Weight Gain in Patients With Psychiatric Conditions: The Need for a Systematic Approach

By Nicole Mori, RN, MSN, APRN-BC
Psychiatric Mental Health Nurse Practitioner, Lindner Center of Hope

 

 

 

The prevalence of obesity and metabolic disorders is significantly higher among people with bipolar disorder than in the general population (McElroy and Keck, 2012; Taylor et al., 2012). In addition to contributing to medical comorbidities (such as cardiovascular and metabolic disease) and early mortality, obesity and excessive weight gain are associated with higher psychiatric morbidity and unfavorable clinical course and outcomes (Calkin et al., 2009). The problem of excessive weight gain in the bipolar population is exacerbated by the metabolic adverse effects of mood stabilizing medications that are commonly used to treat bipolar disorder (e.g., lithium, valproate, and second-generation antipsychotic agents), which often induce significant weight gain and/or metabolic abnormalities such as hyperglycemia and dyslipidemia (Correll et al., 2015). Conversely, loss of excess weight has been associated with improved mood, adherence, and increased patient satisfaction (McElroy, et al, 2016).

Psychiatric prescribers face the challenge of managing bipolar disorder symptoms while attempting to mitigate or reverse excessive weight gain in their patients. Treatment options for obesity and excessive weight gain in bipolar disorder remain limited. Behavioral interventions have modest results, at best, and the use of anti-obesity medications is limited by the risk for mood destabilization associated with stimulants (phentermine) and antidepressants (bupropion) in some patients. The introduction of GLP1-RAs (glucagon-1 peptide-1 receptor agonist), and GIPs (gastric inhibitory polypeptides) in recent years, show promise as highly efficacious treatments. Psychiatric providers are aware of the importance of treating excessive weight gain in their patients but perceive a lack of efficacious options or a lack of practice guidelines on how to use novel agents in a safe manner that does not compromise the patients’ psychiatric health.

The literature shows that even though psychiatric providers are aware of the impact of excessive weight gain in their patients, the problem is not consistently addressed during outpatient visits. A cross-sectional study published by Mojtabal et al. in 2017 shows that weight and metabolic concerns are only addressed in a minority of outpatient psychiatry visits, and that only a subset of psychiatrists are likely to address medical issues in their patients. A study published in 2022 surveyed a group of outpatient psychiatrist and identified common barriers that prevent providers from addressing weight and metabolic abnormalities in this population, including lack of knowledge in this area and administrative support. In addition, there is a lack of coordination between psychiatry and primary care. The authors conclude that supportive chart auditing and additional education for psychiatrists and staff as a possible solution (Aouira et al., 2022).

Managing excessive weight gain in people with chronic psychiatric illness remains a challenge. Weight management is significantly more difficult for this group than the general population, and the treatment options currently available fail to meet the patients’ special needs. The features associated with many psychiatric illnesses and the use of medications conductive to weight gain and metabolic abnormalities call for a systematic approach focused on prevention, monitoring, early intervention. These patients would also benefit from adjunctive treatment that incorporates pharmacological and behavioral interventions, as well as monitoring of metabolic measures and better coordination with primary care. Psychiatric prescribers can monitor the stability of their mental health as they undergo treatment for obesity, and in some cases, willing to prescribe anti-obesity medications but additional training on the use of new medications and support are needed if their efforts are to make a positive impact on this population. Patients would also benefit from access to learning materials that are tailored to their needs and to ongoing support to sustain healthy lifestyle changes. There is a need for an integrated protocol to manage excessive weight gain and metabolic risk in this populations, that supports both clinicians and patients in meeting their treatment goals.

References

Aouira, N., Khan, S., Heussler, H., Haywood, A., Karaksha, A., & Bor, W. (2022). Practitioners’ Perspective on Metabolic Monitoring of Second-Generation Antipsychotics: Existing Gaps in Knowledge, Barriers to Monitoring, and Strategies. Journal of Child and Adolescent Psychopharmacology, 32(5), 296-303.

Calkin, C., Van De Velde, C., Růžičková, M., Slaney, C., Garnham, J., Hajek, T., … & Alda, M. (2009). Can body mass index help predict outcome in patients with bipolar disorder? Bipolar disorders, 11(6), 650-656.

Correll, C. U., Detraux, J., De Lepeleire, J., & De Hert, M. (2015). Effects of antipsychotics, antidepressants, and mood stabilizers on risk for physical diseases in people with schizophrenia, depression, and bipolar disorder. World psychiatry, 14(2), 119-136.

McElroy, S. L., Kemp, D. E., Friedman, E. S., Reilly-Harrington, N. A., Sylvia, L. G., Calabrese, J. R., … & Shelton, R. C. (2016). Obesity, but not metabolic syndrome, negatively affects outcome in bipolar disorder. Acta Psychiatrica Scandinavica, 133(2), 144-153.

Mojtabai, R., & Oleson, M. (2018). Management of common medical conditions by office-based psychiatrists. Psychiatric Services, 69(4), 410-423.

Taylor, V. H., McIntyre, R. S., Remington, G., Levitan, R. D., Stonehocker, B., & Sharma, A. M. (2012). Beyond pharmacotherapy: understanding the links between obesity and chronic mental illness. The Canadian Journal of Psychiatry, 57(1), 5-12.