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Comanagement of Pediatric Depression and Obesity: A Clear Need for Evidence

      Abstract

      Purpose

      The purpose of this article is to provide a review of the existing literature for the comanagement of depression and obesity in the pediatric population.

      Methods

      A review of the current literature was conducted using EBSCOhost and EMBASE to identify evidence and recommendations for the comanagement of depression and obesity among children and adolescents (aged 2–18 years). Additional search criteria included peer-reviewed, English language–only full-text articles published before August 2015.

      Findings

      Multiple factors contribute to and influence the interplay of obesity and depression in the pediatric population. These 2 chronic conditions are affected by multiple factors, including the roles of the family, school, health care practitioners, and access to health care. In addition, there are no formal recommendations for the treatment of depression in the setting of obesity for pediatric or adult populations, and there is only medication approved by the Food and Drug Administration (orlistat) for the treatment of obesity in the adolescent population. Bariatric surgery may play a role in some adolescents, but larger and long-term clinical studies with the use of therapeutic agents in conjunction with lifestyle modification need to be conducted to support this.

      Implications

      The interrelatedness of these 2 separate diseases is not well understood; the presence of 1 of the diseases clearly contributes to the manifestation of the other and likely to the ability to treat the other disease. Current focus is on modifying behavior to decrease weight. Weight loss is associated with improvement in depressive symptoms but may not be adequate to treat depression.

      Key words

      Introduction

      Obesity and depression are significant public health problems in the United States. The causes of obesity are multifaceted and cannot be addressed by a single treatment. In adults and adolescents, depression is associated with obesity, and adolescent girls with depression at increased risk for becoming obese as adults compared with adolescent boys.
      • Blaine B.
      Does depression cause obesity? a meta-analysis of longitudinal studies of depression and weight control.
      • Rofey D.L.
      • Kolko R.P.
      • Iosif A.M.
      • et al.
      A longitudinal study of childhood depression and anxiety in relation to weight gain.
      Likewise, obesity increases the risk for onset of depression.
      • Luppino F.S.
      • de Wit L.M.
      • Bouvy P.F.
      • et al.
      Overweight, obesity, and depression: a systematic review and meta-analysis of longitudinal studies.
      The mechanism by which obesity increases risk for depression is not known but may be related to serotonin. Several studies report treatment-resistant depression in adults with obesity who are treated with selective serotonin reuptake inhibitors (SSRIs).
      • Kurhe Y.
      • Mahesh R.
      Mechanisms linking depression co-morbid with obesity: an approach for serotonergic type 3 receptor antagonist as novel therapeutic intervention.
      • Papakostas G.I.
      • Petersen T.
      • Iosifescu D.V.
      • et al.
      Obesity among outpatients with major depressive disorder.
      • Kloiber S.
      • Ising M.
      • Reppermund S.
      • et al.
      Overweight and obesity affect treatment response in major depression.
      Obesity affects approximately 17% of US children and adolescents (aged 2–19 years) and 35% of US adults.
      Centers for Disease Control and Prevention
      Overweight and Obesity.
      Obesity in children and adolescents is defined as a body mass index (BMI) ≥95th percentile for age and sex. BMI is calculated using weight in kilograms divided by height in meters squared. The Centers for Disease Control and Prevention growth curve for BMI is then used to determine percentile.
      Centers for Disease Control and Prevention
      Growth Charts.
      Depression affects approximately 11% to 20% of adolescents, and the risk for depression increases as a child gets older.
      • Nemiary D.
      • Shim R.
      • Mattox G.
      • Holden K.
      The relationship between obesity and depression among adolescents.
      The prevalence of depression increases significantly among obese boys (20%) and girls (30%).
      • Nemiary D.
      • Shim R.
      • Mattox G.
      • Holden K.
      The relationship between obesity and depression among adolescents.
      Symptoms of depression in adolescents differ from those in adults. Adolescents manifest depression as feeling sick, avoiding school or school problems, worrying excessively about the death of a parent, feeling misunderstood, and being “moody.”

      National Institute for Mental Health. Children׳s Mental Health Awareness: Depression in Children and Adolescents Fact Sheet. Bethesda, MD: National Institute for Mental Health, 2001.

      In 2013, an expert committee released guidelines for the treatment of adult obesity.
      Executive summary: guidelines (2013) for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Obesity Society published by the Obesity Society and American College of Cardiology/American Heart Association Task Force on Practice Guidelines: based on a systematic review from the The Obesity Expert Panel, 2013.
      These guidelines recommended treatment by a team of health care professionals, including registered dietitians, psychologists, exercise specialists, health counselors, or professionals in training. There is not a specific protocol for the treatment of mental health problems, although the guidelines recommend addressing depression.
      Executive summary: guidelines (2013) for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Obesity Society published by the Obesity Society and American College of Cardiology/American Heart Association Task Force on Practice Guidelines: based on a systematic review from the The Obesity Expert Panel, 2013.
      The comanagement of depression and obesity in the pediatric population poses a challenge because there are not specific evidence-based recommendations that address the comanagement of the 2 chronic health problems. The objective of this article is to provide an overview of the comanagement of depression and obesity in the pediatric population.

