Psych Medicines Should be Prescribed in Tandem with Weight Loss Program

Regardless of the type of psychiatric medications taken, including antidepressants and antipsychotics, patients who enroll in a weight loss program achieve weight loss, similar to those not taking these medications. This is important progress for many individuals who fear weight gain when they take psychopharmacological medications.

With Sean Wharton, MD, PharmD, Michael McGee, MD, and J. Michael Gonzalez-Campoy, MD, PhD 

The association of weight gain as a side effect of psychotropic drugs is not a newly discovered concern, still it poses an ongoing concern for patients and physicians alike. After all, considering the weight-promoting potential of antidepressant and antipsychotic medications is necessary given the long-term comorbidities associated with obesity.1,2

Concerns about weight gain may jeopardize the best recommendations for psychopharmacology in addressing the mental health of patients if a patient refuses a beneficial medication due to this link or decides to discontinue the treatment due to distress arising from weight gain,3 according to Canadian researchers

Antidepressants and antipsychotics may promote weight gain but can be managed.

Adherence to Psych Meds Impacted by Weight Gain

"Their fear of weight gain is sometimes so powerful many of our patients will stop taking their medications," says lead author, Sean Wharton, MD, PharmD, an internal medicine specialist and director of the Wharton Medical Clinics, established in Toronto, Ontario to deliver weight and diabetes management.

However, Dr. Wharton and colleagues have found a way to address the impediment to optimal mental health care so that patients avoid related weight gain, and remain amenable to taking their prescribed psychopharmacologic medication—the solution is to initiate a weight management program that emphasizes lifestyle changes, and do it simultaneously with initiation of an anti-depressant medication.3

Study findings,3 published in the journal Obesity, shows the efficacy of this approach whereby a formal weight control intervention and prescription for a psychotropic drug are introduced together. In reporting on this program, Dr. Wharton says that patients who enrolled in his community-based weight management program, on average, were able to shed pounds, whether they were taking an antidepressant, antipsychotic, both, or neither.

While there were minor differences in weight loss observed, such as between men and women; however, the research team demonstrated that even among individuals who were taking a medication that is typically associated with weight gain, they were as likely to lose weight as those prescribed a medication deemed weight neutral or even considered a weight loss-inducing drug.3

In fact, patients (n=17,519) across the board lost a significant among of weight (P < 0.0001). At the trial start, the average body mass index (BMI) of each group—those on antipsychotics, those on antidepressants, those receiving both types of medication, and those taking no psych meds—was similar for all participants, ranging from about 39 to 41 kg/m2. The age of the patients ranged from mid 40s to early 50s.3

Manage Diabetes, Obesity, and Mental Health with Formal Weight Program

When it comes to weight concerns, patients with mental health disorders are typically at a distinct disadvantage, according to Dr. Wharton and colleagues. Past research has demonstrated that the likelihood that those with mental health disorders have up to 1.5 times greater odds of having obesity.4

While it has not been clearly ascertained which way the association plays out, the link between weight gain, and antidepressant and antipsychotic use is well documented, although it varies and is not the same for everyone.5-8

In one such study,5 researchers looked at the weight status of 362 patients taking antidepressant drugs for 6 to 36 months. They found that 55.2% gained weight and that 40.6% gained 7% or more of their baseline weight.

Of the drugs they looked at, including citalopram (Celexa) escitalopram (Lexapro), sertraline (Zoloft), paroxetine (Paxil, others), venlafaxine ( Effexor), duloxetine (Cymbalta) and mirtazapine (Remeron) were all linked with significant weight gain. Fluoxetine (Prozac, Sarafem) was not. The study did not have funding from pharmaceutical companies. 6

Formal Weight Loss Program Tested in Patients Treated with Psych Meds

In looking for a viable protocol, the researchers enrolled individuals diagnosed with a mental health condition in the lifestyle weight loss intervention at the Wharton Medical Clinics. In all, 23% of the patients were taking at least one psychiatric medication.3 Of these, 4,094 patients or 84.4%, took only an antidepressant, 4.2% took only antipsychotics and 11.4% took both. The aim of the study was to compare weight loss for those taking the medications and those not taking them. Data was collected from 2008 to 2017. 3

The program protocol stressed lifestyle change, Dr. Wharton tells EndocrineWeb. Patients answered questions about family history, weight management history and other detail. A bariatric educator gave suggestions for diet. Patients were advised to be active.

"It's not an intensive protocol," Dr. Wharton says. The patients are advised to eat 500 fewer calories daily than their daily calculated calorie need. "There's no fancy dietary plan." The patients could return to the clinic as often as they wished; it usually was every three to four weeks. They would meet with a physician and/or a bariatric educator to adjust their diet and activity when needed.1

Outcomes Support Simultanous Treatment 

Over the 15.8 months of clinic attendance, with a range of 8 to 65 months, patients overall lost on average about 7.5 pounds, or 2.9% of their body weight  (P<0.05). That translated to 27.6% of patients losing 5% or more of their baseline weight and 10.1% losing 10% or more.1

"We did see slightly less weight loss in men taking an antidepressant compared to men taking a combination of an antidepressant and antipsychotic and the group not taking any," says Rebecca Christensen, MSc, a co-author on the paper and a PhD student at the Dalla Lama School of Public Health, at the University of Toronto.

