Journal of General Internal Medicine

, Volume 26, Issue 11, pp 1284–1290 | Cite as

Obesity, Depression, and Health Services Costs Among Middle-Aged Women

  • Gregory E. SimonEmail author
  • David Arterburn
  • Paul Rohde
  • Evette J. Ludman
  • Jennifer A. Linde
  • Belinda H. Operskalski
  • Robert W. Jeffery
Original Research



Both obesity and depression have been associated with significant increases in health care costs. Previous research has not examined whether cost increases associated with obesity could be explained by confounding effects of depression.


Examine whether the association between obesity and health care costs is explained by co-occurring depression.


Cross-sectional study including telephone survey and linkage to health plan records.


4462 women aged 40 to 65 enrolled in prepaid health plan in the Pacific Northwest.

Main Measures

The telephone survey included self-report of height and weight and measurement of depression by the Patient Health Questionnaire (PHQ9). Survey data were linked to health plan cost accounting records.

Key Results

Compared to women with BMI less than 25, proportional increases in health care costs were 65% (95% CI 41% to 93%) for women with BMI 30 to 35 and 157% (95% CI 91% to 246%) for women with BMI of 35 or more. Adjustment for co-occurring symptoms of depression reduced these proportional differences to 40% (95% CI 18% to 66%) and 87% (95% CI 42% to 147%), respectively. Cost increases associated with obesity were spread across all major categories of health services (primary care visits, outpatient prescriptions, inpatient medical services, and specialty mental health care).


Among middle-aged women, both obesity and depression are independently associated with substantially higher health care costs. These cost increases are spread across the full range of outpatient and inpatient health services. Given the high prevalence of obesity, cost increases of this magnitude have major policy and public health importance


depression obesity cost epidemiology 



All listed authors made substantive contributions to the design and conduct of this study; all made substantive contributions to the drafting and/or editing of this manuscript.

Other Contributors

There are no other individuals who made substantial contributions but do not meet criteria for authorship.


Funded by NIMH grant R01 MH068127

Prior Presentation


Conflict of Interest

None disclosed.


