Handling the Risks of Psych Meds
(Column: Ask the Doctor)
Battling the harmful side-effects
Miranda Chaqkos, MD, Associate Professor of Psychiatry and Behavioral Sciences & Associate Director of Neurobiological Disorders & Stephen M. Goldfinger, M.D.
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Question: I had my first psychotic break during 2004 and was hospitalized in December of that year. At that time I was diagnosed with late onset paranoid schizophrenia as I was a female in my mid-forties. I was prescribed neuroleptics: first I was on Risperdal, but could not tolerate it well because it elevated my prolactin level. Then I was switched to Zyprexa for about a year and three months, then I switched again to Abilify. I was doing very well on Zyprexa; however, I gained fifty pounds on that medication. So I switched to Abilify. Same problem: I gained another 35 pounds. I am under the care of a nutritionist, have been on a special diet for months with no positive results. While I stay on this antipsychotic medication, I just balloon upwards in pounds, I just cannot control the weight-gain. I gained a total of 86 lbs in 11 ˝ years. My psychiatrist is considering switching me to Geodon, but I am afraid I will have the same results. Of course, going off the medications would leave me psychotic, not an alternative. I am not allowed to take appetite suppressants like Sibutramine, for example, because it interferes with the brain's chemistry and the neuroleptic. I am at a complete loss as to what to do. Also, I am worried about getting Type 2 diabetes. I need a second opinion, please....
Response: There is an increasing awareness among people who take psychiatric medications of the metabolic problems that can occur as side effects with some antipsychotic medications and mood stabilizers. Your concerns about weight gain are important since we know that obesity can lead to many other medical problems such as hypertension, diabetes and high cholesterol. Recent studies show that people with severe mental illness die up to 30 years earlier, on average, than the general population. A leading cause of death is heart disease.

The “metabolic syndrome” increases your risk for heart disease. The metabolic syndrome is diagnosed in those who meet three or more of the following clinical criteria: increased abdominal fat (measured by waist circumference), low serum high density lipoprotein (HDL; known as “good cholesterol”), high fasting triglycerides, hypertension and/or impaired fasting glucose or diabetes. A large multi-center study funded by the National Institute of Mental Health is The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) schizophrenia trial. This study showed that 41% of patients chronically treated for schizophrenia with antipsychotic medications have the metabolic syndrome.

The first step in preventing the serious health consequence of obesity is regular metabolic monitoring. It is now recommended by the American Psychiatric Association and the American Diabetes Association that individuals starting a new antipsychotic medication should have their weight checked when starting the medicine, and at four weeks, eight weeks and 12 weeks and every three months thereafter. Blood pressure, fasting lipids and fasting glucose should be checked when starting the medicine, after 12 weeks and then yearly. Of course, detection of any medical problems such as diabetes, high cholesterol or hypertension should be treated by your medical doctor to reduce your risk of developing cardiovascular disease. Although weight loss is now your primary goal, if you smoke you should look at this larger picture of overall health and consider reducing your risk of cardiovascular disease by stopping smoking. You would also want to make certain that your doctor ruled out medical causes of obesity such as hypothyroidism.

An increase in weight of more than 7% of your starting weight is considered significant and you should start talking to your psychiatrist about medication regimens that are less likely to cause weight gain. Geodon and Abilify are currently the two antipsychotic medications that have the most benign metabolic profile, and both should be tried under your doctors supervision if you who have significant metabolic problems such as central obesity, diabetes or high cholesterol. If you have tried one of these medications and were not successful in losing weight, you should try the other one as both medications work in very different ways. Geodon is a traditional second generation antipsychotic medication and Abilify is a partial dopamine agonist. There are also two investigational antipsychotic medications that are now in clinical trials that have a favorable metabolic profile. One is asenapine, which is a new second generation antipsychotic medication that does not seem to cause weight gain and may treat negative as well as positive symptoms of schizophrenia. The other medication is bifeprunox that also does not appear to cause weight gain. Since these medications are investigational, you can only try them at sites that have been approved by Human Subject Review Boards to conduct the trials. SUNY Downstate Medical Center is one such site. (Dr. Chakos, a doctor with expertise in treating individuals suffering from schizophrenia or schizoaffective disorder and the guest editor for this column, is currently conducting these trials. You can contact her office at (718) 270-2004 and speak to Ms. Marcela Roy if you are interested in learning more about these clinical trials. You can also email her at marcela.roy@downstate.edu.)

In addition to trying “weight neutral” antipsychotics, it is important to work with a nutritionist to develop healthy eating habits and to slowly increase your level of exercise, perhaps by joining a gym or exercise group. You didn’t mention exercise, and increasing your regimen not only may help with weight reduction, but has well-recognized other positive health benefits as well. Many people find that they eat as a means of comforting themselves and that developing a better support network may reduce your need to soothe yourself with food. Groups such as Weight Watchers can be helpful as you can gain considerable support from other group members who are working on a similar goal.

I would like to close by saying that there is an obesity epidemic in America, and that there is a lot of research that is being conducted to help us better understand the biological basis of obesity. Genes contain the instruction for things such as hair and eye color, body weight and for activities in the body such as how you respond to a drug. Because everyone's genes are different to some degree, the scientific information that is being obtained by studying genes may help us understand why people respond differently to a drug. Through such studies, scientists will discover the many gene variants that contribute to a person’s risk of gaining weight on a medication and will develop new drugs to treat obesity.
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