Behavioral interventions for antipsychotic induced appetite changes

A systematic review of observational studies exploring the relationship between health and non-weight-centric eating behaviours

Eating behaviour that does not centralise weight, otherwise known as weight-neutral, is associated with improved physical and psychological health, and greater health promoting behaviours. However, consolidated evidence is lacking. This study aimed to systematically evaluate 'health-centric' eating behaviour reflective of weight-neutral approaches, and their relationship with health (physical and mental) and health promoting behaviours. A systematic search was performed, identifying observational studies with adult populations, ≥1 physical/mental health outcome(s), and ≥1 validated measure(s) of health-centric eating behaviour. Study design, sample characteristics and outcomes were extracted and characterised into four domains. Our search identified 8281 records, with 86 studies, 75 unique datasets, and 78 unique exposures including 94,710 individuals. Eating behaviours included intuitive eating (n = 48), mindful eating (n = 19), and eating competence (n = 11). There were 298 outcomes identified for body composition, size, and physical health (n = 116), mental health and wellbeing (n = 123), health promoting behaviours (n = 51) and other eating behaviour (n = 8). Higher levels of intuitive eating, mindful eating and eating competence were significantly related to a lower BMI, better diet quality and greater physical activity. Higher intuitive and mindful eating were significantly related to lower levels of disordered eating, and depressive symptoms, and greater body image, self-compassion, and mindfulness. Greater eating competence and intuitive eating were significantly related to higher fruit and vegetable intake, and greater eating competence to higher fibre intake and better sleep quality. Our results demonstrate that 'health-centric' eating behaviours are related to a range of favourable health outcomes and engagement in health promoting behaviours. These findings help to enhance our understanding of eating behaviours that do not centre around body weight, providing support for health-centric eating behaviour in healthcare. Future research should focus on intervention studies and more diverse population groups.

Association between Empathy and Clinical Symptoms among Overweight and Non-Overweight Chinese Chronic Schizophrenia Patients

Patients with schizophrenia are afflicted by severe clinical symptoms and serious cognitive dysfunction. The aim of this study is to investigate the potential relationships between clinical symptoms and empathy and their variations between overweight and non-overweight schizophrenia patients. To address this problem, a group of 776 inpatients diagnosed with chronic schizophrenia (504 overweight patients and 272 non-overweight patients) was recruited. The Positive and Negative Syndrome Scale (PANSS) and its five-factor model were employed to assess clinical symptoms, while empathy levels were measured using the Interpersonal Reactivity Index (IRI). The overweight patients had lower education levels but higher positive symptoms than the non-overweight patients (all p < 0.05). In addition, the overweight patients performed significantly better with respect to empathy (FDR-corrected p < 0.05). Additional multiple regression analyses indicated significant associations between the total score of the IRI and PANSS negative symptoms, gender, and family history of psychiatric disorders among the overweight group; among non-overweight patients, there was a significant correlation between suicide and the total score of the IRI. This study provides evidence suggesting that chronic schizophrenia patients who are overweight may have distinct clinical characteristics, particularly with respect to their empathy, compared with non-overweight patients. Moreover, different variables are associated with empathy in different groups.

Empagliflozin Effectively Attenuates Olanzapine-Induced Body Weight Gain in Female Wistar Rats

