Managing Weight Gain in Bipolar Disorder
If you’re living with bipolar disorder, you may have noticed changes in your weight since starting treatment. You’re not alone. Many people with bipolar disorder experience weight gain as a side effect of their medication, which can impact both physical health and emotional well-being. Understanding why this happens and what you can do about it is an important part of managing your overall treatment plan.
Do mood stabilizers cause weight gain?
One of the biggest challenges in treating bipolar disorder is that many of the medications used to stabilize mood can cause significant weight gain. This includes mood stabilizers like lithium and valproate, as well as a group of medications called atypical antipsychotics. These medications are often essential for managing bipolar symptoms, but they can also lead to changes in metabolism and increased appetite, making weight gain more likely.
Which bipolar disorder medications are most likely to cause weight gain?
While most mood stabilizers carry some risk of weight gain, atypical antipsychotics are especially known for this side effect. These medications can also lead to other metabolic issues, such as changes in blood sugar and cholesterol levels.
Is weight gain in bipolar disorder a cause for concern?
Weight gain isn’t just a cosmetic issue. It’s linked to a higher risk of heart disease and other metabolic conditions, which are already more common in people with bipolar disorder. On top of that, gaining too much weight can be emotionally distressing and may make people feel less satisfied with their treatment—sometimes leading them to stop taking their medications. In fact, studies suggest that weight gain, especially when it involves weight cycling (repeated loss and regain of weight) and central obesity (fat around the abdomen), can make bipolar symptoms worse and contribute to a more difficult overall illness course.
Solutions for Bipolar Disorder Weight Gain
Lifestyle Interventions
Until recently, interventions for weight gain were mostly limited to lifestyle interventions. Inactivity and dietary choices are significant contributors to metabolic abnormalities seen in patients with bipolar disorder, and although dietary and lifestyle changes have the potential for improving the overall quality of life, the results from these interventions often fail to keep up with the accelerated weight gain seen with psychotropics. Clinicians have also attempted to select medications with lesser potential for metabolic dysfunction and increased appetite, but this is not always a viable option.
Bariatric Surgery
Bariatric surgery can be a powerful tool for weight loss, and some research shows that it may also help improve mood. However, it hasn’t been specifically studied in people with bipolar disorder. If you are living with bipolar disorder and are considering bariatric surgery, it’s important to know that this option is generally recommended only for individuals who are in a stable, well-managed phase of their illness (called “euthymia”). It’s a major decision that should involve careful planning and close coordination with both your mental health and medical care teams.
Medications for Mitigating Bipolar Disorder Weight Gain
The use of off-label adjunctive medications for mitigating weight gain has had mixed results. Weight mitigation has been modest, and efficacious medications have produced significant adverse events leading to discontinuation or the cost to the patient has been prohibitive.
Topiramate and Zonisamide
Topiramate and zonisamide are antiepileptic drugs with data suggesting efficacy in weight mitigation. Topiramate has shown significant efficacy in weight mitigation (3.1kg over 6-26 week, according to a meta-analysis), but it is poorly tolerated and is associated with significant cognitive adverse events and paresthesia. The estimated cost for a month’s supply of topiramate ranges from $40-$250. Data suggest that zonisamide also has a significant effect on weight gain mitigation with similar, but milder adverse events.
Naltrexone and Samidorphan
Opioid receptor antagonists like naltrexone and samidorphan have demonstrated modest efficacy in mitigating weight gain associated with olanzapine. Samidorphan, the best-studied opioid antagonist, is associated with modest weight mitigation (1kg with olanzapine), is well-tolerated and is available on the market as part of a proprietary combination with olanzapine with an estimated cost of $1000/month.
Metformin and GLP-1 RAs
Antidiabetic drugs like metformin and glucagon-like peptide-1(GLP-1 RA) receptor agonists have potential for weight mitigation and improvement of metabolic parameters such as dyslipidemia and insulin resistance. Metformin is a popular option for medication-induced weight gain. In patients treated with atypical antipsychotics, the estimated weight mitigation with metformin is 2-3kg and it is generally, well-tolerated. The average estimated monthly cost of Metformin ER 2000mg/daily ranges from $27 to $50.
GLP-1 RAs and similar drugs have the potential for significant mitigation of weight gain associated with psychotropics, and in some cases, weight loss. These drugs are better tolerated than topiramate but additional research on the effects of these drugs on patients with bipolar disorder is needed to determine efficacy and safety. GLP-1 RAs decrease glucagon secretion, have the potential for decreasing insulin resistance and delay gastric emptying, therefore decreasing appetite. In addition, GLP-1 RAs have been shown to improve glucose regulation, lipid levels, and reduce cardiovascular risk. Although GLP-1 agonists have demonstrated effectiveness in inducing weight loss and improving metabolic parameters in type 2 diabetes mellitus and obesity, data shows that only 10% patients eligible for treatment take these medications due to the high cost.
The Path Forward: Addressing Weight Gain in Bipolar Disorder
As we have seen, there are a few options for treatment of excessive weight gain associated with psychotropics, which can be used in addition to lifestyle interventions. Limitations include the modest results seen with some interventions, intolerable adverse events with more effective options or high cost. Additional, affordable treatment options are needed.
Learn more about Bipolar Disorder research and clinical trials at the Lindner Center of HOPE.Works consulted:
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Mangge H, Bengesser S, Dalkner N, Birner A, Fellendorf F, Platzer M, Queissner R, Pilz R, Maget A, Reininghaus B, Hamm C, Bauer K, Rieger A, Zelzer S, Fuchs D, Reininghaus E. Weight Gain During Treatment of Bipolar Disorder (BD)-Facts and Therapeutic Options. Front Nutr. 2019 Jun 11;6:76. doi: 10.3389/fnut.2019.00076. PMID: 31245376; PMCID: PMC6579840.
Wang Y, Wang D, Cheng J, Fang X, Chen Y, Yu L, Ren J, Tian Y, Zhang C. Efficacy and tolerability of pharmacological interventions on metabolic disturbance induced by atypical antipsychotics in adults: A systematic review and network meta-analysis. J Psychopharmacol. 2021 Sep;35(9):1111-1119. doi: 10.1177/02698811211035391. Epub 2021 Jul 27. PMID: 34311625.
By Nicole Mori, RN, MSN, APRN-BC, Lindner Center of HOPE Psychiatric Nurse Practitioner