Wednesday, February 1, 2012

Obesity and Mental Health – Beyond Pharmacotherapy

Continuing my posts on the recent articles on obesity and mental health published in the January issue of the Canadian Journal of Psychiatry, I now turn my attention to a paper by Valerie Taylor and colleagues on the many links between mental health issues and obesity.

Whilst in the previous post I have focussed on the relationship between psychiatric medications and weight gain, a problem that is common knowledge to the mental health community, this article highlights many of the lesser known links between mental health problems and excess weight. These include interesting neurobiological, psychological, and sociological factors, that are now increasingly understood.

For e.g.

“‘Atypical’ depression, a type of major depressive disorder characterized by an increase in the need for sleep and food, may actually characterize the most ‘typical’ presentation of major depression For the majority of people with depression, therefore, a diagnosis of major depression is synonymous with a phenotype that increases vulnerability towards weight problems.”

In fact,

“The neurobiology of depression [also] confers increased risk of obesity. The most common biological perturbation associated with depression is an increase in cortisol. This increase, and the hypothalamic pituitary adrenal axis abnormalities that accompany it, is similar to changes seen in Cushing syndrome, an endocrinological illness caused by an increase in cortisol that is characterized phenotypically by excessive visceral weight gain. While levels of cortisol found in major depression disorders are much lower than that of Cushings, the biological impact of excess cortisol is similar; a predisposition towards increased deposition of centrally located adipose tissue.”

In addition mood disorders often affect sleeping behaviour, which in turn affects important regulators of appetite and metabolism like ghrelin, leptin, adiponectin, and other hormones. Moreover, chronic inflammation may play a role in both major depression and obesity.

In the case of schizophrenia, primary negative symptoms like amotivation, which can be observed even in the earliest stages of the illness, may lead to reduced physical capacity and altered self-perception. Hypodopaminergic activity may in part explain increased propensity for substance use, especially cannabis, which can promote hyperphagia.

There is an increasingly recognized association between obesity and attention deficit disorder, and it may well be that impulsivity may play an important role in overeating.

Also,

“Poor planning and an inability to delay reward, processes largely mediated by the pre-frontal cortex, may lead individuals with ADHD to over-consume highly palatable, fattening foods. A related hypothesis is that individuals with low intrinsic dopamine activity in brain areas mediating reward may attempt to compensate by using various reinforcing behaviors including increased food consumption. This has been termed the “reward deficiency syndrome” and has been described separately in ADHD and in obesity suggesting that ADHD and obesity may thus reflect different manifestations of a single biological change related to low dopamine activity in prefrontal attentional areas and brain reward pathways.”

The paper also discussed findings showing that ADHD is associated with more media consumption, less participation in physical activity and organized sports.

Finally, the paper examines the literature on the relationship between obesity and childhood adverse events like sexual, mental, physical abuse and emotional neglect, which can have important impacts on the hypothalamic-pituitary-adrenal axis as well as on sex hormones that may promote fat accumulation.

“The use of food as a coping strategy or a “self-soothing behavior” is seen in both trauma patients and in those with mood disorders, and it may be related to the use of food to modulate neurotransmitters involved in affect control. Most work in this area has focused on serotonin and dopamine, both of which play a critical role in both eating behavior and mood regulation. It may be that the ability of certain foods to temporarily boost mood can create a behavioral cycle where food is consumed to control feelings of sadness.”

As readers of these posts may be well aware,

“The relationship between trauma and weight is especially evident during weight loss treatment programs and in bariatric surgery programs, a past history of trauma can be a harbinger of post-operative problems. Food and weight gain in response to abuse may be related to a desire to become “bigger” to be able to defend against an abuser, it may have been a way to change appearance when an individual inaccurately felt they were somehow provoking the abuse or it may have become a surrogate comfort mechanism when appropriate supports failed.”

Thus, clinicians (and patients) must be aware of the complex relationship between obesity and mental health issues that go well beyond just the issue of weight gain with psychiatric medications (which of course further compound these issues).

All the more reason, why all health professionals called upon to manage obesity should be well versed in recognizing and helping patients address mental health problems.

AMS
Edmonton, Alberta

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6 Responses to “Obesity and Mental Health – Beyond Pharmacotherapy”

  1. Christina RD says:

    Another interesting post. I agree with most of it but in my clinical experience, around 75% of my clients who are admitted with major depressive disorder have a lack of appetite, find food doesn’t have any appeal, and they may be experiencing weight loss as a result. Of course having a poor appetite can further exacerbate a low mood and low energy.

