When Treating Obesity, Don’t Forget the Mental Health Angle

When the 42-year-old patient came to see Yarickza Lopez, MSN, FNP-C, the 5-ft woman weighed 260 lb and had severe depression and anxiety, type 2 diabetes, high blood pressure, polycystic ovary syndrome, and high cholesterol.

At the time, she was on a plethora of medications, including metformin and Januvia, an atorvastatin, a hypertension drug, and two depression medications, said Lopez, a nurse practitioner who specializes in obesity medicine and is founder and CEO of LB Rejuven8 Aesthetics and Wellness, a med spa based in College Station, Texas. While the patient’s physical conditions were being treated with medication, the root causes of her anxiety and depression had been overlooked for years, Lopez said.

As she treated the patient’s obesity, Lopez dug into her mental health issues and learned she used food as a coping mechanism for anxiety and stress. The patient regularly ate fast food when feeling down or stressed, and her diet at home was extremely carb- and rice-based, Lopez said.

To address this, Lopez incorporated cognitive behavioral therapy into the patient’s treatment plan and started working with her on positive self-talk and habit optimization. The treatment included lots of regular reminders and reassurances about the patient’s self-worth, she said.

“Between the therapy and the medication reducing her food noise, that really helped her to wean off of her cravings,” Lopez said. “We did struggle with self-worth when she would fall back into an old habit, but after a while, old habits made her sick, which was a positive reinforcement to continue eating healthy. She began creating healthy boundaries, and slowly, she started believing in herself again.”

Integrating behavioral therapy made all the difference in the patient’s obesity recovery, Lopez said. Today, the patient has lost 110 lb, she feels better mentally and physically, and she no longer needs her depression medication.

Studies have long shown a strong association between obesity and poor mental health. Patients who are obese, for example, are 18%-55% more likely to develop depression, while about 45% of adults with depression are obese, according to data from the Centers for Disease Control and Prevention. Patients with obesity are also more likely to experience anxiety, dysregulated eating behaviors, and eating disorders than the general population.

The odds of developing a mental health disorder in adolescence, meanwhile, are 7 times higher among children with obesity than among normal-weight children, according to an August 2023 analysis in Psychiatry Research.

“Obesity and mental health are deeply interconnected,” said Sasidhar Gunturu, MD, vice chair and medical director for psychiatric integrated services for the BronxCare Health System. “There is a bidirectional relationship between obesity and mental health, meaning not only can obesity contribute to mental and physical health problems but it can be the opposite as well.”

With the rise of obesity clinics and the use of glucagon-like peptide 1 agonists for weight loss, integrating mental health support into obesity care treatment is critical, said Gunturu, whose research includes a May 2024 STATPearls article on psychological issues associated with obesity. Long-term health outcomes for patients are generally much better when mental and/or behavioral health is integrated into obesity care, he said.

Gunturu is concerned, however, that not enough screenings or mental health interventions are being conducted during obesity treatment.

Obesity management specialist Catherine (Cate) Varney, DO, said mental health is one of the most overlooked aspects in the treatment of obesity. Too frequently, clinicians prescribe obesity medications without considering potential, underlying psychological issues, said Varney, an assistant professor in the department of family medicine at the University of Virginia School of Medicine and obesity medicine director for UVA Health in Charlottesville, Virginia.

“Newer obesity medications have been shown to help patients manage what they describe as ‘food noise’ — the persistent, intrusive, and sometimes obsessive preoccupation with food,” she said. “While these medications provide relief from this aspect, they cannot address the underlying psychological and behavioral factors driving the condition.”

If clinicians fail to directly address or refer patients to mental health professionals who can help with these issues, the risk for negative setbacks and long-term challenges increases significantly, Varney said.

Incorporating Mental Health Into Obesity Care

Integrating mental health support into obesity treatment plans starts with screening for depression, anxiety, and eating disorders like binge eating disorder, Varney said. Screening tools such as the Patient Health Questionnaire-9, General Anxiety Disorder-7, and Binge Eating Disorder Screener can be helpful, she said.

If clinicians are considering treating patients with an anti-obesity medication, it’s essential to assess for these conditions prior to treatment, she said.

“These conditions wouldn’t necessarily restrict the use of anti-obesity medications, but treatment for the psychological component can be simultaneously treated,” she said.