Atypical antipsychotic drugs are commonly associated with undesirable side effects including body weight gain (BWG) and metabolic deficits. Many pharmacological interventions have been tested in an attempt to minimize or prevent these side effects. Preliminary evidence suggests that antidiabetic drugs may be effective in attenuating antipsychotic-induced BWG. In the current study, we examined the effect of an antidiabetic drug empagliflozin (EMPA) on BWG induced by anatypical antipsychotic drug olanzapine (Ola) in female and male Wistar rats. Rats were divided into six groups based on the dose they received: group 1 (female control), group 2 (female EMPA, 20 mg/kg; IG), group 3 (female Ola, 4 mg/kg; IP), group 4 (female Ola, 4 mg/kg; IP + EMPA, 20 mg/kg; IG), group 5 (male control), and group 6 (male Ola, 4 mg/kg; IP). Ola induced sustained increase in BWG. The subsequent treatment of Group 3 and 4 with EMPA attenuated the Ola-induced BWG in female Wistar rats. In terms of the gender difference between female and male Wistar rats, the male control group 5 gained more weight throughout the study as compared to the female control group 1. Similarly, the male Ola group 6 gained more weight throughout the study as compared to the female Ola group 3. However, Ola did not cause any weight difference between male rats treated with Ola in comparison with male control group, thus showing a significant gender difference regarding body weight between male and female Wistar rats regardless of Ola administration. In addition, the present findings showed that EMPA effectively attenuates the Ola induced BWG in female Wistar rats. These novel findings should help to better understand the underlying molecular and behavioral mechanisms contributing to the observed increase in body weight after treatment with Ola and other atypical antipsychotic drugs across male and female rats.

Prevalence of obesity and clinical and metabolic correlates in first-episode schizophrenia relative to healthy controls

OBJECTIVE

People with schizophrenia exhibit a high obesity rate. However, little is known about the prevalence of obesity and its relationship with clinical symptoms and metabolic indicators in first-episode drug-naïve (FEDN) schizophrenia.

METHODS

Demographic and lipid parameters were gathered from 297 FEDN schizophrenia and 325 healthy controls. The patients' symptomatology was evaluated by the Positive and Negative Syndrome Scale (PANSS).

RESULTS

The obesity rate of FEDN patients was 10.77%, similar to that of controls (10.5%). The prevalence of overweight plus obesity of patients was 44.8%, significantly higher than that of controls (36.6%). Compared with non-obese patients, obese patients had higher levels of cholesterol (4.81 ± 0.93 vs 4.22 ± 1.00 mmol/L), triglyceride (0.27 ± 0.21 vs 0.14 ± 0.24 mg/dL), low-density lipoprotein (0.48 ± 0.12 vs 0.40 ± 0.12 mg/dL), greater ratio of triglyceride/high-density lipoprotein (2.01 ± 1.23 vs 1.44 ± 1.26), and higher PANSS positive symptom subscale score (29.81 ± 6.29 vs 27.05 ± 6.15), general psychopathology subscale score (70.75 ± 11.74 vs 66.87 ± 11.37), and total score (149.81 ± 21.08 vs 140.64 ± 21.58), but lower high-density lipoprotein level (1.09 ± 0.21 vs 1.27 ± 0.34 mg/dL) (all p < 0.05). Correlation analysis revealed that body mass index (BMI) was positively correlated with triglyceride, cholesterol, high-density lipoprotein, low-density lipoprotein, triglyceride/high-density lipoprotein ratio, PANSS positive symptoms, general psychopathology, and total scores (all p < 0.05, r = 0.124 ~ 0.335). Multiple regression analysis confirmed that PANSS positive symptoms, total score, and cholesterol level were significantly associated with BMI (all p < 0.05, β: 0.126-0.162).

CONCLUSION

There was no significant difference in the prevalence of obesity between FEDN patients and the control group. Moreover, BMI was positively associated with positive symptom severity in FEDN patients.

Standardizing the Effective Correlated Dosage of Olanzapine and Empagliflozin in Female Wistar Rats

AIM

The primary aim of this study was to standardize the correlated effective dosage of the antidiabetic drug empagliflozin (EMPA) and the antipsychotic drug olanzapine (Ola).

BACKGROUND

Atypical antipsychotics are associated with BWG and metabolic disturbances for which many approaches have been used to minimize these issues, including antidiabetic drugs. The antidiabetic drugs have been quite effective in reversing BWG induced by the administration of antipsychotic drugs in patients who have psychosis, schizophrenia and bipolar disorder.

OBJECTIVE

The objective of this study was to standardize the correlated effective dosage of EMPA and Ola.

METHODS

The study was carried out for 28 days to represent the chronic effect of Ola on female Wistar rats. Rats were divided into three groups based on the dose they received: control (vehicle), Ola-4 and Ola-8 (4 and 8 mg/kg/OD, respectively), and EMPA-10 and EMPA-20 (10 and 20 mg/kg/OD, respectively).

