Minimally Invasive Surgery Symposium 2012

Depression and Suicide

February 23rd, 2012

Leslie J Heinberg, PhDDirector of Behavioral Services, Bariatric & Metabolic InstituteAssociate ProfessorCleveland Clinic Lerner College of Medicine

Overview

• Depression– Pre-operative prevalence

– Does depression impact bariatric outcomes?

– Does bariatric surgery impact depression outcomes?

• Suicide– Is obesity a risk factor?

– Is suicide a potential side effect of surgery?

Depression and Obesity

Depression

• 20.9 million American adults or 9% of the population have a mood disorder

– Major Depression

– depressed/irritable

– loss of interest in previously pleasurable activities

– problems with eating and sleeping

– guilt

– low energy

– difficulty concentrating

– thoughts about death

– at least 2 weeks duration

• Women are twice as likely to have depression than men

Depression and Obesity: Cause and/or Effect

• Direct positive association between obesity and depression in women1

– 1 in 7 obese women have depression

– 37% higher rate than normal-weight women

1. Fabricatore & Wadden, 2006

Depression and Obesity: Cause and/or Effect

• Direct positive association between obesity and depression in women1

– 1 in 7 obese women have depression

– 37% higher rate than normal-weight women

• Either negative or no association in men2

– 1 in 14 obese men have depression

1. Fabricatore & Wadden, 2006 2. Allison et al., 2009

Depression and Obesity: Cause and/or Effect

• Direct positive association between obesity and depression in women1

– 1 in 7 obese women have depression

– 37% higher rate than normal-weight women

• Either negative or no association in men2

– 1 in 14 obese men have depression

• Both men and women with BMI≥40 are more likely to have Major Depression3

– Population-based studies demonstrate 5x as likely to have had depressive episode in last year

1. Fabricatore & Wadden, 2006 2. Allison et al., 2009 3. Onyike et al., 2003

Depression and Obesity: Cause and/or Effect

• Depression obesity– Appetite disturbance is key feature

– Close association between binge eating disorder and depression (~50%)

– Avolition and loss of energy

– Majority of mood stabilizers and anti-depressants have weight gain side effects

• Obesity depression– Body image disturbance

– Stigmatization, Discrimination and Prejudice

– Medical comorbidities

Depression in Bariatric Surgery Candidates

Depression as a Contraindication

• AACE/TOS/ASMBS 2009 Guidelines– “The only contraindications to bariatric surgery are persistent

alcohol and drug dependence, uncontrolled severe psychiatric illness such as depression or schizophrenia, or cardiopulmonary disease that would make the risk prohibitive”

• NIH Consensus Statement on Gastrointestinal Surgery for Severe Obesity (1991)– “Absence of uncontrolled psychotic or depressive disorder”

Prevalence in Bariatric Populations

• Most common diagnosis

• 25-30% of surgical candidates report depression at time of evaluation1,2

• 50% report lifetime prevalence of mood disorder or an anxiety disorder1,2

– 22-24% have lifetime prevalence of a Axis II (personality) disorder

• 72.5% report a lifetime history of psychotropic medication use (87.7% were anti-depressants)3

– 47.7% rate of current use

1. Kalarchian et al., 20072. Mühlhans et al., 20093. Pawlow et al., 2005

Depression predicts other co-morbidities (Ali et al., 2009)

• Poorer quality of life– Physical

– Psychological

• Greater prevalence of certain co-morbidities among depressed patients– Independent of BMI

– dyslipidemia, GERD, back pain, joint pain, sleep apnea, stress incontinence and hernia

5.46

4.55

2.67

1.89

0

1

2

3

4

5

6

# of comorbids severe/complicated

Depression +

Depression -

Medication Concerns

• Pharmacokinetics of psychotropic medication after surgery are not well understood1

– Modeled dissolution rates of anti-depressants are highly divergent (increased, decreased, unchanged)

• Close monitoring of patients is necessary

0

50

100

150

200

250

300

350

MeanAUC

Max.PlasmaConc.

Post-RYGB

BMIControls

1. Love et al., 20082. Roerig et al., 2012

Sertraline 10.5 hour plasma levels2

Depression and Bariatric Surgery Outcome

Depression and Weight Loss Outcomes

• Most studies suggest that depression is associated with less positive outcomes although weight loss remains highly significant

Number of psychiatric disorders and weight loss post LAGB (Kinzl et al., 2006)

10.8

1416.1

0

2

4

6

8

10

12

14

16

18

# of comorbids

>=2

1

0

BM

I un

its lo

st >

30 m

onth

s

Mood Disorders and Weight Loss in LSG (Semanscin-Doerr, Windover, Ashton & Heinberg, 2010)

12.83

22.1

29.6

34.4137.42

44.1645.94

39.83

31.16

18.06

0

5

10

15

20

25

30

35

40

45

50

1 mo 3 mo 6 mo 9 mo 12 mo

Follow-up visits

%E

WL Current Mood

No psych dx

p<.05 at 1, 3, 6 and 9 months

Relationship of depression to 6 month RYGB outcomes (Kalarchian et al., 2008)

