Psychiatric Bulletin (2004) 28: 164-166. doi: 10.1192/pb.28.5.164
© 2004 The Royal College of Psychiatrists
Psychiatric Bulletin (2004) 28: 164-166
© 2004 The Royal College of Psychiatrists
A dedicated nurse-led service for antipsychotic-induced weight gain
An evaluation
*Ruth I. Ohlsen,
Janet Treasure and
Lyn S. Pilowsky
Section of Neurochemical Imaging and Psychiatry, Institute of Psychiatry,
De Crespigny Park, London SE5 8AF and Maudsley Hospital, London SE5 8AZ
Correspondence:
E-mail:
r.ohlsen{at}iop.kcl.ac.uk
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Abstract
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AIMS AND METHOD
To evaluate a psychosocial intervention for patients treated with
antipsychotics with body mass index (BMI) >25. A total of 44 patients (mean
age (s.e.) 37.6 (1.2); 28 female, 16 male) received dietary and exercise
advice with motivational interviewing. Weight and BMI were measured at
baseline and monthly thereafter. Patients were offered weight monitoring for 1
year.
RESULTS
Overall mean weight loss was 3.1 kg (mean 3.22%). Modal (range) weight
change was -4.2 (-19.2 kg to +8.7 kg).
CLINICAL IMPLICATIONS
Overall weight loss was not significant after 355.7 (32.5) (mean, s.e.)
days. Determinants of response remain unclear. Avoiding weight gain in the
first instance is critical. Further research will explore determinants of
antipsychotic-induced weight gain and prevention strategies.
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Introduction
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Antipsychotic-induced obesity carries serious physical and psychological
implications. However, little data are available on management of this
problem. People with schizophrenia are vulnerable to several physical
conditions, including type II diabetes, cardiovascular disorders and the
metabolic syndrome (Ryan & Thakore,
2002). Lifestyle elements such as poor diet, cigarette smoking,
heavy alcohol use and sedentary lifestyle
(Brown et al, 1999)
predispose to ill health. Treatment with antipsychotic medication, which is
associated with weight gain in a significant proportion of patients
(Allison et al, 1999),
exacerbates the risk and stigma associated with schizophrenia. Indeed
antipsychotic-induced weight gain has been identified as a cause of
non-adherence to treatment regimes
(Nasrallah & Mulvihill,
2001; Recasens,
2001).
Little data are available about the response of patients with schizophrenia
who are overweight to psychosocial weight management interventions. We now
evaluate such an intervention in overweight (body mass index (BMI) >25)
individuals treated with antipsychotics.
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Method
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The South London and Maudsley Ethics Committee granted local ethics
approval to formally audit the service.
We invited patients who were overweight, and wanted to lose weight, to
participate in a weight management programme. Patients self-referred, or were
referred to the service through their primary clinical teams. Patients were
in- and out-patients of the South London and Maudsley National Health Service
(NHS) Trust (catchment population 520 000).
The service inclusion criteria were: DSM-IV
(American Psychiatric Association,
1994) diagnosis of schizophrenia, schizoaffective disorder or
bipolar illness; stably maintained on antipsychotic treatment; overweight (BMI
>25); and agreeable to participation in a weight management programme.
The exclusion criteria were: concomitant diagnosis of eating
disorder, learning disability or substance misuse; and any physical problem
(particularly cardiac) that might preclude participation in a weight
management programme.
After screening, 44 patients were included. One patient did not meet the
above criteria (BMI <25) but was included because of significant weight
gain above her baseline (approximately 18 kg) and an abnormal waist-hip ratio.
This patient was highly motivated to access the service.
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Treatment package
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A registered mental and general nurse trained in nutrition and diet theory
ran the service. Patients were assessed at a screening interview. They were
given a self-report ‘diet diary’ to complete, recording all food
and drink consumed over the following week. Patients were seen within a
fortnight, the ‘diet diary’ discussed and an individualised diet
plan dispensed. They had advice on exercise and referral to the hospital
gymnasium (if desired), including a visit to, and tour of, the gym and
introduction to the gym instructor. They were seen weekly or fortnightly for
three sessions of motivational interviewing. Following this, patients were
monitored monthly for weighing.
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Results
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A total of 44 patients (28 female, 16 male) received the intervention. Mean
(s.e.) baseline weight was 96.1 (3.1) kg; mean (s.e.) baseline BMI was 33.1
(0.84). Mean weight change for the whole group was -3.1 kg. All patients were
offered a year of treatment, but some dropped out prematurely and others
requested a longer follow-up. Mean (s.e.) time from baseline to end-point was
355.7 (32.5) days.
To correct for this variation in time, and for the differing number of time
points measured among individuals, data were converted into long clusters,
imported from SPSS-10 into STATA-7 and regression analysis with robust
standard errors performed. We found no significant change in weight overall.
Furthermore, we failed to find any predictors of response.
Patients were on a variety of antipsychotic treatment, and some were also
treated with mood stabilisers and antidepressants
(Table 1). The majority were
receiving clozapine or olanzapine. No relationship was found between the
primary antipsychotic and weight change, nor did antidepressants or mood
stabilisers affect outcome.
