Obesity and metabolism in first episode major depression

Obesity and metabolism in first episode major depression

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VIGNETTE CASE

Ms. Hat is a 21-year-old Caucasian female who was recently diagnosed with single-episode, severe, major depressive disorder (MDD) without psychotic features. She also has significant anxiety symptoms. She does not smoke, drink alcohol or use illicit drugs. She meets the criteria for obesity, with a current body mass index (BMI) of 32.

At her first office visit, her blood pressure is elevated to 137/90. Routine laboratory tests, including thyroid function tests (TSH and free T4) and a lipid panel, are all within normal limits. She had a good clinical response to the combination of a selective serotonin reuptake inhibitor and cognitive behavioral therapy.

Overweight and obesity are associated with MDD severity and antidepressant treatment outcomes.1 The mechanisms underlying these associations are complex and multifactorial and may include stress, dysfunctional eating behaviors, and neuroendocrine abnormalities.1

There is evidence that patients with comorbid major depressive disorder and anxiety have differences in neurobiology2 and response to treatment3 compared to patients without this comorbidity. Thyroid hormones may link weight issues and anxiety in MDD.4 However, previous studies have not comprehensively evaluated these associations in patients with MDD.

The current study

Lou and colleagues5 hypothesized that abnormal thyroid hormones would explain part of the relationship between overweight and obesity and anxiety in patients with major depressive disorder. The authors investigated these associations in a large cohort of Han Chinese outpatients with first-episode MDD, drug-naive.

Inclusion criteria were age between 18 and 60 years, DSM-IV diagnosis of MDD, first episode of depression with no prior antidepressant or antipsychotic treatment, Hamilton Rating Scale for Depression (HAMD) 24 to 17 items, and Han ethnicity. Exclusion criteria were other Axis I disorders, substance use disorders (except nicotine), serious physical conditions, and pregnancy or breastfeeding.

The authors assessed depressive symptoms with the HAMD and anxiety symptoms with the 14-item Hamilton Anxiety Inventory (HAMA). Anthropomorphic measurements included height and weight for BMI calculation, and blood pressure was also obtained.

Overweight was defined as BMI 24 and < 28. Obesity was defined as BMI 28. A fasting blood sample was collected for glucose, lipids, thyroid function (thyroid peroxidase antibody [TPOAb]thyroglobulin antibody [HgAb]thyroid stimulating hormone [TSH]free thyroxine [FT4]and free triiodothyronine [FT3]).

TSH was dichotomized as normal (0.27-4.20 mIU/L) and abnormal (>4.20 mIU/L). Multinomial logistic models were used to evaluate the association between anxiety and overweight and obesity and the potential mediating effect of clinical and physiological measures.

Of 1718 patients, 218 (13%) had severe anxiety. Patients with severe anxiety were older and had longer untreated duration, higher HAMD scores, and a history of suicide attempt. They also had higher levels of thyroid hormones, glucose, lipids and blood pressure.

The prevalence of overweight was higher in patients with than in those without anxiety (63% versus 55%), due to female gender. In the baseline (unadjusted) model, severe anxiety was associated with a 47% greater likelihood of being overweight and a 110% greater likelihood of obesity. However, in the adjusted models, the associations with overweight and obesity were attenuated, mainly by thyroid hormones (TSH and FT4) and blood pressure, and were no longer significant.

Study conclusions

The authors concluded that their study was the first to examine associations between severe anxiety and overweight/obesity in the first episode of major depressive disorder. The main finding was that severe anxiety symptoms in MDD were associated with overweight/obesity and these associations were explained by thyroid hormones and metabolic parameters.

Strengths of the study include the large cumulative sample size and drug status of the participants, which minimizes residual confounding from psychotropic medications. Limitations of the study include the cross-sectional design, which limits the ability to make causal inferences, and the possible effects of depression itself on thyroid function. The findings are relevant to a greater understanding of the pathophysiology of these comorbidities.

The bottom line

Patients with major depressive disorder and severe anxiety, particularly women, were more likely to be overweight and obese, and thyroid hormones and metabolic parameters help explain these associations.

Dr. Miller is a professor in the Department of Psychiatry and Health Behavior at Augusta University in Augusta, Georgia. He sits on the editorial board and serves as section head for schizophrenia Psychiatric times. The author reports that he receives research support from Augusta University, the National Institute of Mental Health, and the Stanley Medical Research Institute.

References

1. Hidese S, Asano S, Saito K, et al. Association of depression with body mass index classification, metabolic disease, and lifestyle: A web-based survey of 11,876 Japanese.J Psychiatr Res. 2018;102:23-28.

2. Cameron O.G. Anxious-depressive comorbidity: effects on the HPA axis and on the noradrenergic functions of the CNS.Essent Psychopharmaceutical. 2006;7(1):24-34.

3. Wu Z, Chen J, Yuan C, et al. Difference in remission in an anxious versus non-anxious Chinese treatment-resistant depression population: a report from the OPERATION study.J Affective disorder. 2013;150(3):834-839.

4. Medici M, Direk N, Visser WE, et al. Thyroid function within the normal range and risk of depression: a population-based cohort study.J Clin Endocrinol Metab. 2014;99(4):1213-1219.

5. Luo G, Li Y, Yao C, et al. Prevalence of overweight and obesity in patients with major depressive disorder with anxiety: mediating role of thyroid hormones and metabolic parameters.J Affective disorder. 2023;335:298-304.

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