      Methods

      Studies were identified by searching EMBASE and the University of Utah EBSCOhost online research database, which includes Alt HealthWatch, BioMed Central, Clinical Key, Cochrane Library, DynaMed, MEDLINE, PsycInfo, and several other research databases. The search was completed using the keywords depression AND obesity with the addition of each of the following terms: treatment, medical management, medication OR drug management or drug therapy, bariatric surgery, pediatric OR adolescents OR childhood.
      The inclusion criteria for this review were (1) peer-reviewed study, (2) published in the English language, (3) provided original data describing treatment of obesity and depression with medication, and (4) study population that included children and/or adolescents aged 2 to 19 years. The search was completed in August 2015.

      Findings

      We began this review as a systematic review with the above rigorous search criteria. A search of the terms depression, depressive symptoms, major depressive disorder, and obesity yielded 13,931 articles. Addition of adolescents, pediatric, and childhood decreased the count to 7 articles of which none met the criteria for treatment of the 2 conditions. The void of research in the area of comanagement of obesity and depression in adolescents unfortunately limits the ability to conduct a systematic review. Although outside the scope of this review, we conducted a search of the literature without the pediatric population modifier and identified 17 articles that met the above criteria. Of these, only 2 specifically evaluated cotreatment of depression and obesity (Figure).
      • Toups M.S.
      • Myers A.K.
      • Wisniewski S.R.
      • et al.
      Relationship between obesity and depression: characteristics and treatment outcomes with antidepressant medication.
      • Faulconbridge L.F.
      • Wadden T.A.
      • Berkowitz R.I.
      • et al.
      Changes in symptoms of depression with weight loss: results of a randomized trial.
      Figure thumbnail gr1
      FigureLiterature Query of EMBASE and EBSCOhost conducted before August 2015.
      The treatment of obesity in the pediatric population generally relies on improving diet, increasing physical activity, and decreasing sedentary time. The most recent expert guidelines for pediatric obesity (1998) were directed at pediatric primary care practitioners and recommend use of the Primary Care Evaluation of Mental Disorders questionnaire, which also screens for eating disorders, and the Children’s Depression Inventory to screen children who seem depressed. Psychological evaluation and treatment are recommended if either tool identifies a significant mental health problem. There is no specific recommendation for the treatment of depression.
      • Barlow S.E.
      • Dietz W.H.
      Obesity evaluation and treatment: Expert Committee recommendations. The Maternal and Child Health Bureau, Health Resources and Services Administration and the Department of Health and Human Services.
      The 2011 Expert Panel on Integrated Guidelines for Cardiovascular Disease in Children and Adolescents (2011) section on obesity similarly focuses on diet and physical activity with no recommendations for treatment of existing mental health problems.
      Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents, National Heart, Lung, and Blood Institute
      Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: summary report.
      The treatment of major depressive disorder in the adolescent population has improved with the introduction of SSRIs, which is still limited to 1 medication approved by the Food and Drug Administration (fluoxetine).

      National Institute of Mental Health. Antidepressant Medications for Children and Adolescents: Information for Parents and Caregivers. http://www.nimh.nih.gov/health/topics/child-and-adolescent-mental-health/antidepressant-medications-for-children-and-adolescents-information-for-parents-and-caregivers.shtml. Accessed March 6, 2015.