RESULTS

Both doses of Ola produced a significant increase in the percentage of BWG, however, Ola-4 produced a higher BWG. Also, both the doses of EMPA were able to reverse the effect of Ola-induced BWG; however, EMPA-20 produced a higher reversal in BWG and normalized the rat's body weight.

CONCLUSION

We conclude that Ola-4 and EMPA-20 were the most effective dosage for experimental purposes in female Wistar rats. The findings of this study standardized the effective correlated dosage of olanzapine and empagliflozin in female Wistar rats that will help understand the underlying molecular and behavioral mechanisms.

The Importance of Second-Generation Antipsychotic-Related Weight Gain and Adherence Barriers in Youth with Bipolar Disorders: Patient, Parent, and Provider Perspectives

Objectives: The objective of this research was to understand physician, patient, and parent perspectives on barriers to second-generation antipsychotic (SGA) medication adherence in youth with bipolar spectrum disorders, and attitudes toward treatment of SGA-related weight gain. Methods: Patients diagnosed with bipolar disorder before age 18, parents of children diagnosed before 18, and clinicians with experience prescribing SGAs for these patients completed surveys regarding SGA-related side effects, adherence barriers, and acceptability of weight management strategies. Results: Patients (n = 225), parents (n = 128), and clinicians (n = 54) reported weight gain as the most concerning SGA-related side effect (45.6%, 38.9%, and 70.4%, respectively). Weight gain was also the top adherence barrier for patients (35.9%), but was ranked fourth (41.8%) by parents. Patients (61.5%) were more likely "definitely" willing to co-initiate another medication to manage weight gain upon SGA initiation than parents (20.1%) or clinicians (1.9%). Conversely, parents (54.9%) and clinicians (84.9%) were "definitely" willing to accept/prescribe a second medication aiming to reverse weight gain of ≥10 lbs., and patients (61.1%) were willing to add another medication to reverse any weight gain. Conclusion: SGA-related weight gain impairs medication adherence in young patients with bipolar disorder. Many young patients would start pharmacologic treatment to mitigate SGA-related weight gain at treatment initiation, parents and clinicians are more hesitant. This research informs patient-centered perspectives on SGA adherence barriers and strategies to minimize potential side effects, which may improve adherence in this vulnerable patient population.

Dietary intake of people with severe mental illness: systematic review and meta-analysis

BACKGROUND

Severe mental illness (SMI) is thought to be associated with lower diet quality and adverse eating behaviours contributing towards physical health disparities. A rigorous review of the studies looking at dietary intake in psychotic disorders and bipolar disorder is lacking.AimsTo conduct a systematic, comprehensive evaluation of the published research on dietary intake in psychotic disorders and bipolar disorder.

METHOD

Six electronic databases were searched for studies reporting on dietary intakes in psychotic disorders and bipolar disorder. Dietary-assessment methods, and dietary intakes, were systematically reviewed. Where possible, data was pooled for meta-analysis and compared with healthy controls.

RESULTS

In total, 58 eligible studies were identified. People with SMI were found to have significantly higher dietary energy (mean difference 1332 kJ, 95% CI 487-2178 kJ/day, P = 0.002, g = 0.463) and sodium (mean difference 322 mg, 95% CI 174-490 mg, P &lt; 0.001, g = 0.414) intake compared with controls. Qualitative synthesis suggested that higher energy and sodium intakes were associated with poorer diet quality and eating patterns.

CONCLUSIONS

These dietary components should be key targets for preventative interventions to improve weight and other physical health outcomes in people with SMI.Declaration of interestS.B.T. and E.T. have clinical dietitian appointments within the South Eastern Sydney Local Health District and do not receive any further funding.