14.8

14.1

13.4

12.5

13

13.5

14

14.5

15

No current/lifetime

Current Axis I

Lifetime Mood

Red

uctio

n in

BM

I

Behavioral predictors of weight regain (≥15% from nadir) post-RYGB (Odum et al., 2009)

24.9

21.4

19

20

21

22

23

24

25

No wt regain

Wt regain

Bas

elin

e D

epre

ssio

n S

core

Weight Loss and Depression Outcomes

• Clear positive benefit on depression due to weight loss surgery– Similar findings for psychological quality of life

Effect of LAGB on depression in patients with and without baseline depressive symptoms (Hayden et al., 2011)

0

5

10

15

20

25

30

BaselineDepression

Random Sample

Presurgery

1 yr

Bec

k D

epre

ssio

n S

core

Effect of RYGB on depression outcomes (Thonney et al., 2010)

0

2

4

6

8

10

12

14

BDI-II HAD

Presurgery

1 yr

2 year

Dep

ress

ion

Sev

erity

Prospective effect of SCID-confirmed anxiety and depression in LAGB and RYGB (de Zwaan et al., 2011)

0

5

10

15

20

25

30

35

Dx Depression Dx Anxiety

Presurgery

6-12 months

24-36 months

p=.002

% D

iagn

osed

Suicide and Suicidal Behavior

Suicide

• Suicide rates have increased by 60% worldwide in the last 45 years1

– 11.5 completed suicides per 100,000

– For every mortality there an estimated 11-400 attempts2

• Risk factors3-4

– Psychopathology

– Depression

– Anxiety

– Personality disorders

– Eating Disorders

– Alcohol and substance abuse

– Chronic medical illness5

– Risk of suicidal behavior between 2-11x greater than healthy adults1. CDC, 20112. MMWR, 20043. Petry et al., 20084. Wilson, 20105. Juurlink et al., 2004

Obesity and Suicide

• Positive association between obesity and suicide has been observed more frequently than a negative or no association1

• Preponderance of studies suggest psychiatric vulnerability in bariatric patients1

• Greater prevalence of suicide history among bariatric patients – 73x greater prevalence of past attempts2

– Past suicide attempts are strongest risk factor for future suicide deaths3

1. Heneghan, Heinberg, Elder, Windover & Schauer, 20122. Windover, Ashton & Heinberg, 20103. Gibb et al., 2005

Excess deaths by suicide following weight loss surgery

10

2

6

1

0

1

2

3

4

5

6

7

8

9

10

Rat

e o

f su

icid

e p

er 1

6,68

3 p

ost

-op

pat

ien

ts

Women Men

WLS patients

Expected rates in USpopulation • Compared PA death

records to national norms

• Did not include accidental drug overdose so may be underestimated

Omalu et al., 2007

Excess deaths by suicide following weight loss surgery

5.2

0.7

13.7

2.4

0

2

4

6

8

10

12

14

Rat

e o

f su

icid

e p

er 1

0,00

0

Women Men

WLS patients

US population

• Compared to suicide rates in US population

• 30% of suicides occurred within the first 2 years– More likely in men

• “Data cannot separate the host characteristics such as increased risk before surgery from the effects of bariatric surgery itself”

Tindle et al., 2010

Excess deaths by traumatic causes following weight loss surgery

2.6

0.9

11.1

6.4

0

2

4

6

8

10

12

Suicide Deaths All nondisease causes

WLS patients

Obese MatchedControls

• Matched using UT drivers’ licenses– Sex, BMI, age and year

• Non-disease related deaths increased by a factor of 1.58 (p=.04)

• Differences in suicides, however, were not significantn

o./

10

,00

0 p

ers

on

-yr

Adams et al., 2007

Suicide History and %EBMI Lost Controlling for Gender (Heinberg et al., 2011)

0

10

20

30

40

50

60

70

80

1 mo 3 mo 6 mo 9 mo 12 mo 18 mo

% E

BM

IL

SA+

SA-

* p<.07

** p<.05

** **

Suicide History and Weight Loss

• May have more positive effects due to closer follow-up by behavioral health care-providers

• Results based upon those who came for follow-up visits

• Except for 12 months, SA+ had better attendance at follow-up visits– This may be the factor that

correlates with better outcomes

0

10

20

30

40

50

60

70

80

90

100

1 mo 3 mo 6 mo 9 mo 12 mo 18 mo

SA+SA-

% A

tten

ding

Vis

it

Heinberg et al., 2011

Future Studies

• Need appropriate control groups– Matched on obesity is better but numerous studies suggest

treatment-seeking obese are more psychiatrically compromised than population-based obese

• Longitudinal studies– Patients presenting for WLS but denied

–Still potential biasing factors

– Studies to show causation aren’t ethically feasible

– Control for comorbid psychiatric illness and medication

– Control for history of substance abuse, self-harm and suicide attempts

Conclusions

• Imperative that clinicians involved in management of obesity appreciate that depression and suicide are threats– Even after improvement or resolution of the obesity, the

underlying psychopathology related to suicide likely remains

• Additional monitoring and more aggressive treatment of at-risk patients would help prevent suicides in our vulnerable population

Thank you

Contact: heinbel@ccf.org

Thank you

heinbel@ccf.org