      Many professionals use the other SSRIs (sertraline, escitalopram, citalopram, fluvoxamine) off label to treat depression in children and adolescents. A study of 25,315 adults (aged 40–49 and 70–74 years) evaluated the association of SSRIs with obesity and dyslipidemia and recommended careful monitoring for these conditions during treatment because use of SSRIs increased abdominal obesity (odds ratio = 1.4; 95% CI, 1.08–1.81) and hypercholesterolemia (odds ratio = 1.36; 95% CI, 1.07–1.73).
      • Raeder M.B.
      • Bjelland I.
      • Emil Vollset S.
      • Steen V.M.
      Obesity, dyslipidemia, and diabetes with selective serotonin reuptake inhibitors: the Hordaland Health Study.
      We are not aware of a similar study in adolescents. A single study of treatment-resistant depression in adolescents receiving venlafaxine needs to be repeated in a population of medication-naive adolescents with obesity and depression.
      • Mansoor B.
      • Rengasamy M.
      • Hilton R.
      • et al.
      The bidirectional relationship between body mass index and treatment outcome in adolescents with treatment-resistant depression.
      The National Institute of Mental Health 2009 report emphasizes the need for studies that evaluate the mechanistic association between obesity and depression to develop effective treatment for both conditions.
      • Allison D.B.
      • Newcomer J.W.
      • Dunn A.L.
      • et al.
      Obesity among those with mental disorders: a National Institute of Mental Health meeting report.
      Bariatric surgery may be the only effective method currently available for comanagement of obesity and depression. Guidelines for adults and adolescents considering bariatric surgery recommend psychosocial behavioral evaluation by a mental health specialist with experience evaluating patients and families for bariatric surgery, but consensus guidelines for the evaluation and management of psychosocial problems do not exist.
      • Mechanick J.I.
      • Youdim A.
      • Jones D.B.
      • et al.
      Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery.
      Short-term outcomes of 0 to 24 months reveal improved psychosocial functioning with decreased depression symptoms that occur with weight loss in adolescents.
      • Zeller M.H.
      • Reiter-Purtill J.
      • Ratcliff M.B.
      • et al.
      Two-year trends in psychosocial functioning after adolescent Roux-en-Y gastric bypass.
      • Jarvholm K.
      • Olbers T.
      • Marcus C.
      • et al.
      Short-term psychological outcomes in severely obese adolescents after bariatric surgery.
      • Sysko R.
      • Devlin M.J.
      • Hildebrandt T.B.
      • et al.
      Psychological outcomes and predictors of initial weight loss outcomes among severely obese adolescents receiving laparoscopic adjustable gastric banding.
      The first of these reports evaluated 16 adolescents (mean age, 16.2 years; mean BMI, 59.9 kg/m2) and conducted measurements at baseline and 6, 12, 18, and 24 months after Roux-en-Y gastric bypass. Decreased depressive symptoms were seen at 12 months, followed by decelerations in gains in year 2 that included weight regain (P < 0.0001) and increased depressive symptoms (P = 0.004).
      • Zeller M.H.
      • Reiter-Purtill J.
      • Ratcliff M.B.
      • et al.
      Two-year trends in psychosocial functioning after adolescent Roux-en-Y gastric bypass.
      The second evaluated 37 adolescents (mean age, 16.6 years) 4 months after undergoing Roux-en-Y gastric bypass with Beck Youth Inventories. There was a significant decrease in raw scores of the Beck Youth Inventories (P = 0.20) from baseline to follow-up.
      • Jarvholm K.
      • Olbers T.
      • Marcus C.
      • et al.
      Short-term psychological outcomes in severely obese adolescents after bariatric surgery.
      The third used the Beck Depression Inventory to evaluate 101 severely obese adolescents aged 14 to 18 years undergoing laparoscopic adjustable gastric banding at baseline and 12 months. There was significant decrease in Beck Depression Inventory score (β slope = −0.885, SE = 0.279, P < 0.01; β quadratic = 0.054, SE = 0.021, P < 0.001).
      • Sysko R.
      • Devlin M.J.
      • Hildebrandt T.B.
      • et al.
      Psychological outcomes and predictors of initial weight loss outcomes among severely obese adolescents receiving laparoscopic adjustable gastric banding.
      Long-term outcomes of large numbers of postoperative adolescents are not yet available. In contrast, a few adults (<50%) who have undergone bariatric surgery and experienced an initial improvement in mental health status subsequently experience a decline in mental health improvements or no benefit at all.
      • Bocchieri L.E.
      • Meana M.
      • Fisher B.L.
      A review of psychosocial outcomes of surgery for morbid obesity.
      Several adult studies have found a higher suicide rate among patients after bariatric surgery than the general public.
      • Tindle H.A.
      • Omalu B.
      • Courcoulas A.
      • et al.
      Risk of suicide after long-term follow-up from bariatric surgery.
      • Peterhansel C.
      • Petroff D.
      • Klinitzke G.
      • et al.
      Risk of completed suicide after bariatric surgery: a systematic review.
      Psychiatric evaluation to identify candidates who are most likely to experience improvement in depressive symptoms and eating disorders needs continued study. Longer-term follow-up is necessary to establish bariatric surgery as an effective treatment for obesity and depression in a select group of individuals.

      Conclusions

      Depression or obesity alone represents a significant disease burden for children and adolescents. Both have long-standing and far-reaching consequences for the health and well-being of the affected individual. This risk is magnified when the 2 issues are combined because it makes the treatment of one more difficult by the presence of the other. This combined burden has been ignored by the research community because often studies of one disease specifically exclude the presence of the other (ie, studies of antidepressants in depressed adolescents specifically exclude participants in the >85th percentile for weight). Much more research is needed to fill the gap in knowledge about the mechanism(s) of the association between obesity and depression (especially women) and mental health disorders. Once a mechanism has been identified, targeted intervention strategies that address the comanagement of obesity and depression can be studied.

      Conflicts Of Interest

      The authors have indicated that they have no conflicts of interest regarding the content of this article.

      Funding Sources

      This study was supported by Career Development Award HL092069 from the National Heart, Lung and Blood Institute (Dr Mihalopoulos).

      Acknowledgments

      Dr Mihalopoulos performed the literature search and wrote the majority of the text of the manuscript. Dr Spigarelli conceived the figure and critically reviewed and edited the text.

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