The impact of psychotropic weight gain on people with psychosis – patient perspectives and attitudes

The psychological journey of weight gain in psychosis

BACKGROUND

Rapid weight gain is common with antipsychotic medication. Lost confidence, low mood and medication non-adherence often follow. Yet, the dynamic interactions between the physical and psychological consequences of weight gain, and implications for intervention, are unknown.

OBJECTIVES

We examined first-person accounts of weight gain to identify preferences for weight change interventions.

DESIGN

A qualitative design was used to explore patients' experiences of weight change in the context of psychosis.

METHOD

Semi-structured interviews, analysed using grounded theory, were conducted with 10 patients with psychosis. Sample validation was conducted with peer researchers with lived experience of psychosis.

RESULTS

Patients described that initially the extent and speed of weight gain was overshadowed by psychotic experiences and their treatment. This led to a shocking realisation of weight gain. The psychological impact of weight gain, most strikingly on the self-concept, was profound. Loss of self-worth and changed appearance amplified a sense of vulnerability. There were further consequences on mood, activity and psychotic experiences, such as voices commenting on appearance, that were additional obstacles in the challenging process of weight loss. Sedative effects of medication also contributed. Unsuccessful weight loss left little hope and few preferences for interventions. Early information about common weight gain trajectories and working with experts-by-experience were valued. Rebuilding self-confidence, efficacy and worth may be a necessary first step.

CONCLUSIONS

The journey of weight gain in patients with psychosis is characterised by loss of self-worth, agency and hope. There are multiple stages in the journey, each with different psychological reactions, that may need different treatment responses.

The use of anti-obesity medications in people with mental illness as an adjunct to lifestyle interventions - Effectiveness, tolerability and impact on eating behaviours: A 52-week observational study

OBJECTIVE

The increasing prevalence of obesity and metabolic syndrome in people with mental illness (MI) is a global health priority. Anti-obesity medications (AOMs) may help with reducing medication induced hunger and weight gain when lifestyle changes are insufficient. Our aim is to evaluate the effectiveness, tolerability, impact on eating behaviours and psychiatric safety of AOMs in this population.

METHODS

We conducted an observational study of 244 adults with MI with at least two risk factors for metabolic syndrome attending an obesity management clinic. Participants received standardised diet, exercise and psychological care, in addition to AOMs tailored to each participant's circumstances. Baseline and 12-month assessments encompassing physical, metabolic and psychological parameters were compared.

RESULTS

Over the course of the study, the average weight loss was 11.79 kg (12.1%), decrease in BMI was 3.90 kg/m² and reduction in waist circumference was 12.6 cm. Participants with good glycaemic control increased from 28.6% to 80.7%, hypercholesterolaemia reduced from 85.2%-29.9% and hypertension rates reduced from 88.9%-52.0%. Depression, anxiety and stress levels for the sample decreased significantly (all p < .01). Eating behaviours improved (all p < .001) at follow-up. Psychiatric side effects including deterioration of mood (28.2%) and suicidality (30.8%) were primarily experienced by those on topiramate.

CONCLUSIONS

AOMs can be effective in achieving clinically meaningful weight loss, improved metabolic co-morbidities and eating behaviours in people living with MI, when combined with a comprehensive lifestyle program. The majority of AOMs are well tolerated but topiramate appears more likely to negatively impact mental health.

Evaluation of an online cognitive behavioural therapy weight loss programme as an adjunct to anti-obesity medications and lifestyle interventions

BACKGROUND AND OBJECTIVES

Obesity is a global pandemic with psychological, physical and metabolic consequences including in people with mental health conditions. Anti-obesity medications (AOMs) are available to treat obesity and can produce clinically meaningful weight loss but do not address associated psychological issues. We evaluated the usefulness and acceptability of an adjunct online cognitive behavioural therapy (CBT) programme for improving psychological outcomes.

METHOD

We conducted a real-world 26-week observational study of 120 adults attending an obesity clinic who undertook a comprehensive weight management programme that included standard diet and exercise interventions, an AOM and an online 10-module CBT intervention. Baseline and 26-week psychological, metabolic and physical measures were compared.

RESULTS

At 26 weeks, depression, anxiety, stress and emotional eating levels for the sample decreased significantly compared to baseline (all p < .01). Satisfaction and acceptability were highly rated. The mean weight loss was 8.13 ± 3.83%. Mean waist circumference reduction was 7.62 ± 3.4 cm.

DISCUSSION

Online CBT has the potential to be a useful adjunct to AOMs and lifestyle interventions for providing psychological support as shown by improvement in mental health, emotional eating and acceptability scales. This warrants further investigation through a randomised controlled trail.

Psychometric properties of Tamil version of Body Weight Image and Self Esteem questionnaire (BWISE) in severe mental illness in a South Indian population

BACKGROUND

Body weight image self-esteem questionnaire (BWISE) has been recently developed to assess psychosocial adjustment related to antipsychotic induced weight gain in Schizophrenia and related disorders. Patients have reported disturbance in body image and poor self esteem due to weight gain leading to treatment non-adherence.

