Brought to you by the Depression Is Real Coalition, The Down & Up Show is dedicated to the reality of depression. Our hosts will talk with some of the world's top experts on depression, as well as people who have been impacted by this illness. The reality of depression is that it is a debilitating and potentially deadly medical condition that affects more than 15 million Americans every year. The other reality of depression is that there is hope.

Down & Up Show #38: Obesity and Depression

DR. REEF KARIM:
So we're going to start now. Welcome to the Down and Up Show on depressionisreal.org. I'm your host for today's show Dr. Reef Karim, psychiatrist, addiction specialist and relationship therapist. Today we're talking to Dr. Gregory Simon of the Group Health Cooperative in Seattle, Washington, and he'll be speaking with us today about his research on the link between depression and obesity.

Dr. Simon is a psychiatrist and health services researcher at Group Health Cooperative as well as Chair of the Scientific Advisory Board for the Depression and Bipolar Support Alliance, and he works to improve the management of common mental disorders in both primary care and mental health specialty practices.

Dr. Simon's recent study association between obesity and depression in middle aged women was published in the Journal of General Hospital Psychiatry. Alright, thank you for joining us today Dr. Simon.

DR. GREGORY SIMON:
You're welcome.

DR. REEF KARIM:
Alright, so let's start out, just let's look at the obvious, why is it important to study the link between depression and obesity in middle aged women? What's the interest there? Why did you undertake this study?

DR. GREGORY SIMON:
Both of these problems are very common. Depression is one of the most important health conditions among women and especially among women in the middle ages where the rates of depression say current depression are as high as 10 or 15 percent, and the lifetime rates of depression are probably as high as 20 or 30 percent.

Obesity is common, and unfortunately growing even more common, so according to the official definition nearly 30 percent of Americans meet criteria for obesity, and the middle ages are often when obesity develops. So since these two problems are common and seem to especially overlap in this group, middle aged women, that's why our study focused on that.

DR. REEF KARIM:
And special interest, from your standpoint is it just the raw numbers, the epidemiology, hey there are a lot of people and they're middle aged that are obese, there's a lot of women. Usually numbers are twice as much as men that have depression so it just makes sense or is there some special reason that you were going this route in regards to research?

DR. GREGORY SIMON:
Previous research has suggested that there is a relationship that women who are depressed are more likely to be overweight or obese, and the reverse, women who are overweight or obese are more likely to be depressed. And any psychiatrist or even primary care physician who treats depression certainly has heard from many patients of course I'm depressed because I have so much trouble losing weight. So our patients certainly tell us there's a relationship there as well.

DR. REEF KARIM:
Okay. Well, let's talk about the study a little bit. Can you explain your methodology for the study; the screening criteria, who the participants were, how you went about formulating the study?

DR. GREGORY SIMON:
The study was conducted at Group Health Cooperative which is a prepaid health plan serving people in Washington State. So we were able to use the records of the health plan to identify women who were between the ages of 40 and 65. We mailed letters and then contacted people for a telephone survey, and the telephone survey asked about height and weight and it also included standard questions about depression, the PHQ or patient health questionnaire, a standard depression measure.

We also asked additional questions about physical activity and a brief measure to assess people's diet or their caloric intake. The response rate was about 60 percent, which is typical for surveys like this. But when we're able to use records to compare the women who responded and did not respond we don't see any big differences. So we don't think that there was any significant bias introduced because the response rate was only 60 percent.

DR. REEF KARIM:
And is that typical of the response rate you would expect?

DR. GREGORY SIMON:
In surveys like this that would be pretty typical. When you're doing surveys you're typically finding response rates between 50 and 70 percent in a study like this.

DR. REEF KARIM:
People not home, people don't want to talk, people are busy.

DR. GREGORY SIMON:
Right.

DR. REEF KARIM:
Okay. What's the relationship then between obesity and depression? What did you find in your study?

DR. GREGORY SIMON:
What we found in our study was that women who were overweight or obese were about twice as likely to report being depressed as women who were of normal weight. But the reverse is true too; women who were depressed were about twice as likely to be overweight or obese. So when we say there's a relationship of course by definition it goes in both directions.

What we saw in our study was a stronger relationship; there had been previous studies suggesting there was a relationship, but typically it was finding about a one and a half times increase in depression among people who were obese, while we found it was two to two and a half times more common.

DR. REEF KARIM:
Well, when you're depressed there's such a lack of motivation, concentration, attention, memory problems; there's a lot of cognitive affects as well. Does it, I mean, would you postulate that it's more I mean, it takes work for middle age people to keep, it's just the way it is.

