The British press dubbed Kate Middleton "Waity Katy" after her courtship with Prince William stretched for years without an engagement – but lately the tabloids are more focused on Katy's weight.

Middleton has always had a lithe, athletic build, but the trim princess-to-be has looked even more slender lately – prompting media cries that she's lost too much weight for her royal wedding and speculation that she may fall prey to the same web of pressures and pain that befell the late Princess Diana.

The prince's longtime love has been spotted working out at Di's old gym and she's rumored to be using a risky no-carb diet to drop pounds – arousing fears she may fall into the same obsessive quest for thinness and perfection that caused Diana so much misery.

But those who know the royal family well call the reports rubbish and say Middleton's emotional state couldn't be more different from the late Diana.

"The British press has been relentless in its attempt to portray Kate Middleton as a fragile young woman who is already falling prey to an eating disorder. It's absurd," said Christopher Andersen, author of "William and Kate: A Love Story" and the bestselling "The Day Diana Died."


The Princess brides: Lady Diana Spencer and Prince Charles in 1981 and Kate Middleton and Prince William in 2010. (Getty)

"Kate looks no thinner to me at all. She's always been a health and exercise fanatic, but not in an unhealthy way," he said.

According to royal lore, Diana became bulimic after Prince Charles hurt her feelings by calling her "chubby."

"Kate is not chubby at all, but if she was, William would never hurt her feelings in that manner," said Andersen. "Charles could be thoughtless, even cruel, in a way Williams never could."

Another difference is the marriages themselves.

There is no "other woman" lurking in the wings to mar Kate and William's special day. One of the reasons Diana became so thin and insecure at the time of her wedding was because she knew her husband-to-be was in love with his now-wife Camilla Parker Bowles.

"Diana was l9 when she married a man she already knew was in love with someone else," Andersen said. "She was driven over the edge by a royal family that treated her pretty shabbily."

Kate Middleton is 10 years older than Diana was at the time of her engagement and in a much better place, emotionally, because she's marrying a guy who seems completely devoted to herm said Andersen.

Another reason why Prince Charles and Princess Diana's marriage bombed was there considerable age gap, said Claudia Joseph, the author of "Kate: The Making of a Princess."

William's parents were 12 years apart in age while the prince and Kate are the same age.

"I think she already has a distinct advantage over Diana. She is older and wiser and will conduct her role in a more dignified and conscientious manner," Joseph said. "Kate has been dating William for nearly eight years and has had ample opportunity to learn from him how to cope with the role."

Joseph also shrugged off rumors that Kate is heading down a path to weight obsession and eating disorders.

"Certainly Kate has lost weight since she became engaged, but many brides drop pounds in the runup to their wedding," she said. "It does not mean she has a problem."

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As director of the Mood and Anxiety Disorders Program and associate professor of psychiatry and neuroscience at Mount Sinai Hospital, Dr. Dan V. Iosifescu is a psychiatrist who specializes in treatment-resistant depression and bipolar disorder. His research looks for novel treatments and understanding the brain mechanisms of these severe conditions.

Who's at risk

Major depression and bipolar disorder are two of the most common disorders seen by psychiatrists.

"Depression affects between 10% and 15% of the population," says Iosifescu. "Bipolar disorder is less frequent, but still affects 2% to 4% of Americans at some point during their lifetime."

A subset of patients who do not improve after multiple treatments is termed "treatment resistant."

These mood disorders can appear similar, and depressive episodes are indistinguishable in bipolar disorder and major depression. "Depressive episodes are characterized by long periods of severe sadness and a lack of interest in doing things" says Iosifescu. "In bipolar disorder, patients experience episodes of depression alternating with episodes of extreme mood elevation called mania or hypomania, which often lead to dangerous behaviors."

Genetics and traumatic life events are the two primary risk factors for depression and bipolar disorder, which both have fairly early ages of onset.

"While bipolar typically begins early in life (50% of patients have their first episode by age 18), depression has a wider range of first onset. However, the majority of patients experience their first episode before age 30," says Iosifescu.

While some patients might have only one or two depressed or manic episodes during their lifetime and can maintain a high level of functioning, patients with treatment-resistant disorder have long, chronic episodes or a series of multiple recurrences and can be highly impaired.

Signs and symptoms

Both depression and bipolar disorder are characterized by multiple psychological and physical symptoms.

"Besides sadness and lack of interest, symptoms of depression include disrupted sleep, low self-esteem, guilt, low energy and fatigue, poor concentration and significant changes in appetite," says Iosifescu. "Importantly, some patients experience suicidal thoughts, and suicide is a cause of mortality in both depression and bipolar disorder."

While most patients can recognize their periods of depression, they are less able to recognize as abnormal the mood elevation (hypomania and mania) of bipolar disorder. "The periods of mania — an abnormally excited, hyper mood — can feel like positive energy to the patient, even as they are perceived as abnormal by those around the patient, and it impairs significantly the patients' ability to function," says Iosifescu.

"In this state, people tend to have excessive involvement in pleasurable activities, disregarding risks or potential negative consequences."

Mania is also associated with high irritability, distractedness, high self-esteem, decreased sleep without fatigue, high levels of activity and pressured speech (very rapid speech).

"Sometimes bipolar disorder is not recognized, as the patient does not remember manic episodes as abnormal. However, the most significant challenge for treatment-resistant patients is finding a treatment that does work, even if it's not standard," says Iosifescu. "A series of novel treatments currently researched, some of them in advanced development, could prove to be lifesaving for these patients."

Traditional treatment

The standard trifecta of treatment options are medications, psychotherapies (counseling or talking therapy) and somatic treatments like electric-shock therapy and transcranial magnetic stimulation.

"We have a good number of FDA-approved drugs for depression and a smaller number for bipolar disorder," says Iosifescu. "The problem is that a lot of these medications belong to the same families of chemicals and work in relatively similar ways. So while they're incredibly helpful for many people, they are ineffective for a minority of our patients."

Psychotherapies seek to improve the patient's sense of well-being and provide tools for overcoming problems.

"For instance, cognitive behavioral therapy focuses on the abnormal thinking patterns that patients develop and helps them recognize and correct their distorted perceptions," says Iosifescu.

Somatic therapies apply energy directly to the brain to cause positive changes in depression and mood.

"Along with electro-convulsive therapy, commonly known as electric shock therapy, more modern treatments include transcranial magnetic stimulation, a magnetic field that stimulates currents in the brain, and vagus nerve stimulation, which modulates electric signals in the brain," says Iosifescu. "While electric shock therapy tends to be very effective, it has significant side effects. Transcranial magnetic stimulation and vagus nerve stimulation have limited efficacy."

Research breakthroughs

Doctors are seeking new therapies to help patients who have proven resistant to treatment.
"One very important novel treatment is ketamine, a medication currently used for anesthesia," says Iosifescu. "Recent studies, including several from our group at Mount Sinai, showed that ketamine works reliably and much faster than other antidepressants, with significant improvement occurring after only a few days even in treatment-resistant patients."

The success of ketamine points to a potential whole new family of drugs for treating depression, with activity on glutamate brain receptors, in contrast to current antidepressants, which produce their effects via serotonin, norepinephrine and dopamine.

Questions for your doctor

If you're diagnosed and undergoing a new treatment regimen, ask: "How soon can I expect improvement?" "If it's not working after eight weeks, it's time to take another approach," says Iosifescu.

Another key question is, "How will we know that the treatment is working?"

Not all depression symptoms improve at the same pace. "We have a wide enough variety of treatments that even after you've tried a few, we can find something else that works on very different mechanisms to help you manage these disorders and improve your quality of life," says Iosifescu.

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