AIM

Assessment of psychometric properties of Tamil version of Body weight image self-esteem questionnaire (BWISE) in our population.

METHODOLOGY

In a cross sectional, validation study conducted at Schizophrenia Research Foundation (SCARF), 203 consenting outpatients with DSM IV diagnosis of Schizophrenia and related psychotic disorder fulfilling inclusion/exclusion criteria were administered BWISE.

RESULTS

The mean age of the sample was 38.21 ± 10.32 years. BWISE ratings showed that patients (54%) reported weight gain with current medications and were aware of increase in weight. Only three percent reported to have severe psychosocial adjustment to the weight gain while remaining reported moderate (55%) and mild (42%) psychosocial adjustment. Validation of Tamil version of BWISE was found to be of moderate range (internal consistency 0.55-0.72). Principal Component analysis of BWISE identified 3 components with a 50.36% variance.

CONCLUSIONS

BWISE could be used as a useful screening instrument to assess the psychosocial consequences of weight gain in patients.

Body image and paranoia

Paranoia builds upon feelings of vulnerability. Our clinical experience indicates that negative body image, including concerns regarding weight, may be one source of feeling vulnerable and hence raise the risk of paranoia. There has been no empirical test of an association between body image and paranoia. Our aim was to provide the first test of this issue by examining in epidemiologically representative cohorts the cross-sectional associations between paranoia and a proxy measure of body image. This was an initial exploration of a potentially important but overlooked issue. Data were used from 5515 participants in the US National Comorbidity Survey-Replication (NCS-R). To validate the findings, the analyses were replicated with 10,113 participants in the US National Comorbidity Survey-Adolescents (NCS-A). Concerns about weight were associated with paranoia in the NCS-R (OR = 1.48, p = 0.006, CI = 1.123, 1.955) and NCS-A (OR = 1.67, p < 0.001, CI = 1.490, 1.873). The associations remained significant after controlling for gender and body mass index. The results show that negative body image and paranoia are associated in the general population, consistent with the idea that paranoia may build upon feelings of vulnerability arising from body image concerns. Studies are needed to examine whether there is a causal relationship.

Individual Factors Affecting Self-esteem, and Relationships Among Self-esteem, Body Mass Index, and Body Image in Patients With Schizophrenia

The purposes of this study were to identify correlations between body mass index, body image, and self-esteem in patients with schizophrenia and to analyse the specific factors affecting self-esteem. This study had a descriptive design, utilising a cross-sectional survey. Participants were patients with schizophrenia who were admitted to a mental health facility in South Korea. A total of 180 questionnaires were distributed, and an appropriate total sample size of 167 valid questionnaires was analysed. Self-esteem was significantly correlated with body image, the subscale of appearance orientation, and body areas satisfaction. However, body mass index exhibited no significant correlation with any variable. The variables found to have a significant explanatory power of 21.4% were appearance orientation and body areas satisfaction. The explanatory power of all factors was 33.6%. The self-esteem of patients with schizophrenia was influenced by body mass index and body image. The positive symptoms of schizophrenia can be controlled by medication, whereas negative symptoms can be improved through education and nursing care with medication. Thus, psychiatric nurses should develop education and care programs that contribute to the positive body image and self-esteem of patients with schizophrenia.

Gender differences in mood stabilizer medications prescribed to Veterans with serious mental illness

BACKGROUND

Mood stabilizer medications (MSMs) can induce significant weight gain and other metabolic side effects. Research suggests that women are more susceptible to psychotropic medication-induced metabolic side effects than men. We examined gender differences in the likelihood of receiving an MSM with a lower liability for weight gain using data from the U.S. Department of Veterans Affairs (VA) healthcare system.

METHODS

We identified 3823 VA patients with a schizophrenia or bipolar disorder diagnosis who initiated treatment with a MSM between 10/2006 and 9/2011. We used multivariable logistic regression analysis to examine gender differences in the likelihood of incident prescription of MSMs with low versus medium/high metabolic risk, adjusting for fiscal year of prescribing and demographic, mental health, and physical health characteristics.

RESULTS

Overall, 47% of women were prescribed a low metabolic risk MSM compared to 26% of men (p<0.0001). In multivariable analysis, women were 2.19 times as likely as men to be prescribed a low metabolic risk MSM (95% CI: 1.84-2.60, p<0.0001). Several demographic and clinical covariates were also independently related to prescribing of MSMs by level of metabolic risk.

LIMITATIONS

This study used retrospective administrative data collected from a VA healthcare system database, which does not allow us to understand the context in which MSM treatment decisions were made.

CONCLUSIONS

Prescribing choices for MSMs by VA mental health prescribers and female Veterans may reflect a growing awareness of the potential adverse health consequences of these treatments in women.

Changes in body weight and psychotropic drugs: a systematic synthesis of the literature

INTRODUCTION

Psychotropic medication use is associated with weight gain. While there are studies and reviews comparing weight gain for psychotropics within some classes, clinicians frequently use drugs from different classes to treat psychiatric disorders.

