Addressing Obesity in Psychiatric Patients

Nicole Mori, RN, MSN, APRN-BC

Research Advanced Practice Nurse, Research Institute at Lindner Center of HOPE

Obesity, defined as a body mass index (BMI) ≥30 mg/kg, remains one of the main contributors to preventable disease and health care costs. It is also associated with increased risk for Type 2 diabetes, cardiovascular disease, and some cancers, in addition to lower quality of life and functional impairment.   Patients with psychiatric illness are 50 percent more likely to be obese than the general population.  The higher rates of obesity are contributing directly and indirectly to the marked reduction in life expectancy among those with mental illness.  In addition to being an important medical comorbidity, obesity has been associated with a more severe course of psychiatric illness, lower health-related quality of life, poor self-esteem, stigma, and discrimination.  Obesity, like mental illness, is a complex, chronic condition requiring long term management.  The treatment of overweight psychiatric patients poses unique challenges and both the psychiatric illness and the weight problem must be targets for treatment in order to achieve optimal outcomes.

The strong relationship between obesity and psychiatric illness is evidenced by the high prevalence of obesity among drug-naïve patients. Commonly-occurring symptoms such as psychomotor retardation, inactivity, hypersomnia, increased appetite, and hyperphagia are thought to contribute to weight gain.  Furthermore, binge eating behavior, eating unusually large amounts of food with a sense of loss of control over eating, is very common in people with psychiatric illness.    Binge eating behavior is a risk factor for obesity, and when present in psychiatrically ill people, is associated with greater psychiatric and medical morbidity.  Lastly, treatment with most mood stabilizers, antipsychotics, and some antidepressants is associated with significant weight gain, which renders them less acceptable to patients and leads to discontinuation.

Weight management poses unique challenges to psychiatric patients. As we have seen, both the behaviors associated with psychiatric illness and the use of certain psychotropic medications, contribute to weight gain.  In addition, the symptoms and cognitive deficits associated with mental illness are a barrier to participation in behavioral weight loss interventions.  Finally, the use of most weight control drugs is limited by their psychiatric side effects and their interactions with psychotropic medications.  Obesity and excessive weight gain place a disproportionate burden on psychiatric patients’ health, complicate adherence to treatment, and reduce quality of life.  Treatment of psychiatric illness needs to include weight management strategies and a greater integration of behavioral and medical care.

Clinicians can help improve outcomes by maintaining a focus on both the psychiatric condition and the weight problem when treating this population. First of all, regular monitoring of psychiatric symptoms should be accompanied by monitoring of weight, BMI, vital signs as well as metabolic lab parameters (e.g., lipids and glucose).  Assessing for binge eating behavior or an eating disorder is important because additional referrals and greater integration of behavioral and medical care may be indicated for patients with disordered eating.

Prescribers can mitigate weight gain associated with psychotropic medications by selecting medications with lower potential for weight and metabolic disturbances whenever possible.   Knowledge of the pharmacology of obesity and eating disorders is helpful in guiding treatment choices and avoiding adverse events.  Some FDA-approved weight-loss agents have antidepressant effects, and some off-label adjunctive medications may be beneficial to depressed patients who binge eat.  Treating mental health patients with FDA-approved weight-loss drugs requires caution due to the potential effects on psychiatric symptoms as well as drug-drug interactions.  For instance, in treating patients with bipolar disorder, medications with lower risk for mood de-stabilization should be used and most medications should be avoided in patients with hypomanic, manic or mixed symptoms.

Although new weight-loss medications have come to market in recent years, there is no research to inform their use in mental health patients.   Clinical trials typically exclude people with a psychiatric illness and those taking psychotropic medication.  Research to find effective weight-control medications that are safe for this population is greatly needed.

 

References

Allison, D. B., Newcomer, J. W., Dunn, A. L., Blumenthal, J. A., Fabricatore, A. N., Daumit, G. L., … & Alpert, J. E. (2009). Obesity among those with mental disorders: a National Institute of Mental Health meeting report.American journal of preventive medicine36(4), 341-350.

McElroy, S. L., Crow, S., Biernacka, J. M., Winham, S., Geske, J., Barboza, A. B. C., … & Frye, M. A. (2013). Clinical phenotype of bipolar disorder with comorbid binge eating disorder. Journal of affective disorders150(3), 981-986.

McElroy, S. L., Guerdjikova, A. I., Mori, N., & Keck Jr, P. E. (2016). Managing Comorbid Obesity and Depression through Clinical Pharmacotherapies. Expert Opinion on Pharmacotherapy, (just-accepted).

The Research Institute at the Lindner Center of HOPE is conducting a 40 week, placebo-controlled study of liraglutide, a novel weight loss agent, in patients with bipolar disorder with a BMI ≥30 or with a weight-related medical comorbidity and a BMI ≥27. For additional information, contact Anna Guerdjikova @ 513-536-0721. Anna.guerdjikova@lindnercenter.org

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