[Skip to Content]
[Skip to Content Landing]

Effect of Integrated Behavioral Weight Loss Treatment and Problem-Solving Therapy on Body Mass Index and Depressive Symptoms Among Patients With Obesity and DepressionThe RAINBOW Randomized Clinical Trial

Educational Objective
To learn about an integrated collaborative care intervention for obesity and depression.
1 Credit CME
Key Points

Question  Does an integrated collaborative care intervention improve weight loss and depressive symptoms among patients with obesity and depression?

Findings  In this randomized clinical trial that included 409 patients with obesity and depression, an intervention that integrated behavioral weight loss treatment and problem-solving therapy with as-needed antidepressant medications resulted in statistically significant reductions in body mass index compared with usual care (−0.7 vs −0.1, respectively) and depressive symptoms (−0.3 vs −0.1 on the 20-item Depression Symptom Checklist; score range, 0-4) at 12 months.

Meaning  A collaborative care intervention integrating behavioral weight loss treatment and problem-solving therapy with as-needed antidepressant medication led to statistically significant reductions in body mass index and depressive symptoms compared with usual care; however, the effect sizes were modest and of uncertain clinical importance.


Importance  Coexisting obesity and depression exacerbate morbidity and disability, but effective treatments remain elusive.

Objective  To test the hypothesis that an integrated collaborative care intervention would significantly improve both obesity and depression at 12 months compared with usual care.

Design, Setting, and Participants  The Research Aimed at Improving Both Mood and Weight (RAINBOW) randomized clinical trial enrolled 409 adults with body mass indices (BMIs) of 30 or greater (≥27 for Asian adults) and 9-item Patient Health Questionnaire (PHQ-9) scores of 10 or greater. Primary care patients at a health system in Northern California were recruited from September 30, 2014, to January 12, 2017; the date of final 12-month follow-up was January 17, 2018.

Interventions  All participants randomly assigned to the intervention (n = 204) or the usual care control group (n = 205) received medical care from their personal physicians as usual, received information on routine services for obesity and depression at their clinic, and received wireless physical activity trackers. Intervention participants also received a 12-month intervention that integrated a Diabetes Prevention Program–based behavioral weight loss treatment with problem-solving therapy for depression and, if indicated, antidepressant medications.

Main Outcomes and Measures  The co–primary outcome measures were BMI and 20-item Depression Symptom Checklist (SCL-20) scores (range, 0 [best] to 4 [worst]) at 12 months.

Results  Among 409 participants randomized (mean age of 51.0 years [SD, 12.1 years]; 70% were women; mean BMI of 36.7 [SD, 6.4]; mean PHQ-9 score of 13.8 [SD, 3.1]; and mean SCL-20 score of 1.5 [SD, 0.5]), 344 (84.1%) completed 12-month follow-up. At 12 months, mean BMI declined from 36.7 (SD, 6.9) to 35.9 (SD, 7.1) among intervention participants compared with a change in mean BMI from 36.6 (SD, 5.8) to 36.6 (SD, 6.0) among usual care participants (between-group mean difference, −0.7 [95% CI, −1.1 to −0.2]; P = .01). Mean SCL-20 score declined from 1.5 (SD, 0.5) to 1.1 (SD, 1.0) at 12 months among intervention participants compared with a change in mean SCL-20 score from 1.5 (SD, 0.6) to 1.4 (SD, 1.3) among usual care participants (between-group mean difference, −0.2 [95% CI, −0.4 to 0]; P = .01). There were 47 adverse events or serious adverse events that involved musculoskeletal injuries (27 in the intervention group and 20 in the usual care group).

Conclusions and Relevance  Among adults with obesity and depression, a collaborative care intervention integrating behavioral weight loss treatment, problem-solving therapy, and as-needed antidepressant medications significantly improved weight loss and depressive symptoms at 12 months compared with usual care; however, the effect sizes were modest and of uncertain clinical importance.

Trial Registration  ClinicalTrials.gov Identifier: NCT02246413

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

Article Information

Corresponding Author: Jun Ma, MD, PhD, Institute of Health Research and Policy, University of Illinois, 1747 W Roosevelt Rd, Room 586 (MC 275), Chicago, IL 60608 (maj2015@uic.edu).

Accepted for Publication: February 1, 2019.

Author Contributions: Dr Ma had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Ma, Lewis, Lavori.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Ma, Rosas, Lv, Xiao, Lewis.

Critical revision of the manuscript for important intellectual content: Ma, Rosas, Xiao, Snowden, Venditti, Lewis, Goldhaber-Fiebert, Lavori.

Statistical analysis: Xiao, Lavori.

Obtained funding: Ma, Lewis.

Administrative, technical, or material support: Rosas, Lv, Snowden, Venditti, Lewis.

Supervision: Ma, Rosas, Venditti.

Conflict of Interest Disclosures: Dr Lavori reported receiving personal fees from Palo Alto Medical Foundation Research Institute. No other disclosures were reported.