So is it lack of motivation to exercise, to go to the gym, to watch your diet? Or is there actually a physiological connection, like we talked about coronary artery disease and depression, we talk about medical complications associated with depression. Is there some kind of weight satiety, physiological affect in the way that we put on pounds associated with depression? Or does it seem like it's more of a mental health cognitive thing?

DR. GREGORY SIMON:
Right. Well, we don't believe that there's something fundamentally different about metabolism in people who are depressed; a calorie is a calorie is a calorie. So people who are depressed and people and people who are not depressed we don't believe that their bodies burn calories any differently.

But it's likely that there are multiple causes for the relationship between obesity and depression. What we find not surprisingly is that people who are depressed report less physical activity; they burn up fewer calories in exercise every day. They also report that they eat more or consume more calories.

And as you know overeating is a very common symptom of depression; it's included in the diagnostic criteria for depression describe either losing appetite or increased appetite and overeating. Binge eating, especially among women is often a common symptom associated with depression. So there probably are more than one mechanism, probably both decreased physical activity and increased caloric intake.

DR. REEF KARIM:
Okay. In the discussion portion of your study you explain that your findings might overestimate your association between obesity and depression. Can you talk more about this to our audience?

DR. GREGORY SIMON:
If you look at the previous research, and there is actually interestingly is research going back 30 years or so about obesity and depression, what you find is some suggestion that the relationship between obesity and depression varies across different groups of people.

For instance, it looks like there may be a stronger relationship between obesity and depression in White women compared to Hispanic or African American women.

There may be a stronger relationship between obesity and depression in people who have a higher level of education or a higher household income. What this may mean is that people who are White, have higher educational attainment or have a higher income there may be more stigma associated with being obese, and therefore being obese or overweight may be more depressing.

Our study was done in people who had health insurance so they tended to be people who were more middle class, tended to be more educated probably than average and were more often White or Caucasian. So it may be that the women we were studying were the group of women where the relationship between obesity and depression is the strongest.

Other studies that have been done, for instance with larger numbers of African American women find a weaker relationship between obesity and depression. Rates of overweight and obesity are higher in African American women and there may be that there is less stigma associated with obesity.

I think that's one of the interesting ideas our study suggests that we've certainly begun to pay more attention to obesity and talk about it as a major public health issue, but we want to be careful not to stigmatize people who are obese because then we may just be making the problem worse by contributing to them being depressed and having even more difficulty losing weight.

DR. REEF KARIM:
Well, that's a major point. If you're obese we want to empower you to try to lose weight from a health standpoint, but depression, the onset of depression or the worsening of depression is absolutely a worse health condition. It's a major point.

DR. GREGORY SIMON:
And I think if we turn to what we know about helping people make other kinds of health behavior changes, whether it's related to losing weight or stopping smoking or increasing physical activity that the last thing we want to do is to scold people who are already discouraged. What we don't want to do is to continue to tell people how bad something is for them when they already know that.

The language we often use, to borrow from Bill Miller's motivational interviewing language, is the language of importance and confidence, that for some people the issue may be I don't yet recognize that this is an important problem. For those people we may need to talk about how unhealthy it is.

But a lot of people already know that they have a serious problem and they're struggling to deal with it, and they don't need to be told anymore that it's a serious problem because all that does is make them more discouraged. If people already recognize the importance, what we need to help them with is confidence, feeling more confident that they can make the changes.

DR. REEF KARIM:
It's interesting you mention Bill Miller and motivation interviewing, you know as an addition specialist we utilize motivational interviewing all the time. But it's a skill set that's not necessarily specific to the addiction world, it's specific to just anything, anytime that you're trying to, as you said use the language, the importance of confidence, in any way, whether we're dealing with an intervention or we're dealing with weight loss or we're dealing with any kind of behavioral change.

DR. GREGORY SIMON:
Oh, I certainly agree you know and I think it's a very powerful tool that's broadly applicable to help people make changes. And I think for people, whether they're psychiatrists or family doctors who deal with the issues of depression and obesity, it's very important to recognize that critical difference that what we don't want to do it is to take people who are overweight or obese and depressed and already feel discouraged and to simply scold them about not making progress.

Most people already recognize that their weight is a problem, they've often struggled for years and made many unsuccessful attempts to lose weight, and what they need is not more scolding, what they need is more encouragement and confidence building.