Assessment of cardiovascular risk in an Italian psychiatric outpatient sample: A chart review of patients treated with second-generation antipsychotics

Despite the call by the scientific community for a systematic monitoring of physical health in people with psychiatric illnesses, national and international audits have reported poor quality of cardiovascular risk assessments and management in this vulnerable population. Available evidence indicates that in people affected by mental illness, life expectancy is reduced by 10-20 years, mainly due to cardiovascular accidents and metabolic syndrome (MetS)-related diseases. The primary aim of the present study was to evaluate the accuracy of cardiovascular risk monitoring in an outpatient sample of patients taking second-generation antipsychotics. The sample consisted of 200 patients consecutively recruited from two community mental health centres. A clinical chart review was performed on the following laboratory tests: total cholesterol, high- and low-density lipoprotein, serum triglycerides, fasting blood glucose, γ-glutamyl transpeptidase. Blood pressure and waist circumference were measured. A complete cardiovascular risk assessment was available only in 60 patients out of 200 (33.3%). The only variable associated with laboratory tests for MetS was receiving three or more psychotropic medications, which increased fourfold the probability of metabolic screening. In the subsample of patients with full screening, the prevalence of MetS was 33.3%. Our findings suggest that mental health professionals working in community mental health services should incorporate a more systematic assessment of physical health in their practice, and intervene proactively to reduce the significant cardiovascular burden carried by people with several mental illness.

Reasons for lithium discontinuation in men and women with bipolar disorder: a retrospective cohort study

BACKGROUND

Lithium remains first choice as maintenance treatment for bipolar affective disorder. Yet, about half of all individuals may stop their treatment at some point, despite lithium's proven benefits concerning the prevention of severe affective episodes and suicide.

METHODS

Retrospective cohort study in the Swedish region of Norrbotten into the causes of lithium discontinuation. The study was set up to (1) test whether patients with bipolar affective disorder or schizoaffective disorder, treated with lithium maintenance therapy, were more likely to discontinue lithium because of adverse effects than lack of therapeutic effectiveness, (2) explore gender differences, (3) understand the role of diagnosis and (4) identify who, patient or doctor, took the initiative to stop lithium. Review of medical records for all episodes of lithium discontinuation that had occurred between 1997 and 2013 with the intent to stop lithium for good.

RESULTS

Of 873 patients treated with lithium, 54% discontinued lithium, corresponding to 561 episodes of lithium discontinuation. In 62% of episodes, lithium was discontinued due to adverse effects, in 44% due to psychiatric reasons, and in 12% due to physical reasons interfering with lithium treatment. The five single most common adverse effects leading to lithium discontinuation were diarrhoea (13%), tremor (11%), polyuria/polydipsia/diabetes insipidus (9%), creatinine increase (9%) and weight gain (7%). Women were as likely as men to take the initiative to stop lithium, but twice as likely to consult a doctor before taking action (p < 0.01). Patients with type 1 BPAD or SZD were more likely to discontinue lithium than patients with type 2 or unspecified BPAD (p < 0.01). Patients with type 1 BPAD or SZD were more likely to refuse medication (p < 0.01). Conversely, patients with type 2 or unspecified BPAD were three times as likely to discontinue lithium for lack or perceived lack of effectiveness (p < 0.001).

CONCLUSIONS

Stopping lithium treatment is common and occurs mostly due to adverse effects. It is important to discuss potential adverse effects with patients before initiation and continuously during lithium treatment, to reduce the frequency of potentially unnecessary discontinuations.

A review of the nutritional challenges experienced by people living with severe mental illness: a role for dietitians in addressing physical health gaps

People experiencing a severe mental illness (SMI), such as schizophrenia, schizoaffective disorder, bipolar affective disorder or depression with psychotic features, have a 20-year mortality gap compared to the general population. This 'scandal of premature mortality' is primarily driven by preventable cardiometabolic disease, and recent research suggests that the mortality gap is widening. Multidisciplinary mental health teams often include psychiatrists, clinical psychologists, specialist mental health nurses, social workers and occupational therapists, offering a range of pharmacological and nonpharmacological treatments to enhance the recovery of clients who have experienced, or are experiencing a SMI. Until recently, lifestyle and life skills interventions targeting the poor physical health experienced by people living with SMI have not been offered in most routine clinical settings. Furthermore, there are calls to include dietary intervention as mainstream in psychiatry to enhance mental health recovery. With the integration of dietitians being a relatively new approach, it is important to review and assess the literature to inform practice. This review assesses the dietary challenges experienced by people with a SMI and discusses potential strategies for improving mental and physical health.