Funding/Support: This research was supported by award R01HL119453 from the National Heart, Lung, and Blood Institute and internal funding from the Palo Alto Medical Foundation Research Institute and the University of Illinois, Chicago.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Data Sharing Statement: See Supplement 5.

Additional Contributions: We thank Wayne Katon, MD (deceased), who contributed significantly to the conception and design of the study. We also thank the following paid research team members who contributed to the conduct of the study: Elizabeth Jameiro, MD, Nancy Wittels, MS, Veronica Luna, BS, Andrea Blonstein, MBA, RD, Kristen M. J. Azar, MSN/MPH (all from Sutter Health); Hoang Nguyen (Blue Shield of California); Lenard I. Lesser, MD, MSHS (One Medical); and Elizabeth Ward, MD (Pacific Coast Psychiatric Associates). We also thank the data and safety monitoring board members who received compensation for their time: William L. Haskell, PhD (chair), Manisha Desai, PhD, Sandra Tsai, MD, Mickey Trockel, MD, Manpreet Singh, MD, MS (all from Stanford University), and Alex Leow, MD, PhD (University of Illinois, Chicago). The data and safety monitoring board reviewed the study protocol initially and data quality and safety monitoring reports semiannually thereafter. We extend special thanks to the participants and their families who made this study possible.

