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In an ideal world, patients suffering from depression would have the option of being treated both with medication and psychotherapy. Different mental health professionals might deliver these two therapies—for example, a psychiatrist overseeing the drug(s) and a psychologist, social worker, or psychiatric nurse practitioner for psychotherapy.
The benefit of combining these two interventions is not based simply on assuming that more is better than less, but on analyses of many studies that compared the effects of one treatment against both for short and long-term outcomes. In an extensive review of 52 such studies treating over 3600 patients with depressive or anxiety disorders, the evidence was overwhelming in favor of combining drugs and psychotherapy. Both treatments contribute about equally to the outcome, and are not dependent on the other.
But of course patients and practitioners do not live in an ideal world, and as this review suggests, combined treatment is not used sufficiently in current clinical practice. The pandemic is probably making it even more difficult for patients and practitioners to connect in person. An article in the August edition of the New England Journal of Medicine discusses the rising number of cases of mental illness, and strategies for assessment and treatment that do not require office visits. Hopefully, some (many?) months from now, the mental healthcare system will be able to return to pre-Covid conditions, and eventually move toward providing the combined care recommended.
But patients may not be obtaining all the help they need, even when psychotherapy is added to drug treatment. Weight gain is a known side effect of treatment with antidepressants and related medications and may begin in the first few weeks of treatment. The risk of weight gain is not trivial. In a survey of weight status in almost 136,762 men and 157,957 women over several years, Gafoor and associates wanted to determine whether antidepressant use was associated with increased weight. They found significantly more weight gained among the 18,000 men and 35,000 women treated with antidepressants than among the non-treated population. Moreover, weight continued to be gained for as long as eight years. The authors voice concern over the contribution of antidepressant use to the prevalence of obesity. Moreover, weight gain may cause some patients to stop treatment prematurely, or avoid going back on the drugs in the future if the depression or anxiety renews a need for treatment. Patients whose weight was normal prior to treatment are understandably disturbed and unhappy at finding themselves in the overweight or obese categories. They may be subjected to the fat shaming attitudes of others, and may find it difficult to explain that their weight gain was a side effect of their medication even in a weight-loss support group. And there is anecdotal evidence that weight loss may be hard to achieve weeks or even months after antidepressant treatment has ended.
Is enough being done to prevent or minimize weight gain as a side effect of the drugs? Are interventions started earlier enough in the therapeutic sessions before more than a pound or two of weight has been gained? Or is the issue ignored to prevent the patient from rejecting pharmacological treatment if this side effect were known? Should consultation with a dietician be included as part of the treatment package and if so, what type of dietary intervention would be successful?
At the very least, the patient should be alerted to the possibility of weight gain as a side effect and asked to be aware of any change in cravings for snacks, especially those high in carbohydrate, plus a decrease in satiety after meals. These changes in appetite may be evidence that the antidepressant(s) is affecting the ability of serotonin to modulate satiety. Knowledge that this neurotransmitter is involved in meal termination led to the development of weight-loss drugs. It was thought that making the dieter somewhat full before eating might result in less food being consumed. Unfortunately, much less information is available about how antidepressants inhibit this function of serotonin and cause overeating and weight gain. Indeed, perhaps the absence of counseling on how to prevent this antidepressant side effect is due to not knowing how.
Several years ago we were presented with this problem when establishing a weight-loss clinic at McLean hospital, a Harvard-associated psychiatric hospital. Our clients both from the hospital and community had gained weight while on a variety of psychotropic drugs. They all had trouble controlling snacking, and some would eat two meals in a row because they never felt full. Giving diet drugs that increased serotonin activity was not an option but a natural, non-drug alternative was. Since serotonin synthesis and activity is increased by carbohydrate consumption we told our clients to eat a small amount of a carbohydrate prior to lunch and dinner. We hoped that this might increase serotonin synthesis sufficiently to produce a sense of satiety before the meals began. A calorie-controlled meal plan, exercise and counseling were of course included in the weight-loss program. Interestingly, many of our clients had never had a weight problem before going on their medication, and once they no longer felt the absence of satiety, following a healthy diet and exercising did not seem difficult.
Other dietary interventions may also work and should be tried. But doing nothing to control the weight gain should not be an option. As Ben Franklin said, “An ounce of prevention is worth a pound of cure.”
