national norms. Six months after surgery, there was a 62.5 percent decrease in excess body weight, accompanied by a 13 percent reduction of depressive symptoms, while at 12 months after surgery, there was a 76.9 percent loss of excess body weight, as well as an 18 percent resolution of depression. It may be surmised from our data that loss of excess body weight following bariatric surgery is accompanied by a reduction of depressive symptoms.

Tips for Avoiding Depression after Treatment

Exercise – There is no doubt that regular physical exercise and activity is the cheapest and most efficient way to control your mood. Not only does exercise release brain chemicals which fight depression, it also gives a person a greater sense of control over his or her life.
Get rid of anger – Remember, an old definition of depression is “anger turned inward.” Unresolved resentment can damage both your relationships and health. Chronic anger and hostility can be your worst enemies. If anger is a problem, try taking an anger or stress management class to learn techniques to ward off long-standing angry feelings.
Keep a positive attitude – There is an entire field called “positive psychology,” which has grown from research that indicates the people with positive attitudes fight disease better and live healthier lives. I know it’s easier said than done, but remember the famous saying of Abraham Lincoln… “Most folks are about as happy as they make up their minds to be.”
Don’t take yourself too seriously – This is a tip that I’ve learned both from my own life and many of my patients. Humor is an important part of life. Some people have the ability to laugh at themselves, while others don’t. And each day, everything changes anyway. Laughing is good for all of us. Seeing the silly parts of life may give you a fresh point of view and change your mood.
Stay motivated – Try to set a goal for yourself, and then develop a plan of simple, small steps to get to the goal. Perhaps exercise is a good place to start. The keys to motivation are to not get overwhelmed with a goal that is too big or unrealistic, and to write things down to keep track of progress.
Talk to someone – If you were seeing a mental health professional before treating your obesity, keep in touch with them after as well. Remember, treating your obesity has a major emotional impact, and your life will change. Although these changes are mostly for the better, it is a good idea to have someone other than family or friends to talk to as you adjust to your new life.
Use medications if prescribed – If you were taking prescribed antidepressant medication before treating your obesity, check with your doctor to see if you can remain on it. It may give you that “boost” you need during your recovery. Many of our patients have found that they can reduce or eliminate these medications after they see changes in their weight and quality of life.

About the Author:
David Engstrom, PhD, is a clinical health psychologist, board certified in Clinical Psychology. He practices in Scottsdale, Arizona and is a psychologist at Scottsdale Bariatric Center. Dr. Engstrom is an active member of the American Society for Bariatric Surgery and is a specialist in applying mindfulness techniques to long-term weight management. Dr. Engstrom currently serves on the OAC Advisory Board.

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