Significant weight loss following clozapine use, how is it possible? A case report and review of published cases and literature relevant to the subject

It has been repeatedly shown that clozapine is more efficacious than other antipsychotics in the management of treatment-resistant schizophrenia. However, clozapine is associated with a number of side effects including weight gain. Antipsychotic-induced weight gain has been linked with a number of untoward events including psychological factors such as stigma and low self-esteem, and physical factors such as metabolic syndromes and untimely death. The mechanism underlying antipsychotic (including clozapine)-induced weight gain is not clearly understood, although it is said to involve several brain areas, several neurotransmitters, neuropeptides and genetic factors. To some individuals however, clozapine use is associated with significant weight loss (13.5-50% of body weight). The observed weight loss in these groups of patients has not been attributed to any underlying diagnosable physical disorders. There have been a handful cases published with this phenomenon, which seems to be contrary to what is expected when clozapine is prescribed. From the currently published cases three groups emerge - those who lost weight simply by taking clozapine, those who lost weight due to improved mental state, engaging in diet and increased exercise, and those for whom weight loss was a sign of a poor response to clozapine. A case of JX who has a diagnosis of schizoaffective disorder is presented. JX lost over 26% of her body weight when she was prescribed clozapine. A detailed review of other published cases is undertaken. The underlying mechanisms involving weight loss are discussed and the implications to clinicians are highlighted. Coordinated studies to examine these groups of patients may provide some insight, not only in the mechanism of clozapine-induced weight loss, but also in the better management of patients with treatment-resistant schizophrenia involving clozapine use.

Type 2 diabetes in children and adolescents on atypical antipsychotics

Youth receiving treatment with antipsychotics are particularly susceptible to weight gain, type 2 diabetes (T2D), and associated metabolic disorders, which is directly associated with excess morbidity and mortality in this vulnerable population. The risk of T2D is 2- to 3-fold that of the general population, starts early in the course of treatment, and reflects the effects of weight gain in conjunction with direct effects of antipsychotics on the hypothalamus, pancreatic beta cells, and insulin-sensitive peripheral tissues. Close monitoring with early intervention through lifestyle intervention, switching away from antipsychotics with deleterious metabolic effects, and adjunctive treatment with metformin are modalities available to mitigate weight gain and improve cardiometabolic health in these patients. Despite rapidly advancing knowledge in the field, patient's access to metabolic screening and quality care remains limited. Efforts must be made to broaden reach of early cardiometabolic intervention among these patients in order to avert serious cardiovascular disease burden in the future.

Mental health starts with physical health: current status and future directions of non-pharmacological interventions to improve physical health in first-episode psychosis

People with psychotic disorders have reduced life expectancy compared with the general population. This difference is primarily due to increased prevalence of cardiovascular disease associated with antipsychotic drugs and with modifiable risk factors, including weight gain, low exercise, poor diet, and high prevalence of cigarette smoking. We review non-pharmacological interventions for physical health behaviour in patients with chronic and first-episode psychosis. Our findings suggest that weight loss and attenuation of weight gain are achievable but limited and might not persist beyond the end of an intervention. Evidence for smoking cessation interventions is scarce. The case for early intervention to prevent deterioration of physical health is strong. We propose a framework for development of interventions, which addresses three main factors largely absent in previous research: (1) examination of aetiological factors related to poor physical health, (2) theory-driven interventions that target aetiological factors, and (3) assessment of feasibility.

