10.1192/pb.28.5.164Access the most recent version at doi: 2004 28: 164-166 Psychiatric Bulletin

  Ruth I. Ohlsen, Janet Treasure and Lyn S. Pilowsky  

gain: An evaluationA dedicated nurse-led service for antipsychotic-induced weight  

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Psychiatr ic Bul let in (2004), 28, 164^166

RU T H I . OH L S EN , J A N E T T R E A S UR E AND LYN S . P I LOW S K Y

A dedicated nurse-led service for antipsychotic-inducedweight gainAn evaluation

AIMS AND METHOD

To evaluate a psychosocialintervention for patients treatedwith antipsychotics with body massindex (BMI) 425. A total of 44patients (mean age (s.e.) 37.6 (1.2); 28female, 16 male) received dietary andexercise advice with motivationalinterviewing.Weight and BMI were

measured at baseline and monthlythereafter. Patients were offeredweight monitoring for 1year.

RESULTS

Overall mean weight loss was 3.1kg(mean 3.22%). Modal (range) weightchange was 74.2 (719.2 kg to+8.7 kg).

CLINICAL IMPLICATIONS

Overall weight loss was not significantafter 355.7 (32.5) (mean, s.e.) days.Determinants of response remainunclear. Avoiding weight gain in thefirst instance is critical. Furtherresearch will explore determinants ofantipsychotic-induced weight gainand prevention strategies.

Antipsychotic-induced obesity carries serious physical andpsychological implications. However, little data areavailable on management of this problem. People withschizophrenia are vulnerable to several physical condi-tions, including type II diabetes, cardiovascular disordersand 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 anti-psychotic medication, which is associated with weightgain in a significant proportion of patients (Allison et al,1999), exacerbates the risk and stigma associated withschizophrenia. Indeed antipsychotic-induced weight gainhas been identified as a cause of non-adherence totreatment regimes (Nasrallah & Mulvihill, 2001; Recasens,2001).

Little data are available about the response ofpatients with schizophrenia who are overweight topsychosocial weight management interventions. We nowevaluate such an intervention in overweight (body massindex (BMI) 425) individuals treated with antipsychotics.

MethodThe South London and Maudsley Ethics Committeegranted local ethics approval to formally audit the service.

We invited patients who were overweight, andwanted to lose weight, to participate in a weightmanagement programme. Patients self-referred, or werereferred to the service through their primary clinicalteams. Patients were in- and out-patients of the SouthLondon and Maudsley National Health Service (NHS) Trust(catchment population 520 000).

The service inclusion criteria were: DSM-IV (AmericanPsychiatric Association, 1994) diagnosis of schizophrenia,schizoaffective disorder or bipolar illness; stablymaintained on antipsychotic treatment; overweight(BMI425); and agreeable to participation in a weightmanagement programme.

The exclusion criteria were: concomitant diagnosisof eating disorder, learning disability or substance misuse;

and any physical problem (particularly cardiac) that mightpreclude participation in a weight managementprogramme.

After screening, 44 patients were included. Onepatient did not meet the above criteria (BMI 525) butwas included because of significant weight gain aboveher baseline (approximately 18 kg) and an abnormalwaist-hip ratio. This patient was highly motivated toaccess the service.

Treatment packageA registered mental and general nurse trained innutrition and diet theory ran the service. Patients wereassessed at a screening interview. They were given aself-report ‘diet diary’ to complete, recording all food anddrink consumed over the following week. Patients wereseen within a fortnight, the ‘diet diary’ discussed and anindividualised diet plan dispensed. They had advice onexercise and referral to the hospital gymnasium (ifdesired), including a visit to, and tour of, the gym andintroduction to the gym instructor. They were seenweekly or fortnightly for three sessions of motivationalinterviewing. Following this, patients were monitoredmonthly for weighing.

ResultsA total of 44 patients (28 female, 16 male) received theintervention. Mean (s.e.) baseline weight was 96.1(3.1) kg; mean (s.e.) baseline BMI was 33.1 (0.84). Meanweight change for the whole group was 73.1kg. Allpatients were offered a year of treatment, but somedropped out prematurely and others requested a longerfollow-up. Mean (s.e.) time from baseline to end-pointwas 355.7 (32.5) days.

To correct for this variation in time, and for thediffering number of time points measured amongindividuals, data were converted into long clusters,imported from SPSS-10 into STATA-7 and regression

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analysis with robust standard errors performed.We foundno significant change in weight overall. Furthermore, wefailed to find any predictors of response.

Patients were on a variety of antipsychotic treatment,and some were also treated with mood stabilisers andantidepressants (Table 1). The majority were receivingclozapine or olanzapine. No relationship was foundbetween the primary antipsychotic and weight change,nor did antidepressants or mood stabilisers affectoutcome.

DiscussionTo our knowledge, this is one of the largest studies toreport the effects of a psychosocial intervention designedspecifically to treat overweight people on psychotropicmedications for serious mental illness. Overall weight losswas small, but the majority (72.7%) lost weight. Thisrelative failure to lose weight must be set in the contextof the study in which people are referred following rapidweight gain on antipsychotic medication.