The researchers can't explain that finding for sure, but Dr. Wharton says that ''maybe people on two medications are mentally stable and can engage in a weight loss program better."1

While the weight loss may not seem dramatic after adjusting for confounding factors, offering no statistically significant difference between treatment groups, Dr. Wharton says their results correlate with those of similarly trialed weight loss interventions.5-6 More importantly, he tells EndocrineWeb, “the findings suggest that weight gain is not inevitable for patients who are taking psychiatric medications.”

Patients Benefit Most when Prescribed Weight Loss and Mental Health Meds

The study results are both valuable and not surprising, says Michael McGee, MD, chief medical officer at The Haven at Pismo, an addiction treatment center near San Luis Obispo, California. Dr. McGee is a psychiatrist and author of "The Joy of Recovery: The New 12-Step Guide to Recovery from Addiction,” as well as an advisory board member to PsyCom.

He sees this study as valuable since weight gain is very much on the minds of people who are prescribed psychiatric medication. "Patients fear the possibility of weight gain and complain when their weight increases, especially among women. Many of whom often do gain weight, but it is not a given," he tells EndocrineWeb.

In his experience, many patients typically experience an increase of five to 10% of their initial weight, as they are unable to avoid weight gain or to lose weight on their own. So he endorsing the concept of referring patients to a structured weight loss program as a very beneficial method to help minimize that inevitability. Dr. McGee adds: Prescribing weight loss medications may help, too.

Dr. McGee also suggests that clinicians suggest that patients focus on mindful eating—what you eat, how you eat, and why you eat. He reminds his patients to try to avoid ''eating for gratification or self-soothing."

The same advice holds for patients who have prediabetes, type 2 diabetes, or are struggling with weight maintenance, he says. The goal is to create a setting so these patients feel they can safely take their psychopharmacological medications without the complication of undesirable weight gain.

With Weight Gain, Some Psychotropics Are Worse than Others

The link between weight gain and psych medications will differ by medication type, says J. Michael Gonzalez-Campoy, MD, PhD, FACE, medical director and CEO of the Minnesota Center for Obesity, Metabolism and Endocrinology, in Eagan.

"In general, the use of most antipsychotic medications is associated with weight gain," he says, "with the exception of fluoxetine and bupropion (eg, Wellbutrin), the use of antidepressants is weight neutral or associated with modest weight gain. This is a pharmacologic effect," Dr. Gonzalez-Campoy says.

As such, clinicians should inform all patients of the potential for weight gain, ''and the subsequent development or exacerbation of hyperglycemia, hypertension and dyslipidemia," he tells EndocrineWeb.

"It is the standard of care to provide patients who are prescribed antipsychotic medications access to a weight management program and to establish surveillance for the development of metabolic complications of weight gain," so we should all be approaching patients under the care of a mental health professional in this manner.

One bright spot, he notes, is that in general, patients who are prescribed antipsychotics accept the potential for weight gain since they are more concerned about their mental health, so their medication adherence is good. Conversely, those who are deemed in need of an antidepressant are not so accepting of the prospect for weight gain, he finds. And there’s the risk that weight gain will negatively impact the patient’s mental health outlook.

Balancing Mental Health Treatment and Healthy Weight

These patients will likely benefit most from participating in a formal weight management intervention as part of their mental health process. As such, when a prescription for an antipsychotic and most antidepressants is written, a concomitant prescription for a weight control program should be written, too, Dr. Gonzalez-Campoy tells EndocrineWeb.

Dr. Wharton agrees. "Advise your patients to immediately begin a lifestyle modification program." This is more likely to be feasible if there is a program close by, or one supported by the patient’s health plan; suggesting a specific weight management program in the area, is a very good idea, he says.

That makes it easier for practitioners because the results of the Canadian study, which focused on what may be considered a non-intensive program, suggests that many types of weight management programs could work,3 according to Dr. Wharton.

Reminding patients about the necessity of maintaining good mental health, and the findings of the new research, can be valuable, says Rebecca Christensen, MSc, a co-author of the study with Dr. Wharton. She suggests doctors tell patients who need the psychiatric medications: "Taking these medications [for mental health issues] is really important. Don't be concerned about the potential weight gain because we can mitigate it."

Dr. Wharton is on the advisory board for Novo Nordisk and Bausch Health and reports funding from Novo, Eli Lilly, Janssen, and Astra Zeneca. None of the others have any relevant financial disclosures.

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