What treatment options are available for a 62-year-old woman, with a body mass index (BMI) within the normal range, who is experiencing depression related to her weight and body shape?

Treatment for Depression Related to Body Image in a Woman with Normal BMI

This 62-year-old woman with a BMI of 23.4 kg/m² (normal range) experiencing depression about her weight and body shape requires psychological intervention as the primary treatment, not weight loss therapy, because her distress stems from body image disturbance rather than actual obesity. 1

Why Weight Loss Treatment is Inappropriate

• Her BMI of 23.4 kg/m² falls well within the normal range (18.5-24.9 kg/m²), making her ineligible for weight loss medications, which are FDA-approved only for BMI ≥30 kg/m² or BMI ≥27 kg/m² with weight-related comorbidities. 2
• Body weight perception, rather than actual BMI, is the primary driver of psychological distress and unhealthy behaviors in women who perceive themselves as heavier than they actually are. 3
• Weight bias internalization—not actual body weight—is the strongest predictor of psychological distress and body dissatisfaction, even more than BMI itself. 4

Primary Treatment Approach: Mental Health Intervention

Screen for depression severity using the Patient Health Questionnaire-9 (PHQ-9) to determine the intensity of treatment needed. 1

Psychological Referral is Essential

• Refer to a mental health provider, particularly one specializing in eating disorders and body image disturbances, because body image disturbances and maladaptive eating patterns require specialized behavioral therapy. 1
• Patients with lower Weight Efficacy Lifestyle Questionnaire Short-Form scores (<53 points) should be referred to a healthcare professional experienced in obesity counseling and behavioral therapy, though in this case the focus should be on body image rather than weight loss. 1

Depression Treatment Options

• Pharmacotherapy combined with supportive counseling is more effective than either modality alone for depression. 5
• Antidepressant medication outcomes do not differ based on BMI category, so standard depression treatment protocols apply regardless of her normal weight status. 6
• The newer antidepressant medications achieve much greater patient adherence than earlier agents and are better tolerated. 5

Behavioral Therapy Components

Cognitive-behavioral therapy targeting body image distortion and weight bias internalization should be the cornerstone of treatment. 4

• Address the distorted body weight perception, as women who perceive themselves as heavier than their actual BMI are at greater risk for depressed mood and unhealthy weight control behaviors. 3
• Focus on reducing weight bias internalization, which mediates the relationship between perceived weight discrimination and body dissatisfaction. 4
• Screen for and address any unhealthy weight control behaviors such as fasting, diet pills, or laxative use that may be present. 3

What NOT to Do: Critical Pitfalls

• Do not prescribe weight loss medications or recommend caloric restriction, as she does not meet criteria for obesity treatment and such interventions could reinforce her distorted body image. 2
• Do not validate her perception that weight loss is needed, as this would be medically inappropriate given her normal BMI and could worsen body image disturbance. 1
• Avoid focusing solely on pharmacotherapy without addressing the underlying body image issues, as the psychological component requires specialized intervention. 1, 5

Monitoring and Follow-up

• Depression is considered a chronic disease with increasing likelihood of recurrence with each episode, often requiring prolonged maintenance of medication if pharmacotherapy is initiated. 5
• Most patients with mild to moderate depression can be effectively managed in primary care, with referral required for those unresponsive to therapy or who are suicidal. 5
• Regular follow-up should monitor both depressive symptoms and any development of disordered eating patterns. 1