Obesity: When mental health evaluation is required

You’ve tried everything to cut weight. But it seems that no matter what you do, you always end up – late at night with your arm half-encircling a bowl of ice cream – greedily downing decadent dairy to push down the doldrums.

Or maybe chips are your thing. Whatever crashing-and-burning looks like to you personally, the experience of skewering a well-laid diet plan at the 11th hour is quite universal. It can even be comical; no one’s perfect, after all.

However, for many who are obese, the struggle to lose weight goes much deeper than having to make difficult choices and stick with them. Obesity is associated with higher rates of certain mental disorders, like depression, and experts say those can hamstring the most adamant efforts to shed pounds and keep them off.

“Data is mounting that people who are depressed or have binge eating disorder … the two go together very frequently – will have a harder time losing weight, compared to people who are emotionally well,” says Susan McElroy, chief research officer at the Lindner Center of HOPE, a private psychiatric facility in Mason, Ohio.

McElroy, a professor of psychiatry and neuroscience at the University of Cincinnati College of Medicine, has closely studied the link between mental health and obesity. “Obesity is so hard to treat, and it so often co-occurs with mental disorders that I think [all] people with obesity should receive a comprehensive mental health evaluation.”

That could involve seeing a psychiatrist or psychologist, for example, to undergo an assessment for depression and binge eating, as well as other mental health conditions like bipolar disorder, which is also more common in people who are obese. “Obesity is also associated with anxiety disorders [and] attention deficit-hyperactivity disorder,” McElroy says.

Though still only a minority of people who are obese suffer from psychological issues like depression, Dr. Philip R. Muskin, chair of the Scientific Program Committee of the American Psychiatric Association, agrees that checking for mental conditions makes sense. “When you’re depressed it may be very difficult to make healthy choices,” he says, including eating well.

However, he thinks this could be accomplished, to start, through screening in a primary care setting, such as by having patients take a simple health questionnaire that gauges depression. “Not just for obese patients, for every patient in primary care practice, I think it’s worthwhile to do this screening,” Muskin says, pointing out that depression is also independently strongly linked to cardiovascular disease. “It’s an important health consideration.”

That’s not to say that simply treating a mental health disorder known to be associated with a higher rate of obesity will necessarily lead to weight loss in an obese individual. McElroy points out that research she’s undertaken finds even successfully treating binge eating disorder with antidepressants only led to a small reduction in the body weight of usually about 2 or 10 pounds over six to 10 weeks in study subjects.

In other cases, treating issues like depression in obese individuals – whether through medication and/or talk therapy – didn’t precipitate losing weight at all. In addition, certain antidepressant medications like Prozac can increase a person's appetite, making it that much harder to control portions.

Still, not treating underlying mental health issues, experts say, most assuredly makes it more difficult for many people to tackle obesity or maintain weight loss over the long term. “You can see vicious circles frequently – where somebody gets depressed, they start gaining weight … they’re less likely to go out and do things,” says clinical psychologist Patrick M. O'Neil, past president of The Obesity Society, which fosters research and seeks to improve the treatment of obesity.

A person who is depressed is likely to slow down – to be less physically active, he adds, and though some who are depressed eat less, others eat more. “They’re more likely to gain more weight. The more weight they gain, the more unhappy they become.”

O’Neil says this increase in appetite is seen in a variant of depression called seasonal affective disorder, which tends to coincide with shorter days, when there’s less sunlight. People who suffer from this disorder may be drawn to consume carbohydrates or just eat more food overall, in addition to sleeping more, O’Neil says.

Experts recommend considering whether you have a history of depression or other mental health disorders that could complicate weight-loss efforts.

To better understand the patterns in one’s own life, O’Neil suggests creating a weight graph that tracks fluctuations. Take a look at when weight problems started and see if they coincide with mood changes, particularly depression. “Because if you are trying to lose weight, you are having to do some things that take significant energy – physical and psychological,” he says, like making behavioral changes.

He adds that makes it important to be sensitive to the impact of properly managing depression. “Food for most all of us is a source of reward and enjoyment and pleasure,” O’Neil says, adding it can also be a comfort. Since depression makes it harder to derive pleasure from things, not getting to eat one’s favorite foods – or at least as much of them – can prove a double whammy.

“So we do encourage people to find some other sources of enjoyment – some rewarding activities that they can engage in,” O’Neil says. “That sounds kind of trivial, but it’s important.” It could be anything from going on a hike or taking a walk in the park to taking up a new hobby and spending more time visiting with family and friends.

Exercise can also lift one’s spirits – and help combat depression, research shows – while also burning calories. “I advise every single one of my patients to exercise,” Muskin says, irrespective of whether they’re trying to shed weight. He notes that there’s strong data supporting the health benefits of getting at least 150 minutes of aerobic exercise weekly, as is widely recommend.

Treating the mind as one seeks to improve the body also requires, Muskin says, viewing mental disorders through the same prism as any other malady, like pneumonia. “[If we’re] helping patients see that depression is really an illness and it should be treated, then we’re not stigmatizing people. I think we’re putting people in control of their own lives,” he says. And experts say that, for some, addressing the mental health component could be critical to getting weight under control, too.