Minimally Invasive Surgery Symposium 2012 Depression and Suicide February 23 rd, 2012 Leslie J Heinberg, PhD Director of Behavioral Services, Bariatric & Metabolic Institute Associate Professor Cleveland 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 women 1 – 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 women 1 – 1 in 7 obese women have depression – 37% higher rate than normal-weight women Either negative or no association in men 2 – 1 in 14 obese men have depression 1.Fabricatore & Wadden, Allison et al., 2009

Depression and Obesity: Cause and/or Effect Direct positive association between obesity and depression in women 1 – 1 in 7 obese women have depression – 37% higher rate than normal-weight women Either negative or no association in men 2 – 1 in 14 obese men have depression Both men and women with BMI≥40 are more likely to have Major Depression 3 – Population-based studies demonstrate 5x as likely to have had depressive episode in last year 1.Fabricatore & Wadden, Allison et al., 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 Obesitydepression – 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 evaluation 1,2 50% report lifetime prevalence of mood disorder or an anxiety disorder 1,2 – 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., Mühlhans et al., 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

Medication Concerns Pharmacokinetics of psychotropic medication after surgery are not well understood 1 – Modeled dissolution rates of anti-depressants are highly divergent (increased, decreased, unchanged) Close monitoring of patients is necessary 1.Love et al., Roerig et al., 2012 Sertraline 10.5 hour plasma levels 2

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) BMI units lost >30 months

Mood Disorders and Weight Loss in LSG (Semanscin- Doerr, Windover, Ashton & Heinberg, 2010) p<.05 at 1, 3, 6 and 9 months

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

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

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) Beck Depression Score

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

Prospective effect of SCID-confirmed anxiety and depression in LAGB and RYGB (de Zwaan et al., 2011) p=.002 % Diagnosed

Suicide and Suicidal Behavior

Suicide Suicide rates have increased by 60% worldwide in the last 45 years 1 – 11.5 completed suicides per 100,000 – For every mortality there an estimated attempts 2 Risk factors 3-4 – Psychopathology – Depression – Anxiety – Personality disorders – Eating Disorders – Alcohol and substance abuse – Chronic medical illness 5 – Risk of suicidal behavior between 2-11x greater than healthy adults 1.CDC, MMWR, Petry et al., Wilson, Juurlink et al., 2004

Obesity and Suicide Positive association between obesity and suicide has been observed more frequently than a negative or no association 1 Preponderance of studies suggest psychiatric vulnerability in bariatric patients 1 Greater prevalence of suicide history among bariatric patients – 73x greater prevalence of past attempts 2 – Past suicide attempts are strongest risk factor for future suicide deaths 3 1.Heneghan, Heinberg, Elder, Windover & Schauer, Windover, Ashton & Heinberg, Gibb et al., 2005

Excess deaths by suicide following weight loss surgery 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 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 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 significant no./10,000 person-yr Adams et al., 2007

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

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