However, there was a wide variation in response totreatment (Fig. 1). Modest lifestyle changes and smallweight losses (around 3 kg) prevented 58% of a popula-tion 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 thisgroup was 3.1kg. Though not statistically significant, suchweight losses could have had some benefit by holding offincipient diabetes or IGT.

Methodological considerationsThis study is a naturalistic audit of a standardised weightloss programme. A randomised controlled trial (RCT)would provide more information on the efficacy of thisapproach in comparison with no treatment. However, thecurrent report is an essential step for designing a mean-ingful RCT. The data show no significant determinant ofresponse, implying that comparator groups could bemixed in terms of age, race and gender. The size of theoverall effect also suggests that it might be ethical torandomise patients to a study in which there is a non-treatment/waiting list arm, though this might limitrecruitment to the RCT. The variation in length of follow-up time was a potential limitation in performing thestatistical analysis. Using STATA-7, it was possible toconvert the data into long clusters and control for thedifferences in follow-up time by performing regressionwith robust standard errors. An analysis using the

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Table 1. Medication at baseline and ethnicity

Medication Caucasian African/Caribbean Asian/Mixed All

Clozapine 6 5 2 13Olanzapine 5 11 1 17Risperidone/amisulpride 3 2 1 6Quetiapine 2 1 0 3Conventional 3 2 0 5Mood stabiliserYes 6 5 1 12No 13 16 3 32AntidepressantYes 6 3 3 12No 13 18 1 32

Fig.1. Individual weight change (kg) from baseline to end-point in the study plotted against the y-axis (n=44). The points are distributedaround zero (no weight change), and there is a wide variability of response. There were no clear demographic or clinical determinants ofresponse.

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random effects model was also performed in STATA-7and yielded the same results. The length of time patientswere monitored had no effect on weight change. Thisbears out earlier reports that continuous contact with atherapist does not greatly improve the effect of weightloss intervention (Leibbrand & Fichter, 2002) in main-stream populations.

Baseline weights before the start of antipsychotictreatment were unobtainable. Estimates of how muchweight had actually been gained since the inception ofantipsychotic treatment are unreliable. It is difficult toestimate how much weight these patients might havegained without intervention. Allison et al (1999) showedweight gains of 5.5 kg on clozapine and 4.5 kg onolanzapine after 10 weeks’ treatment; the patients in thestudy reported here were generally stabilised on theirmedication for longer periods of time. Patients whoremained stable, or who gained weight, might havegained more weight without the intervention.

Previous findingsLittle data are available on managing antipsychotic-induced weight gain. Pharmacological approaches are notwithout adverse side-effects and might complicateadherence to antipsychotic medication. Pharmacologicalinterventions are not recommended as suitable for themajority of patients (Werneke et al, 2002). A systematicsearch of Medline and PubMed revealed several instancesof 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 olanza-pine to receive either psychoeducation or no inter-vention.Weight changes between the two groups werestatistically significant; mean weight loss for the treat-ment group was 0.27 kg and mean weight gain for thenon-treatment group was 4.35 kg. Umbricht et al (2001)described weight losses of 0-21kg in six patients after7-10 biweekly sessions of individual/group cognitive-behavioural therapy. Ball et al (2001) described a cohortof 11 patients (seven males, four females) with olanza-pine-related weight gain who attended mainstream‘Weight Watchers’ meetings and were offered supervisedexercise sessions. Overall weight loss was not significant.This sample is larger than that of Umbricht et al and Ballet al, and the mean baseline BMI (33.1) greater than in theUmbricht (29.6) and the Ball samples (31.9). The presentdata extend earlier research on response to psychosocialweight management interventions.

At present we have no information that can explainthe process of change. The patients who lost weightadhered to the prescribed diet, and exercised. Patientswho gained weight or remained stable claimed to havefollowed the diet and exercise regimen also.We areplanning a qualitative evaluation of the service using theFocus Group interview technique to uncover theelements of the programme that were helpful to somepatients, and inform future service planning and delivery.

ConclusionsThe available literature suggests that weight lossprogrammes, whether psychosocial or pharmacological inthe context of antipsychotic medication, do not produceeffective, long-term results (Devlin et al, 2000). A focuson prevention, however, could be of benefit. A simpleprogramme to promote healthy eating and lifestylechanges could be incorporated into psychiatric carepackages as soon as antipsychotic medication isprescribed.

Further research will investigate biologicaldeterminants of antipsychotic-induced weight gain (inparticular pharmacogenetic and hormonal influences),identify high-risk groups and follow up the presentcohort to determine longevity of response over time.

AcknowledgementsThis work was carried out with unrestricted charitablegrants from AstraZeneca, Novartis and Janssen-Cilag.L.S.P. is supported by a UK Medical Research CouncilSenior Clinical Research Fellowship (G116/101). R.I.O. andL.S.P. have received research grants, consultancy andlecture fees from GlaxoSmithKline, Bristol-Myers-Squibb,AstraZeneca, Janssen-Cilag, Sanofi-Synthelabo, Novartisand Eli Lilly.

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*Ruth Ohlsen JanetTreasure Lyn Pilowsky Section of NeurochemicalImagingand Psychiatry, Institute of Psychiatry, De Crespigny Park, London SE5 8AFandMaudsley Hospital, London SE5 8AZ. E-mail: r.ohlsen@iop.kcl.ac.uk

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