OBJECTIVE

To undertake a systematic review of all classes of psychotropics to provide an all encompassing evidence-based tool that would allow clinicians to determine the risks of weight gain in making both intra-class and interclass choices of psychotropics.

METHODOLOGY AND RESULTS

We developed a novel hierarchical search strategy that made use of systematic reviews that were already available. When such evidence was not available we went on to evaluate randomly controlled trials, followed by cohort and other clinical trials, narrative reviews, and, where necessary, clinical opinion and anecdotal evidence. The data from the publication with the highest level of evidence based on our hierarchical classification was presented. Recommendations from an expert panel supplemented the evidence used to rank these drugs within their respective classes. Approximately 9500 articles were identified in our literature search of which 666 citations were retrieved. We were able to rank most of the psychotropics based on the available evidence and recommendations from subject matter experts. There were few discrepancies between published evidence and the expert panel in ranking these drugs.

CONCLUSION

Potential for weight gain is an important consideration in choice of any psychotropic. This tool will help clinicians select psychotropics on a case-by-case basis in order to minimize the impact of weight gain when making both intra-class and interclass choices.

Weight gain associated with taking psychotropic medication: an integrative review

People with serious mental illness have higher morbidity and mortality rates than general populations, and overweight/obesity-related conditions are prevalent. Psychotropic medications are a primary factor in significant weight gain. Adolescents and young adults, particularly those with first-episode psychoses taking atypical antipsychotics, are susceptible to weight gain. This paper reports findings from an integrative review of research investigating the impact and treatment of psychotropic-induced weight gain. Four databases were searched, yielding 522 papers. From these and hand-searched papers, 36 research reports were systematically classified and analysed. The review revealed people experiencing psychotropic-induced weight gain perceive it as distressing. It impacts on quality of life and contributes to treatment non-adherence. Weight management and prevention strategies have primarily targeted adults with existing/chronic illness rather than those with first-episode psychoses and/or drug naiveté. Single and multimodal interventions to prevent or manage weight gain produced comparable, modest results. This review highlights that the effectiveness of weight management interventions is not fully known, and there is a lack of information regarding weight gain prevention for young people taking psychotropics. Future research directions include exploring the needs of young people regarding psychotropic-related weight gain and long-term, follow-up studies of lifestyle interventions to prevent psychotropic-related weight gain.

Study protocol: a randomised controlled trial investigating the effect of a healthy lifestyle intervention for people with severe mental disorders

BACKGROUND

The largest single cause of death among people with severe mental disorders is cardiovascular disease (CVD). The majority of people with schizophrenia and bipolar disorder smoke and many are also overweight, considerably increasing their risk of CVD. Treatment for smoking and other health risk behaviours is often not prioritized among people with severe mental disorders. This protocol describes a study in which we will assess the effectiveness of a healthy lifestyle intervention on smoking and CVD risk and associated health behaviours among people with severe mental disorders.

METHODS/DESIGN

250 smokers with a severe mental disorder will be recruited. After completion of a baseline assessment and an initial face-to-face intervention session, participants will be randomly assigned to either a multi-component intervention for smoking cessation and CVD risk reduction or a telephone-based minimal intervention focusing on smoking cessation. Randomisation will be stratified by site (Newcastle, Sydney, Melbourne, Australia), Body Mass Index (BMI) category (normal, overweight, obese) and type of antipsychotic medication (typical, atypical). Participants will receive 8 weekly, 3 fortnightly and 6 monthly sessions delivered face to face (typically 1 hour) or by telephone (typically 10 minutes). Assessments will be conducted by research staff blind to treatment allocation at baseline, 15 weeks, and 12-, 18-, 24-, 30- and 36-months.

DISCUSSION

This study will provide comprehensive data on the effect of a healthy lifestyle intervention on smoking and CVD risk among people with severe mental disorders. If shown to be effective, this intervention can be disseminated to treating clinicians using the treatment manuals.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) identifier: ACTRN12609001039279.

The development and evaluation of a complex health education intervention for adults with a diagnosis of schizophrenia

Life expectancy in adults with schizophrenia is reduced by approximately 15 years compared with others in the population. Two thirds of premature deaths result from natural causes triggered by unhealthy lifestyles and the side-effects of antipsychotic medication. There is a need to develop and evaluate health education interventions for people with this diagnosis. In this paper we describe how with reference to the UK Medical Research Council's complex interventions framework we developed and evaluated a health education intervention designed specifically for adults with schizophrenia. The study was completed in three separate but interrelated phases: (1) theoretical work was undertaken to identify the components of effective health education interventions; (2) this information was synthesized to develop the intervention; and (3) the intervention was tested in an open exploratory trial which used mixed methods to evaluate the feasibility, acceptability and potential effect of the intervention. 45 service users were referred, 39 attended the groups and 65% attended at least half of the sessions. Participants reported significant increases in their consumption of fruit and vegetables and levels of physical activity. Results suggest that this model of health education is feasible and acceptable for this population and that it shows promise in supporting health-related behaviour changes.