Hales  CM, Fryar  CD, Carroll  MD,  et al.  Trends in obesity and severe obesity prevalence in US youth and adults by sex and age, 2007-2008 to 2015-2016.  JAMA. 2018;319(16):1723-1725. PubMedGoogle ScholarCrossref
National Institute of Health. Major depression: 2017. https://www.nimh.nih.gov/health/statistics/major-depression.shtml. Accessed April 12, 2018.
Inter-university Consortium for Political and Social Research. National Comorbidity Survey Replication (NCS-R) lifetime and twelve-month prevalence estimates 2007. https://www.hcp.med.harvard.edu/ncs/index.php. Accessed June 16, 2008.
Pereira-Miranda  E, Costa  PRF, Queiroz  VAO,  et al.  Overweight and obesity associated with higher depression prevalence in adults.  J Am Coll Nutr. 2017;36(3):223-233.PubMedGoogle ScholarCrossref
Pratt  LA, Brody  DJ.  Depression and Obesity in the US Adult Household Population, 2005–2010: NCHS Data Brief, No. 167. Hyattsville, MD: National Center for Health Statistics; 2014.
Nigatu  YT, Bültmann  U, Schoevers  RA,  et al.  Does obesity along with major depression or anxiety lead to higher use of health care and costs.  Eur J Public Health. 2017;27(6):965-971.PubMedGoogle ScholarCrossref
Ladwig  KH, Marten-Mittag  B, Löwel  H,  et al.  Synergistic effects of depressed mood and obesity on long-term cardiovascular risks in 1510 obese men and women.  Int J Obes (Lond). 2006;30(9):1408-1414.PubMedGoogle ScholarCrossref
Ma  J, Yank  V, Xiao  L,  et al.  Translating the Diabetes Prevention Program lifestyle intervention for weight loss into primary care.  JAMA Intern Med. 2013;173(2):113-121.PubMedGoogle ScholarCrossref
Wadden  TA, Butryn  ML, Hong  PS, Tsai  AG.  Behavioral treatment of obesity in patients encountered in primary care settings.  JAMA. 2014;312(17):1779-1791.PubMedGoogle ScholarCrossref
Ciechanowski  P, Wagner  E, Schmaling  K,  et al.  Community-integrated home-based depression treatment in older adults.  JAMA. 2004;291(13):1569-1577.PubMedGoogle ScholarCrossref
Ciechanowski  P, Chaytor  N, Miller  J,  et al.  PEARLS depression treatment for individuals with epilepsy.  Epilepsy Behav. 2010;19(3):225-231.PubMedGoogle ScholarCrossref
Zhang  A, Park  S, Sullivan  JE, Jing  S.  The effectiveness of problem-solving therapy for primary care patients’ depressive and/or anxiety disorders.  J Am Board Fam Med. 2018;31(1):139-150.PubMedGoogle ScholarCrossref
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. 2011;41(1):119-130.PubMedGoogle ScholarCrossref
Pagoto  S, Schneider  KL, Whited  MC,  et al.  Randomized controlled trial of behavioral treatment for comorbid obesity and depression in women.  Int J Obes (Lond). 2013;37(11):1427-1434.PubMedGoogle ScholarCrossref
Ma  J, Xiao  L, Lv  N,  et al.  Profiles of sociodemographic, behavioral, clinical and psychosocial characteristics among primary care patients with comorbid obesity and depression.  Prev Med Rep. 2017;8:42-50.PubMedGoogle ScholarCrossref
Kroenke  K, Spitzer  RL, Williams  JB.  The PHQ-9.  J Gen Intern Med. 2001;16(9):606-613.PubMedGoogle ScholarCrossref
Arroll  B, Goodyear-Smith  F, Crengle  S,  et al.  Validation of PHQ-2 and PHQ-9 to screen for major depression in the primary care population.  Ann Fam Med. 2010;8(4):348-353.PubMedGoogle ScholarCrossref
Xiao  L, Huang  Q, Yank  V, Ma  J.  An easily accessible web-based minimization random allocation system for clinical trials.  J Med Internet Res. 2013;15(7):e139.PubMedGoogle ScholarCrossref
Pocock  SJ, Simon  R.  Sequential treatment assignment with balancing for prognostic factors in the controlled clinical trial.  Biometrics. 1975;31(1):103-115.PubMedGoogle ScholarCrossref
Efron  B.  Forcing sequential experiment to be balanced.  Biometrika. 1971;58(3):403-417. doi:10.1093/biomet/58.3.403Google ScholarCrossref
Kramer  MK, Kriska  AM, Venditti  EM,  et al.  Translating the Diabetes Prevention Program.  Am J Prev Med. 2009;37(6):505-511. PubMedGoogle ScholarCrossref
Knowler  WC, Barrett-Connor  E, Fowler  SE,  et al.  Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin.  N Engl J Med. 2002;346(6):393-403.PubMedGoogle ScholarCrossref
Bandura  A.  Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice Hall; 1986.
Ma  J, Yank  V, Lv  N,  et al.  Research Aimed at Improving Both Mood and Weight (RAINBOW) in primary care.  Contemp Clin Trials. 2015;43:260-278.PubMedGoogle ScholarCrossref
Glass  RM, Allan  AT, Uhlenhuth  EH,  et al.  Psychiatric screening in a medical clinic.  Arch Gen Psychiatry. 1978;35(10):1189-1195. PubMedGoogle ScholarCrossref
Katon  WJ, Lin  EH, Von Korff  M,  et al.  Collaborative care for patients with depression and chronic illnesses.  N Engl J Med. 2010;363(27):2611-2620.PubMedGoogle ScholarCrossref
Spitzer  RL, Kroenke  K, Williams  JB, Löwe  B.  A brief measure for assessing generalized anxiety disorder: the GAD-7.  Arch Intern Med. 2006;166(10):1092-1097. PubMedGoogle ScholarCrossref
LeBlanc  ES, Patnode  CD, Webber  EM,  et al.  Behavioral and pharmacotherapy weight loss interventions to prevent obesity-related morbidity and mortality in adults.  JAMA. 2018;320(11):1172-1191. PubMedGoogle ScholarCrossref
Weathers  FW, Litz  BT, Herman  DS,  et al. The PTSD checklist: reliability, validity, and diagnostic utility. Paper presented at: the Annual Meeting of the International Society for Traumatic Stress Studies; 1993; San Antonio, TX.
Spitzer  RL, Kroenke  K, Williams  JB.  Validation and utility of a self-report version of PRIME-MD.  JAMA. 1999;282(18):1737-1744.PubMedGoogle ScholarCrossref
DiCiccio  TJ, Efron  B.  Bootstrap confidence intervals.  Statistic Sci. 1996;11(3):189-228. doi:10.1214/ss/1032280214Google ScholarCrossref
International Conference on Harmonisation E9 Expert Working Group.  ICH harmonised tripartite guideline: statistical principles for clinical trials.  Stat Med. 1999;18(15):1905-1942.PubMedGoogle Scholar
Peirson  L, Douketis  J, Ciliska  D,  et al.  Treatment for overweight and obesity in adult populations.  CMAJ Open. 2014;2(4):E306-E317.PubMedGoogle ScholarCrossref
Berwick  DM, Nolan  TW, Whittington  J.  The triple aim.  Health Aff (Millwood). 2008;27(3):759-769.PubMedGoogle ScholarCrossref
University of Washington. PEARLS program: 2016. https://depts.washington.edu/hprc/evidence-based-programs/pearls-program/. Accessed June 27, 2018.
Press  MJ, Howe  R, Schoenbaum  M,  et al.  Medicare payment for behavioral health integration.  N Engl J Med. 2017;376(5):405-407.PubMedGoogle ScholarCrossref
Tice  JA, Chapman  RS, Seidner  M, Ollendorf  DA, Weissberg  J, Pearson  SD. Diabetes Prevention Programs: effectiveness and value: final evidence report and meeting summary. https://icer-review.org/wp-content/uploads/2016/07/CTAF_DPP_Final_Evidence_Report_072516.pdf. Accessed July 29, 2018.
Ma  J, Strub  P, Xiao  L,  et al.  Behavioral weight loss and physical activity intervention in obese adults with asthma.  Ann Am Thorac Soc. 2015;12(1):1-11.PubMedGoogle ScholarCrossref
Xiao  L, Lv  N, Rosas  LG, Au  D, Ma  J.  Validation of clinic weights from electronic health records against standardized weight measurements in weight loss trials.  Obesity (Silver Spring). 2017;25(2):363-369.PubMedGoogle ScholarCrossref
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right

Name Your Search

Save Search
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience

Lookup An Activity


My Saved Searches

You currently have no searches saved.

With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
State Requirements