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Discussion
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To our knowledge, this is one of the largest studies to report the effects
of a psychosocial intervention designed specifically to treat overweight
people on psychotropic medications for serious mental illness. Overall weight
loss was small, but the majority (72.7%) lost weight. This relative failure to
lose weight must be set in the context of the study in which people are
referred following rapid weight gain on antipsychotic medication.
However, there was a wide variation in response to treatment
(Fig. 1). Modest lifestyle
changes and small weight losses (around 3 kg) prevented 58% of a population
without psychoses (n=550) with impaired glucose tolerance (IGT) developing
diabetes over a 5-year period (Tuomilehto
et al, 2001). The mean weight loss for this group was
3.1kg. Though not statistically significant, such weight losses could have had
some benefit by holding off incipient diabetes or IGT.
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Fig. 1. Individual weight change (kg) from baseline to end-point in the study
plotted against the y-axis (n=44). The points are distributed around zero (no
weight change), and there is a wide variability of response. There were no
clear demographic or clinical determinants of response.
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Methodological considerations
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This study is a naturalistic audit of a standardised weight loss programme.
A randomised controlled trial (RCT) would provide more information on the
efficacy of this approach in comparison with no treatment. However, the
current report is an essential step for designing a meaningful RCT. The data
show no significant determinant of response, implying that comparator groups
could be mixed in terms of age, race and gender. The size of the overall
effect also suggests that it might be ethical to randomise patients to a study
in which there is a nontreatment/waiting list arm, though this might limit
recruitment to the RCT. The variation in length of followup time was a
potential limitation in performing the statistical analysis. Using STATA-7, it
was possible to convert the data into long clusters and control for the
differences in follow-up time by performing regression with robust standard
errors. An analysis using the random effects model was also performed in
STATA-7 and yielded the same results. The length of time patients were
monitored had no effect on weight change. This bears out earlier reports that
continuous contact with a therapist does not greatly improve the effect of
weight loss intervention (Leibbrand &
Fichter, 2002) in mainstream populations.
Baseline weights before the start of antipsychotic treatment were
unobtainable. Estimates of how much weight had actually been gained since the
inception of antipsychotic treatment are unreliable. It is difficult to
estimate how much weight these patients might have gained without
intervention. Allison et al
(1999) showed weight gains of
5.5 kg on clozapine and 4.5 kg on olanzapine after 10 weeks’ treatment;
the patients in the study reported here were generally stabilised on their
medication for longer periods of time. Patients who remained stable, or who
gained weight, might have gained more weight without the intervention.
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Previous findings
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Little data are available on managing antipsychotic-induced weight gain.
Pharmacological approaches are not without adverse side-effects and might
complicate adherence to antipsychotic medication. Pharmacological
interventions are not recommended as suitable for the majority of patients
(Werneke et al,
2002). A systematic search of Medline and PubMed revealed several
instances of non-pharmacological management of antipsychotic-induced weight
gain in people with severe mental illness
(Ball et al 2001;
Umbricht et al, 2001;
Littrell et al, 2003).
Littrell et al randomised 70 patients treated with olanzapine to
receive either psychoeducation or no intervention. Weight changes between the
two groups were statistically significant; mean weight loss for the treatment
group was 0.27 kg and mean weight gain for the non-treatment group was 4.35
kg. Umbricht et al
(2001) described weight losses
of 0-21 kg in six patients after 7-10 biweekly sessions of individual/group
cognitive-behavioural therapy. Ball et al
(2001) described a cohort of 11
patients (seven males, four females) with olanzapine-related weight gain who
attended mainstream ‘Weight Watchers’ meetings and were offered
supervised exercise sessions. Overall weight loss was not significant. This
sample is larger than that of Umbricht et al and Ball et al,
and the mean baseline BMI (33.1) greater than in the Umbricht (29.6) and the
Ball samples (31.9). The present data extend earlier research on response to
psychosocial weight management interventions.
At present we have no information that can explain the process of change.
The patients who lost weight adhered to the prescribed diet, and exercised.
Patients who gained weight or remained stable claimed to have followed the
diet and exercise regimen also. We are planning a qualitative evaluation of
the service using the Focus Group interview technique to uncover the elements
of the programme that were helpful to some patients, and inform future service
planning and delivery.
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Conclusions
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The available literature suggests that weight loss programmes, whether
psychosocial or pharmacological in the context of antipsychotic medication, do
not produce effective, long-term results
(Devlin et al, 2000). A focus on prevention, however, could be of benefit. A simple programme to
promote healthy eating and lifestyle changes could be incorporated into
psychiatric care packages as soon as antipsychotic medication is
prescribed.
Further research will investigate biological determinants of
antipsychotic-induced weight gain (in particular pharmacogenetic and hormonal
influences), identify high-risk groups and follow up the present cohort to
determine longevity of response over time.
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Acknowledgments
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This work was carried out with unrestricted charitable grants from
AstraZeneca, Novartis and Janssen-Cilag. L.S.P. is supported by a UK Medical
Research Council Senior Clinical Research Fellowship (G116/101). R.I.O. and
L.S.P. have received research grants, consultancy and lecture fees from
GlaxoSmithKline, Bristol-Myers-Squibb, AstraZeneca, Janssen-Cilag,
Sanofi-Synthelabo, Novartis and Eli Lilly.
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Abstract
Introduction
