Behavioral treatment for obesity
In light of the increasing prevalence of overweight and obesity in the general population and elevated prevalence among individuals with a variety of psychiatric disorders, psychiatrists frequently encounter patients who are overweight or obese. They are also quite likely to deal with patients who are experiencing weight gain in response to psychiatric medications.34 There is evidence that most physicians, including psychiatrists, have not received adequate training to counsel patients regarding obesity and options for treatment.35
Behavioral treatments for obesity generally include 3 components: dietary change; increased physical activity; and behavior therapy techniques, such as goal-setting, selfmonitoring, stimulus control, and behavioral contracting.36 In addition to weight loss itself, a goal of behavioral interventions is to introduce lifestyle changes that increase the likelihood that weight loss will be maintained.37 A typical behavioral weight loss program includes 12 to 16 lessons that cover specific strategies, such as recording daily food and calorie intake, avoiding triggers for unhealthy eating, increasing physical activity, obtaining social and family support, and modifying thoughts and emotions that undermine weight loss.38 Behavioral interventions generally result in weight losses of about 8% to 10% of initial body weight.39
Effect of psychiatric disorders on obesity treatment
Patients with comorbid obesity and psychiatric conditions may have difficulty with adhering to weight loss treatment recommendations. Depression or anxiety may interfere with the ability to adopt new behaviors—particularly those that require effort, such as preparing healthier meals or exercising. There is evidence that weight management patients with major depressive disorder lose less weight than their counterparts without depression.40 Poor impulse control associated with ADHD and ASPD can undermine self-control efforts as well.28
Patients who struggle with overweight and obesity may be reluctant to take medications that will further contribute to weight gain, or they may discontinue treatment prematurely if weight gain occurs.41 Sensitivity to these concerns can allow psychiatrists to anticipate challenges and barriers to effective treatment of psychiatric conditions. Bariatric surgery is becoming an increasingly popular treatment for severe obesity. Psychiatric evaluations to assess patients' ability to adhere to the behavioral changes required to benefit from surgery are an important part of the treatment process.42
Treating obese patients with psychiatric disorders
Behavioral assessment of obese patients can identify psychiatric conditions that might interfere with treatment.43 Experts recommend treating depression before starting patients on a weight loss program, although there is also evidence that successful treatment of obesity can lead to significant improvement in mood.34 Exercise can improve mood, and it is a vital component of a successful weight loss intervention. Thus, introducing exercise during treatment for depression can give patients a head start on improving health before they begin a weight loss program.
Patients with anxiety disorders may become alarmed by the physical sensations they experience during exercise. Many require a gradual increase in exercise intensity to learn that heart rate and respiration will return to normal after exertion. Anxious patients may also need encouragement and even gradual exposure to overcome avoidance of behaviors that trigger anxiety, such as weighing themselves or keeping records of weight or food intake.
Patients with ADHD are likely to have difficulty adopting many weight loss strategies, particularly those like self-monitoring of food intake that rely on the ability to keep organized records and make entries on a regular basis. It may be necessary to work with these patients to develop routines for planning meals, finding time for regular exercise, and organizing food diaries and other self-monitoring materials.
Concern about the increased prevalence and negative health effects of obesity continues to grow. Greater understanding of psychiatric comorbidity may facilitate the development of more effective prevention and treatment interventions.