DR. REEF KARIM:
So for people in our audience look up motivational interviewing because it's definitely a skill, if you find the treatment provider it can really help in a lot of different cases for behavioral modification with family members or yourself. Let's keep going. So in your study you focused on women, but do you believe that you would have found similar results if you had researched depression and obesity in men?

DR. GREGORY SIMON:
Here the evidence is a bit mixed. Our study looked only at women, but if you look at previous research there is some evidence that there may be a stronger relationship between depression and obesity in women than there is in men.

There are some studies that have shown that it's about the same, some studies showing that there is a relationship in women and not in men, and there are even a few older studies saying that the relationship could be reversed in men that in men there may be lower depression among those who are overweight or obese.

We don't know the full explanation for that, but one possible explanation that once again relates to stigma, that being overweight or obese may be more stigmatized in women than it is in men.

DR. REEF KARIM:
Yeah. That's interesting. What are the treatment options available for people who suffer from depression and obesity both as opposed to just one or the other?

DR. GREGORY SIMON:
Well, when you're treating depression whether you're a psychiatrist or a primary care doctor you certainly need to be aware of overweight and obesity as something that often occurs with depression. What we find is that in women with severe depression well over half of them meet criteria for obesity and more than two thirds are overweight or obese.

So it almost goes without saying that women who are in treatment for depression the majority, maybe the overwhelming majority are going to have weight issues or to be overweight or obese. The things you need to consider certainly it's true that anti depressant medications can affect weight; there are some medicines that are associated with weight gain and that may not be something that patients are aware of, the weight gain may be gradual.

So providers certainly need to monitor for that and be aware of it and consider alternative medications if a medicine seems to be contributing to weight gain. In terms of counseling or psycho therapy it's certainly important to incorporate weight issues and physical activity into a psycho therapy program for depression. Most psycho therapy programs for depression do focus on re-activation, increasing involvement in positive activities, increasing social contact.

And we would argue based on the results of our studies and others that physical activity in people who are depressed can help in a variety of ways. There's certainly evidence that increased physical activity helps with depression, but if it also contributes to weight loss then you can get a double benefit.

DR. REEF KARIM:
Oh, that's great. Okay. What are some of the consequences of untreated depression in somebody who is also obese?

DR. GREGORY SIMON:
Well, our study was a cross sectional study. So we can say there's a relationship and we can only speculate about what comes first or what causes what. But there certainly have been longitudinal studies, studies that looked at are people who are overweight or obese more likely to become depressed, and the answer is yes, and are people who are depressed more likely to become overweight or obese, and the answer there is yes too.

There also is some evidence about the effects of treatment for obesity weight loss programs among people who are depressed. And what that evidence tends to say is that people who are depressed tend to drop out of weight loss treatment programs. That shouldn't be surprising since depression is all about feeling hopeless and discouraged and unworthy.

What the evidence says is that people who are depressed who stick with weight loss programs do lose weight, it's not that weight loss programs don't work for people who are depressed, but they tend to drop out so they may need more attention and encouragement to keep engaged.

DR. REEF KARIM:
Right. Well, what can be done to raise awareness about the effect depression has on people with other chronic diseases like obesity, not to mention the importance of physical activity and healthy habits among those suffering from depression?

DR. GREGORY SIMON:
Right. I don't think we need to do much to raise the awareness among the patients, you know I think people who struggle with depression and obesity together they're very well aware of this and we're not, interestingly the findings of our study will come as no surprise to the vast majority of people who live with these problems.

But what may happen is they may be seeing a doctor or a therapist about depression and may not think that weight, obesity, physical activity are really relevant to that. Or on the other hand they may be seeing somebody about weight loss and not think that they need to talk with them about depression.

So if anything the pe--the places where we need to raise awareness are among providers. People who treat depression need to think of obesity as being very interrelated with that and they have to think about it, and people who lead weight loss programs or help people lose weight need to be aware of depression and how that affects people's likelihood of dropping out.

DR. REEF KARIM:
Okay. Any closing thoughts, anything else about your study, about obesity, depression that you'd like to share with our audience?

DR. GREGORY SIMON:
Well, the main point that I'd want to emphasize to an audience of providers, especially family physicians or mental health providers who treat depression is to see obesity and depression as an interrelated thing and to realize that if you're going to make progress you're probably going to need to deal with both of those problems at once.

DR. REEF KARIM:
Well, that's great. I mean, I think this is a really enlightening discussion. Thank you for speaking with us today Dr. Simon.

DR. GREGORY SIMON:
You're very welcome.

DR. REEF KARIM:
Great. And join us next week for another segment of the Down and Up Show on depressionisreal.org. I'm Dr. Reef Karim.