Metabolic syndrome among psychiatric inpatients with schizophrenia in Indonesia

Despite the fact that antipsychotic medication increases the risk of metabolic syndrome (MetS), the rate of MetS among psychiatric patients in Indonesia is rarely reported. This study aimed to investigate the prevalence of MetS among inpatients with schizophrenia in Indonesia. Eighty-six hospitalised psychiatric patients with schizophrenia were randomly recruited, and underwent physical examination including a blood test. MetS was assessed based on the International Diabetes Federation (IDF) criteria for South Asia. Among the sample, only eight patients (9.3%) met the IDF criteria for MetS. Women have a higher rate of MetS than men (23.8% vs 4.6%; p=0.02). Reduced high-density lipoprotein (HDL) cholesterol was the most frequent (81.4%) metabolic abnormality among them, followed by central obesity (29.1%), raised triglycerides (23.3%), raised fasting plasma glucose (12.8%), and raised blood pressure (10.5%). Among the various antipsychotics, no differences in MetS prevalence were observed in this population. The rate of MetS among the psychiatric inpatients in this study is lower compared both to the previously reported rate in the general population and to the findings among psychiatric patients with schizophrenia in developed countries. Several factors related to the reduced rate of MetS in this psychiatric inpatient population will be discussed.

Clinical management of comorbid diabetes and psychotic disorders

Individuals with psychotic disorders experience substantial health disparities with respect to diabetes, including increased risk of incident diabetes and of poor diabetes outcomes (eg, diabetes complications and mortality). Low-quality medical care for diabetes is a significant contributor to these poor health outcomes. A thoughtful approach to both diabetes pharmacotherapy and drug management for psychotic disorders is essential, irrespective of whether treatment is given by a psychiatrist, a primary care provider, or an endocrinologist. Exposure to drugs with high metabolic liability should be minimised, and both psychiatric providers and medical providers need to monitor patients to ensure that medical care for diabetes is adequate. Promising models of care management and team approaches to coordination and integration of care highlight the crucial need for communication and cooperation among medical and psychiatric providers to improve outcomes in these patients. Evidence-based programmes that promote weight loss or smoking cessation need to be more accessible for these patients, and should be available in all the settings where they access care.

Metformin inhibits food intake and neuropeptide Y gene expression in the hypothalamus

Metformin may reduce food intake and body weight, but the anorexigenic effects of metformin are still poorly understood. In this study, Sprague-Dawley rats were administered a single intracere-broventricular dose of metformin and compound C, in a broader attempt to investigate the regula-tory effects of metformin on food intake and to explore the possible mechanism. Results showed that central administration of metformin significantly reduced food intake and body weight gain, par-ticularly after 4 hours. A reduction of neuropeptide Y expression and induction of AMP-activated protein kinase phosphorylation in the hypothalamus were also observed 4 hours after metformin administration, which could be reversed by compound C, a commonly-used antagonist of AMP-activated protein kinase. Furthermore, metformin also improved lipid metabolism by reducing plasma low-density lipoprotein. Our findings suggest that under normal physiological conditions, central regulation of appetite by metformin is related to a decrease in neuropeptide Y gene expres-sion, and that the activation of AMP-activated protein kinase may simply be a response to the anorexigenic effect of metformin.

Eating disorders in schizophrenia: implications for research and management

Objective. Despite evidence from case series, the comorbidity of eating disorders (EDs) with schizophrenia is poorly understood. This review aimed to assess the epidemiological and clinical characteristics of EDs in schizophrenia patients and to examine whether the management of EDs can be improved. Methods. A qualitative review of the published literature was performed using the following terms: "schizophrenia" in association with "eating disorders," "anorexia nervosa," "bulimia nervosa," "binge eating disorder," or "night eating syndrome." Results. According to our literature review, there is a high prevalence of comorbidity between schizophrenia and EDs. EDs may occur together with or independent of psychotic symptoms in these patients. Binge eating disorders and night eating syndromes are frequently found in patients with schizophrenia, with a prevalence of approximately 10%. Anorexia nervosa seems to affect between 1 and 4% of schizophrenia patients. Psychopathological and neurobiological mechanisms, including effects of antipsychotic drugs, should be more extensively explored. Conclusions. The comorbidity of EDs in schizophrenia remains relatively unexplored. The clearest message of this review is the importance of screening for and assessment of comorbid EDs in schizophrenia patients. The management of EDs in schizophrenia requires a multidisciplinary approach to attain maximized health outcomes. For clinical practice, we propose some recommendations regarding patient-centered care.