A number of studies have shown a direct link between a higher body mass index (BMI) and increased risk for depression.1-7 Body image dissatisfaction, as well as weight and shape concerns, were found to contribute to the relationship between obesity and depression.2 In a study by Pratt and Brody, 43% of adults with depression were also obese.1 The authors suggest that adults with depression are more likely to be obese than adults without depression — and that as depression severity increases, obesity rates rise.1
Depression has also been shown to interfere with weight loss.8 Patients with obesity and untreated depression lose less weight during weight loss treatment, while patients who recover from depression have weight loss success equal to that of those who are not depressed.8 Weight loss has also been shown to improve depressive symptoms. A study by Busch et al found that the patients who were most depressed who participated in a weight loss program experienced a reduction in depression symptoms in relationship to reduced weight.9
Both depression and obesity are associated with medical comorbidities.10,11 Moderate to severe depression can cause severe difficulty, decline in function, and even suicide, while obesity is associated with cardiovascular disease, cancer, sleep apnea, liver disease, and infertility.10
Identifying depression may improve weight loss in patients with obesity, and weight loss may improve the symptoms of depression, suggesting that screening for both diseases is essential to health promotion and prevention of further disease.
To that end, the authors established a quality improvement project to identify patients who could benefit from both depression and obesity management in an urgent care/primary care center.
Quality Improvement Project: A Care Model
Prior to the study, patients being seen at the urgent care setting were routinely screened for obesity with an automated BMI calculation reported in the electronic medical record, but they were not screened or evaluated for depression.
The quality improvement model for this project is the Care Model, which consists of 3 overlapping spheres: community, health systems, and provider organization.12 The Care Model guided the project’s structure to include resources, policies, and processes such as self-management support for patients.
The goal of the project was to identify patients with a BMI of ≥30 mg/kg2 (World Health Organization definition of obesity) and screen them using the Patient Health Questionnaire (PHQ)-2 to identify any patients with undiagnosed depression. The objectives included initiating PHQ-2 in 50% of patients who were obese and were seen in the office over 12 weeks; administering the PHQ-9 to 100% of patients who screened positive on the PHQ-2 over 12 weeks; and referring 50% of patients who screened positive on the PHQ-9 to undergo psychiatric examination.
Use of the PHQ-2 and PHQ-9 in the obese population is a valid and reliable way to identify patients with depression.13 The PHQ-2 is made up of the first 2 questions of the PHQ-9. According to the American Psychological Association, patients who score ≥10 on the PHQ-9 are 7 to 13.6 times more likely to be diagnosed with depression.13 The PHQ-9 has a sensitivity of 88% and a specificity of 88%. After identifying patients with obesity and depression, the provider can offer education and/or guidance for both conditions.
Inclusion criteria included adults between the ages of 18 and 69 years with a BMI of ≥30 mg/kg2 seen in the office, able to read and speak English, and willing to participate in the project. Exclusion criteria included patients who were out of the age range, who had a normal or overweight BMI (≥25 kg/m2), who were not English speakers, who had previously been screened for the project, or who were seen through the house call or telemedicine services.
Demographic data was collected, including age, gender, history of depression, and use of antidepressant medications, and the project was approved by the University of South Alabama’s Institutional Review Board.