Speak up! There may be options that don't cause weight gain

Schizophrenia is a challenging problem to manage. I'm not a huge fan of medication, but I AM a huge fan of keeping people safe as well as healthy. And in the case of schizophrenia, that often means medication MUST be part of the treatment plan.

I wish, though, that in the process of keeping our schizophrenic loved ones safe with regards to reducing self-harming and otherwise destructive behaviors, we could keep them metabolically safe. In other words, I wish we could also create an antipsychotic that didn't significantly increase weight gain, as well as risk of diabetes and heart disease. The most we seem to be able to do, right now, it seems, is be aware of the relative health risks that medications in this category pose.

One medication that seems to be working well, is ziprasidone (Geodon). One hundred eighty five individuals with schizophrenia or schizoaffective disorder who were initially on either risperidone (Risperdal), olanzapine (Zyprexa), or conventional antipsychotic agents, were switched to ziprasidone, and maintained on this medication for one year. Cholesterol, triglyceride, weight, and behavioral measures were recorded at regular follow-up intervals during this time.

In the individuals who had been switched from risperidone or olanzapine, there were overall significant improvements in weight, total cholesterol, and triglyceride levels. These changes did not seem to show up, however, in those who were switched over from other antipsychotics.

The take home message here is that there seems to be a spectrum along which these medications lie, from most weight-neutral to least weight-neutral. It's important to be aware that if you or someone you know is on medications and you notice changes in metabolic health, that you ask about alternatives.

I know that there are many other reasons why psychiatrists make medication choices in their treatment planning. I have several clients in my case load who simply are not well managed unless they are using the weight-promoting antipsychotics. Their treatment goals are different than what I am referring to here.

If there is a weight/cholesterol/diabetes issue whose onset seems to correlate with the use of an antipsychotic medication, and there are medication options that have not been considered, it is surely worth inquiring about the possibility of using them. Often times, the burden of this communication falls on the loved one, as the person with the problem is not in a cognitive place to be able to do this for himself/herself.

Just know, often times there are options, and it is your right to ask for a discussion about what those options are.

Weiden PJ, Newcomer JW, Loebel AD, Yang R, Lebovitz HE. Long-Term Changes in Weight and Plasma Lipids during Maintenance Treatment with Ziprasidone. Neuropsychopharmacology. 2008 Apr;33(5):985-94

Antipsychotics, weight gain, and beautiful minds

My very first experience in mental health was with a young man with schizophrenia who was also diabetic. It was very challenging to help him with his diet, because he was pretty obsessed with telling me how he'd been recruited away from his professional football career to invent the atomic bomb, and that he'd recently invented the Toyota Corolla. I remember thinking, even as a young intern, that it was sad that someone with so much creative energy was sitting in a locked psychiatric unit instead of focusing his mind in a productive direction.

It turns out, schizophrenia and diabetes are a very common combination. No one really knows why, but my guess is that with time, we'll learn that there is some kind of genetic link between the two problems. What makes this relationship especially important to understand, is that there are medications for schizophrenia that can exacerbate the diabetes, as well as other metabolic syndrome-related problems such as increased triglycerides.

A recent study showed that while rates of metabolic syndrome increased over time in patients prescribed antipsychotics, regardless of the specific type of medication, that the risk of developing metabolic syndrome was three times greater in those individuals using second generation antipsychotics. These people also experienced a greater degree of weight gain. The two medications that appeared to be the most problematic were olanzapine (Zyprexa) and clozapine (Clozaril).

The good news is, that there is also research supporting the fact that behavioral and nutrition "training" with individuals who are on these medications can help to lessen the degree of the negative side effects. I have worked with individuals who have not been able to manage their schizophrenia without using one of these two medications, so I understand their value and necessity for the well-being, productivity, and SAFETY of many people who use them. I just wish that every physician who prescribed them also automatically referred their patient to a nutrition professional who could maximize the benefit of the medication while minimizing the risks these medications pose. And I wish that insurance companies would recognize the importance of utilizing this kind of professional help in mental health, so that reimbursement was available. That would encourage many of these people to actually seek help before problems even started.

Sometimes we assume that when a person has a diagnosis such as schizophrenia, or bipolar disorder, that they aren't a candidate for certain types of services. I've not experienced that at all. In fact, some of my most motivated clients have been individuals with these diagnoses. I love my time with them because they are often highly intelligent and creative. They just need people in their lives who take them seriously, who assume that they're intelligent and treat them as such, and who are willing to show them the ropes as far as being healthy.

I think, if I went through my life being treated as if I was not intelligent, that I'd start to believe it myself. Maybe someday, we won't be so afraid of diagnoses such as schizophrenia, and we'll be as comfortable interacting with people who have mental diagnoses as we are with people who have diabetes or high cholesterol.

Imagine how many potential Vincent Van Goghs and John Forbes Nash Jrs. (A Beautiful Mind) are out there just waiting for us to help them access their potential?

De Hert M, Schreurs V, Sweers K, Van Eyck D, Hanssens L, Sinko S, Wampers M, Scheen A, Peuskens J, van Winkel R. Typical and atypical antipsychotics differentially affect long-term incidence rates of the metabolic syndrome in first-episode patients with schizophrenia: A retrospective chart review. Schizophr Res. 2008 Feb 23 [Epub ahead of print]

Kalarchian MA, Marcus MD, Levine MD, Haas GL, Greeno CG, Weissfeld LA, Qin L. Behavioral treatment of obesity in patients taking antipsychotic medications. J Clin Psychiatry 2005 Aug;66(8):1058-63.

Wu MK, Wang CK, Bai YM, Huang CY, Lee SD. Outcomes of obese, clozapine-treated inpatients with schizophrenia placed on a six-month diet and physical activity program. Psychiatr Serv 2007 Apr;58(4):544-50.

Scocco P, Longo R, Caon F. Weight change in treatment with olanzapine and a psychoeducational approach. Eat Behav 2006 May;7(2):115-24.

Kwon JS, Choi JS, Bahk WM, Yoon Kim C, Hyung Kim C, Chul ShinY, Park BJ, Geun Oh C. Weight management program for treatment-emergent weight gain in olanzapine-treated patients with schizophrenia or schizoaffective disorder: A 12-week randomized controlled clinical trial. J Clin Psychiatry 2006 Apr;67(4):547-53.

Alvarez Jimenez M, Gonzalez Glanch C, Vazquez Barquero JL, Perez Iglesias R, Matinez Garcia O, Perez Pardal T, Ramirez Bonilla ML, Crespo Facorro B. Attenuation of antipsychotic-induced weight gain with early behavioral intervention in drug-naive first-episode psychosis patients: A randomized controlled trial. J Clin Psychiatry 2006 Aug;67(8):1253-60.

Mauri M, Simoncini M, Castrogiovanni S, Iovieno N, Cecconi D, Dell'agnello G, Quadrigli M, Rossi A, Donda P, Fagiolini A, Cassano GB. A Psychoeducational Program for Weight Loss in Patients who have Experienced Weight Gain during Antipsychotic Treatment with Olanzapine. Pharmacopsychiatry. 2008 Jan;41(1):17-23.