Antipsychotic Meds and Obesity
(Column: Ask the Doctor)
How to prevent weight gain while taking antipsychotic medications
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. I then switched to Zyprexa for about a year and three months, and finally switched to Abilify.
What was the problem?
I was doing very well on Zyprexa, but I gained fifty pounds on that medication. So I switched to Abilify. I had the same problem. I gained another 35 pounds. I am under the care of a nutritionist and have been on a special diet for months with no positive results. While I am on antipsychotic medication, I cannot control my weight. I gained a total of 86 lbs in one and a half years. My psychiatrist is considering switching me to Geodon, but I am afraid it 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.
Answer: Awareness about the metabolic side effects associated with some antipsychotic medications and mood stabilizers which include weight gain, diabetes, and hypercholesterolemia is increasing. 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 members of the general population. A leading cause of death is heart disease. The metabolic syndrome is diagnosed in those who meet 3 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. The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) schizophrenia trial, a large multi-center trial funded by the National Institute of Mental Health showed that 41% of patients chronically treated for schizophrenia with antipsychotic medications have the metabolic syndrome.
The first step in preventing health consequences 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 4 weeks, 8 weeks, and 12 weeks after starting the medication, and every 3 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. Your doctor may also want to rule out any medical causes of obesity such as hypothyroidism.
An increase in weight of more than 7% of your starting weight is considered significant. Geodon and Abilify are currently the two antipsychotic medications that have the most benign metabolic profile; both should be tried under your doctor’s supervision. If you have tried one of these medications and were not successful in losing weight, you should try the other as the two medications work very differently. Geodon is a traditional second generation antipsychotic medication, and Abilify is a partial dopamine antagonist. There are also two 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 cause weight gain and may treat negative as well as positive symptoms of schizophrenia. The other medication is bifeprunox which is a new partial dopamine antagonist and also does not 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.
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. Many people find that they eat as a means of comforting themselves and that developing a better support network may reduce the need to soothe yourself with food. Groups such as weight watchers can be helpful in gaining support from other group members who share a similar goal.
There is an obesity epidemic in America, and a lot of research is currently being conducted to help us better understand the biological basis of obesity. Genes contain the instruction for traits such as hair and eye color, body weight and how the body responds to different drugs. Through such studies, scientists may discover how gene variants contribute to a person’s risk of weight gain due to certain medications and will hopefully develop new drugs to treat obesity.