    I have read studies showing that seasonal affective disorder is more likely to be associated with weight gain than other types of depression. Weight gain is more common in the milder forms of depression in my experience, and some degree of depression is often present with other types of mental health conditions.

    The antipsychotic medications can have a sedating side effect which leaves people feeling tired. Food choices can be a way to try and get an energy and mood boost. When you are feeling tired you are not likely to be doing the kind of regular cooking and grocery shopping that leads to healthier eating habits, you rely more heavily on convenience foods.

    I have also observed how stress will often significantly alter eating habits. Rapid weight gain can be a sign that the person has a lot of stress in their life.

  2. Nancy says:

    When I read this article it was a confirmation of what I’ve experienced for 40 years. When I’m depressed I sleep and sit and eat convenient – often high sugar high fat – food. There’s nothing like a chocolate bar or bowl of ice cream to sooth. It’s also a way to try to get some energy, since I feel like I have none. Sometimes I wished I had the “typical” depression where I wouldn’t want to eat.

    I’ve also been in 2 abusive relationships so that trauma added to the problems I already had. Getting bigger was a way to protect myself although I recognize it’s a very poor coping mechanism.

  3. hopefulandfree (RNegade) says:

    The use of food (as a kind of substance abuse) is misidentified, oversimplified, and/or misunderstood as “a coping strategy or a ‘self-soothing’ behavior” in people who have experienced complex trauma if (post)traumatic stress researchers such as Onno van der Hart are correct in hypothesizing that the origins of some disordered eating behaviors are, in fact, forms of “structural dissociation” (as described in “The Haunted Self.”) In addition, given the procedural realities of modern surgery, undergoing bariatric surgery for the purpose of forever altering one’s body may, in fact, trigger additional structural dissociation for patients who may experience it as reminiscent of traumatic domination. For instance, for a survivor of severe or chronic trauma, the following experiences of powerlessness may hold a completely different meaning–and result in a different outcome–than for someone with a more benign history: being rendered unconscious and immobile, undressed and transported in altered states of consciousness (drugged), loss of body integrity (being cut open), and (not incidentally) being told–and submitting because convinced–it is all done for their own “good.” If deep shame and disgust (related to helplessness) drives structural dissociation (as hypothesized) then bariatric surgery, with its implicit promise of restoring “goodness” (health), may result in highly unpredictable and unintended consequences for previously traumatized people.

  4. Slccom says:

    Christina, I think that you will find that if you do some real depression screening that those of use with the “atypical” depression don’t seek help as much, in large part (pun intended) due to the medical industry’s prejudice against overweight people. And excessive weight loss is imminently life-threatening.

    Interestingly, society expects us to be superhuman and resist the abnormal hormone effects and either not gain or lose weight while we are at our most vulnerable and fragile. Our failure to do so earns us contempt and abuse, which in turn deepens our depression.

    Nice cycle!

  5. Christina RD says:

    Good point Slccom, an inpatient mental health population is not necessarily reflective of the general population. Many of our clients are admitted because the family has noticed there’s a problem, and atypical depression may be more likely to go unnoticed by family as well.

  6. Susan says:

    I was diagnosed and treated for a major depressive disorder,spent a number of weeks in the hospital.My Dr.Kellyat the Misicordia Hospital was awesome ,upon entering the hospital I was underweight and no appetite,once they found the right meds to treat me (350 mgs of effexor and 5 mg of invega ) I was great it was the invega that helped me turn the corner ,with it my anxiety left and my joy returned ! Only problem was ,so did my appetite….TOO much! I gained over 75 lbs in a little over a year and started researching the drug,some people (like ME!) gain an average of 3 lbs a month ,part way through my treatment I left Alberta and moved to B.C. ,it took 10 months to see another psychiatrist and he took me off the invega as his opinion was that invega is a temporary drug till you are stable and some people never stop gaining.I am now mentally stable on the effexor but I have high blood pressure and am having trouble treating it.I am still 55 lbs overweight and cannot seem to lose anymore ,Could the effexor also be keeping the weight on? does it affect metabolism? It has effected elimination but I have not wanted to go off it as I never want to be that depressed again.My healthy weight is about 115 lbs. any insight you could offer would be appreciated.

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