  1. 1.
    Bertakis KD, Azari R. Obesity and the use of health care services. Obes Res. 2005;13(2):372–9.PubMedCrossRefGoogle Scholar
  2. 2.
    Quesenberry CP, Jr., Caan B, Jacobson A. Obesity, health services use, and health care costs among members of a health maintenance organization. Arch Intern Med. 1998;158(5):466–72.PubMedCrossRefGoogle Scholar
  3. 3.
    Andreyeva T, Sturm R, Ringel JS. Moderate and severe obesity have large differences in health care costs. Obes Res. 2004;12(12):1936–43.PubMedCrossRefGoogle Scholar
  4. 4.
    Daviglus ML, Liu K, Yan LL, et al. Relation of body mass index in young adulthood and middle age to Medicare expenditures in older age. JAMA. 2004;292(22):2743–9.PubMedCrossRefGoogle Scholar
  5. 5.
    Cai L, Lubitz J, Flegal KM, Pamuk ER. The predicted effects of chronic obesity in middle age on Medicare costs and mortality. Med Care. 2010;48(6):510–7.PubMedCrossRefGoogle Scholar
  6. 6.
    Onyike C, Crum R, Lee H, Lyketsos C, Eaton W. Is obesity associated with major depression? Results from the Third National Health and Nutrition Examination Survey. Am J Epidemiol. 2003;158:1139–47.PubMedCrossRefGoogle Scholar
  7. 7.
    Heo M, Pietrobelli A, Fontaine K, Sirey J, Faity M. Depressive mood and obesity in US adults: comparison and moderation by sex, age, and race. Int J Obes. 2005;(epub Nov 15).Google Scholar
  8. 8.
    Ma J, Xiao L. Obesity and depression in US women: results from the 2005–2006 National Health and Nutritional Examination Survey. Obesity (Silver Spring). 2010;18(2):347–53.CrossRefGoogle Scholar
  9. 9.
    Zhao G, Ford ES, Dhingra S, Li C, Strine TW, Mokdad AH. Depression and anxiety among US adults: associations with body mass index. Int J Obes (Lond). 2009;33(2):257–66.CrossRefGoogle Scholar
  10. 10.
    Simon G, Ludman E, Linde J, et al. Association between obesity and depression in middle-aged women. Gen Hosp Psychiatry. 2008;30:32–9.PubMedCrossRefGoogle Scholar
  11. 11.
    Simon G, VonKorff M, Saunders K, et al. Association between obesity and psychiatric disorders in the US adult population. Arch Gen Psychiatry. 2006;63:824–30.PubMedCrossRefGoogle Scholar
  12. 12.
    Simon GE, Ludman EJ, Linde JA, et al. Association between obesity and depression in middle-aged women. Gen Hosp Psychiatry. 2008;30(1):32–9.PubMedCrossRefGoogle Scholar
  13. 13.
    Simon G, Ormel J, VonKorff M, Barlow W. Health care costs associated with depressive and anxiety disorders in primary care. Am J Psychiat. 1995;152:352–7.PubMedGoogle Scholar
  14. 14.
    Simon G, VonKorff M, Barlow W. Health care costs of primary care patients with recognized depression. Arch Gen Psychiatry. 1995;52:850–6.PubMedGoogle Scholar
  15. 15.
    Unützer J, Patrick D, Simon G, et al. Depressive symptoms and the cost of health services in HMO patients age 65 and over: a four-year prospective study. JAMA. 1997;277:1618–23.PubMedCrossRefGoogle Scholar
  16. 16.
    Taplin S, Thompson R, Schintzer F, Anderman C, Immanuel V. Revisions in the risk-based Breast Cancer Screening Program at Group Health Cooperative. Cancer. 1990;66:812–8.PubMedCrossRefGoogle Scholar
  17. 17.
    Cochran W. Sampling techniques. New York: Wiley; 1977.Google Scholar
  18. 18.
    Huang F, Chung H, Kroenke K, Delucchi K, Spitzer R. Using the Patient Health Questionnaire-9 to measure depression among racially and ethnically diverse primary care patients. J Gen Intern Med. 2006;21:547–52.PubMedCrossRefGoogle Scholar
  19. 19.
    Kroenke K, Spitzer R, Williams J. The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606–13.PubMedCrossRefGoogle Scholar
  20. 20.
    Lowe B, Kroenke K, Herzog W, Grafe K. Measuring depression outcome with a brief self-report instrument: sensitivity to change of the Patient Health Questionnaire (PHQ-9). J Affect Disord. 2004;81:61–6.PubMedCrossRefGoogle Scholar
  21. 21.
    Spitzer R, Kroenke K, Williams J. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. JAMA. 1999;282:1737–44.PubMedCrossRefGoogle Scholar
  22. 22.
    Linde JA, Simon GE, Ludman EJ, et al. A Randomized Controlled Trial of Behavioral Weight Loss Treatment versus Combined Weight Loss/Depression Treatment among Women with Comorbid Obesity and Depression. Ann Behav Med. (in press).Google Scholar
  23. 23.
    Weinberg C. Toward a clear definition of confounding. Am J Epidemiol. 1993;137:1–8.PubMedGoogle Scholar
  24. 24.
    Katon WJ. Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biol Psychiatry. 2003;54(3):216–26.PubMedCrossRefGoogle Scholar
  25. 25.
    Rohde P, Ichikawa L, Simon GE, et al. Associations of child sexual and physical abuse with obesity and depression in middle-aged women. Child Abuse Negl. 2008;32(9):878–87.PubMedCrossRefGoogle Scholar
  26. 26.
    Simon G, Chisholm D, Treglia M, Bushnell D. Course of depression, health services costs, and work productivity in an international primary care study. Gen Hosp Psychiatry. 2002;24:328–35.PubMedCrossRefGoogle Scholar
  27. 27.
    Simon G, Revicki D, Heiligenstein J, et al. Recovery from depression, work productivity, and health care costs among primary care patients. Gen Hosp Psychiatry. 2000;22:153–62.PubMedCrossRefGoogle Scholar
  28. 28.
    McEwen LN, Coelho RB, Baumann LM, Bilik D, Nota-Kirby B, Herman WH. The cost, quality of life impact, and cost-utility of bariatric surgery in a managed care population. Obes Surg. 2010;20(7):919–28.PubMedCrossRefGoogle Scholar
  29. 29.
    Sampalis JS, Liberman M, Auger S, Christou NV. The impact of weight reduction surgery on health-care costs in morbidly obese patients. Obes Surg. 2004;14(7):939–47.PubMedCrossRefGoogle Scholar
  30. 30.
    Cremieux PY, Buchwald H, Shikora SA, Ghosh A, Yang HE, Buessing M. A study on the economic impact of bariatric surgery. Am J Manag Care. 2008;14(9):589–96.PubMedGoogle Scholar
  31. 31.
    Makary MA, Clarke JM, Shore AD, et al. Medication utilization and annual health care costs in patients with type 2 diabetes mellitus before and after bariatric surgery. Arch Surg. 2010;145(8):726–31.PubMedCrossRefGoogle Scholar
  32. 32.
    Rivenes AC, Harvey SB, Mykletun A. The relationship between abdominal fat, obesity, and common mental disorders: results from the HUNT study. J Psychosom Res. 2009;66(4):269–75.PubMedCrossRefGoogle Scholar
  33. 33.
    Marijnissen RM, Bus BA, Holewijn S, et al. Depressive symptom clusters are differentially associated with general and visceral obesity. J Am Geriatr Soc. 2011;59(1):67–72.PubMedCrossRefGoogle Scholar
  34. 34.
    Katon W, Unutzer J, Fan M, et al. Cost-effectiveness and net benefit of enhanced treatment of depression for older adults with diabetes and depression. Diabetes Care. 2006. 2006;29:265–70.PubMedCrossRefGoogle Scholar
  35. 35.
    Katon WJ, Russo JE, Von Korff M, Lin EH, Ludman E, Ciechanowski PS. Long-term effects on medical costs of improving depression outcomes in patients with depression and diabetes. Diabetes Care. 2008;31(6):1155–9.PubMedCrossRefGoogle Scholar
  36. 36.
    Simon GE, Katon WJ, Lin EH, et al. Cost-effectiveness of systematic depression treatment among people with diabetes mellitus. Arch Gen Psychiatry. 2007;64(1):65–72.PubMedCrossRefGoogle Scholar
  37. 37.
    Unutzer J, Katon WJ, Fan MY, et al. Long-term cost effects of collaborative care for late-life depression. Am J Manag Care. 2008;14(2):95–100.PubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2011

Authors and Affiliations

  • Gregory E. Simon
    • 1
    • 4
    Email author
  • David Arterburn
    • 1
  • Paul Rohde
    • 2
  • Evette J. Ludman
    • 1
  • Jennifer A. Linde
    • 3
  • Belinda H. Operskalski
    • 1
  • Robert W. Jeffery
    • 3
  1. 1.Group Health Research InstituteSeattleUSA
  2. 2.Oregon Research InstituteEugeneUSA
  3. 3.Division of Epidemiology and Community Health, School of Public HealthUniversity of MinnesotaMinneapolisUSA
  4. 4.Center for Health StudiesSeattleUSA

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