Minimally Invasive Surgery Symposium 2012 Depression and Suicide February 23 rd, 2012 Leslie J...
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Transcript of Minimally Invasive Surgery Symposium 2012 Depression and Suicide February 23 rd, 2012 Leslie J...
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
• 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 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 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
• 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