Treatment generally includes first-line cognitive behavioral therapy but can also include medication therapy, Varney adds. If clinicians aren’t capable of managing this aspect, due to restrictions in time, clinic resources, or expertise, they should refer the patient to a licensed clinical social worker, psychologist, or psychiatrist, she said.

Registered dieticians can also help patients develop an individualized and sustainable eating plan that supports both physical health and emotional well-being, she said.

Communication and collaborative care among all clinicians treating the patient is key, said Gunturu.

At BronxCare Health System, behavioral health is integrated into 11 primary care practices, and clinicians conduct routine mental health screenings on all obesity care patients, he said. An interdisciplinary case management team, which includes primary care physicians, mental health specialists, family practitioners, pharmacists, and social workers, treats patients as a team and regularly discusses cases.

Multiple specialists thinking and assessing patients together help fill treatment gaps and often determine more answers when patients aren’t improving, Gunturu said. In one recent case, a 42-year-old woman with depression was being treated with semaglutide injections for 2 months, but her obesity levels were not improving, and her depression continued to worsen, he said.

A team of specialists sat down with social workers, a clinical care coordinator, and a member of the managed care team to brainstorm. The care coordinator suggested making a home visit, where she ultimately found the patient had a broken refrigerator and no safe storage area to store her medications. Within a week, the team obtained vouchers for the patient that helped fix her refrigerator, Gunturu said. She was able to store and take her medications, and within 12 weeks, the patient had lost about 15 lb, and her depression improved.

“Sometimes we don’t think about small things, but they can make a big difference,” he said. “A lot of these problems you see, the social determinants of health, can play an important factor.”

Recognizing the Role of Trauma

Another often overlooked aspect in obesity care is the role of trauma, said Zerimar Ramírez López, MD, a psychiatry resident at BronxCare Health System.

Many patients with obesity, especially those who have binge eating disorder, have a history of adverse childhood experiences or posttraumatic stress disorder, and also emotional trauma, she said. A growing body of research demonstrates a significant relationship between childhood abuse and adult obesity.

“These experiences can shape eating behaviors, emotional regulation, and metabolic health in profound ways,” Ramírez López said. “If we don’t address trauma in obesity treatment, we’re missing a key piece of the puzzle.”

Clinicians should shift away from defining patients’ success purely by weight loss numbers and focus on broader markers, such as sleep habits and improved self-control, she said. As patients move through treatment, for example, ask whether their sleeping habits have improved, whether they feel more in control of their eating behaviors, and if they are engaging more in their daily lives.

Even when patients experience obvious health benefits from weight loss, they may struggle with body dysmorphia, lingering concerns about their appearance, or feelings of inadequacy, Varney adds.

Issues like loose skin or other physical changes can fuel the belief that they are “not good enough” or that they haven’t achieved the ideal body image, Varney said. Post-weight loss, many patients may also face a paralyzing fear of regaining weight, which can lead to increased anxiety, stress, and obsession with maintaining their weight loss, she said. The fear can be exacerbated by concerns about accessing, affording, or continuing anti-obesity medications.

“The mental health support should not stop when the patient reaches their goal or maintenance weight,” she said.

In Varney’s practice, she has seen another issue pop up after weight loss that can cause mental distress for patients: family tensions. A patient’s weight loss can sometimes trigger food-related tensions within the family due to changes in the patient’s eating habits or interests or cause jealousy and resentment among family and friends.

“While the patient may achieve new confidence and health benefits, it can also introduce emotional and psychological complexities that can strain relationships if not addressed,” Varney said.

In these cases, Varney’s practice offers a monthly support group for those who have undergone bariatric surgery. For patients without a surgical history, she recommends or refers patients for couple or family counseling through local clinics and religious organizations.

Effect of Medications on Mental Health

A particularly pressing issue in the realm of obesity and mental health care is the impact of GLP agonists on mental health, Ramírez López said.

Recent reports have described the so-called “Ozempic Blues,” a phenomenon where patients can experience mood changes, anhedonia, or emotional blunting, she said. There have also been instances of behavioral activation effects, such as increased anxiety or impulsivity after using such medications. The side effects are not yet well understood, and more research is needed on their association, Ramírez López said.

Gunturu adds it’s important to talk to patients about these potential side effects when considering or starting new anti-obesity medications.

“When you distort the reward pathway in the brain, it can have some consequences,” he said. “The best way we can approach this is to talk to patients and let them know this can happen in the first 2 months. Be aware of it. You can do some behavioral techniques that can help motivate yourself.”