Detecting and Managing Adverse Effects of Antipsychotic Medications: Current State of Play

Antipsychotic Drug Prescription in Pediatric Intensive Care Units: A 10-Year U.S. Retrospective Database Study

Delirium recognition during pediatric critical illness may result in the prescription of antipsychotic medication. These medications have unclear efficacy and safety. We sought to describe antipsychotic medication use in pediatric intensive care units (PICUs) contributing to a U.S. national database. This study is an analysis of the Pediatric Health Information System Database between 2008 and 2018, including children admitted to a PICU aged 0 to 18 years, without prior psychiatric diagnoses. Antipsychotics were given in 16,465 (2.3%) of 706,635 PICU admissions at 30 hospitals. Risperidone (39.6%), quetiapine (22.1%), and haloperidol (20.8%) were the most commonly used medications. Median duration of prescription was 4 days (interquartile range: 2-11 days) for atypical antipsychotics, and haloperidol was used a median of 1 day (1-3 days). Trend analysis showed quetiapine use increased over the study period, whereas use of haloperidol and chlorpromazine (typical antipsychotics) decreased ( p  < 0.001). Compared with no antipsychotic administration, use of antipsychotics was associated with comorbidities (81 vs. 65%), mechanical ventilation (57 vs. 36%), longer PICU stay (6 vs. 3 days), and higher mortality (5.7 vs. 2.8%) in univariate analyses. In the multivariable model including demographic and clinical factors, antipsychotic prescription was associated with mortality (odds ratio [OR] = 1.09, 95% confidence interval [CI]: 1.02-1.18). Use of atypical antipsychotics increased over the 10-year period, possibly reflecting increased comfort with their use in pediatric patients. Antipsychotics were more common in patients with comorbidities, mechanical ventilation, and longer PICU stay, and associated with higher mortality in an adjusted model which warrants further study.

Sexual dysfunction in people treated with long-acting injectable antipsychotics in monotherapy or polypharmacy: a naturalistic study

Sexual dysfunction, psychosis, and antipsychotics are known to be related, but the precise association between them is still unknown. Most evidence about the prevalence of sexual dysfunction in people treated with antipsychotic drugs comes from studies with restrictive samples. That is why our main objective was to determine the prevalence of sexual dysfunction in a real-life sample of outpatients treated with antipsychotics, considering gender. A cross-sectional naturalistic study was developed, including people treated with long-acting injectable antipsychotics, with or without other psychotropic drugs. Participants were interviewed to assess sexual satisfaction through a Likert scale (0 to 10) and the presence of sexual dysfunction (the Psychotropic-Related Sexual Dysfunction Questionnaire, PRSexDQ-SALSEX). The participants also had a blood test to determine prolactin (men and women) and testosterone levels (men only). A total of 131 people participated in the study (90 men and 41 women). Some extent of sexual dysfunction was found in 62.2% of men and 51.2% of women. The most frequent sexual dysfunction symptom for both genders was the loss of libido (45%). Hyperprolactinemia was present in 56% of men and 61% of women. The presence of sexual dysfunction was associated with higher doses of antipsychotics, hyperprolactinemia, and smoking in men and with smoking and hyperprolactinemia in postmenopausal women. This study provides real-life evidence of sexual dysfunction and hyperprolactinemia in persons treated with long-acting injectable antipsychotics segregated by gender. The high rates of sexual dysfunction and hyperprolactinemia detected corroborate the need to consider these aspects in clinical practice.

Safety Profile of Antipsychotic Drugs: Analysis Based on a Provincial Spontaneous Reporting Systems Database

Introduction: Antipsychotic drugs are the main therapy for schizophrenia and have been widely used in mental disorder fields. However, the research on the safety of antipsychotic drugs in the real-world is rare. The purpose of this research is to evaluate the safety of antipsychotic drugs based on real-world data. Methods: ADR reports collected by the Henan Adverse Drug Reaction Monitoring Center from 2016 to 2020 were analyzed. We described the safety of antipsychotic drugs by descriptive analysis and four signal mining methods. Meanwhile, the risk factors for serious adverse reactions of antipsychotics were identified. Results: A total of 3363 ADR reports related to antipsychotics were included. We found that the number of adverse drug reaction reports and the proportion of serious adverse reactions have increased year by year from 2016 to 2020. Most adverse drug reactions occurred within 3 months after taking the medicine. The symptoms caused by typical antipsychotics and atypical antipsychotics were different and dyskinesia was more common in typical antipsychotics. Most patients improved or recovered after treatment or intervention while only one patient had sequelae. Low-level hospitals, psychiatric hospitals, youth, and old age could increase the risk of serious adverse reactions. Four off-label signals were found through signal mining, including amisulpride-pollakiuria, ziprasidone-dyspnoea, quetiapine-urinary incontinence, olanzapine-hepatic function abnormal. Conclusion: We found that most ADRs occurred within 3 months after taking the medicine, so close observation was required for patients during the first 3 months of treatment. The ADRs of antipsychotics involved multiple organ-system damages but were not serious. It might be recommended to take alternative drugs after a serious ADR occurred. The symptoms caused by typical APDs and atypical APDs were different. For patients with typical APDs, dyskinesia was more common and should be given special attention. Statistics showed that low-level hospitals, psychiatric hospitals, youth, and old age were risk factors for serious ADRs. The four off-label signals obtained by signal mining should be paid special attention, including amisulpride-pollakiuria, ziprasidone-dyspnoea, quetiapine-urinary incontinence, and olanzapine-hepatic function abnormal.

Potential Side Effects and Adverse Events of Antipsychotic Use for Residents With Dementia in Assisted Living: Implications for Prescribers, Staff, and Families

Antipsychotic medications are frequently prescribed to assisted living (AL) residents who have dementia, although there is a lack of information about the potential side effects and adverse events of these medications among this population. Oversight and monitoring by family members is an important component of AL care, and it is important to understand family awareness of antipsychotic use and reports of potential side effects and adverse events. This cross-sectional, descriptive study of family members of 283 residents with dementia receiving antipsychotic medications in 91 AL communities found high rates (93%) of symptoms that could be potential side effects and a 6% rate of potential adverse events. The majority of families were aware their relative was taking an antipsychotic. Findings suggest that obtaining family perspectives of potential side effects and adverse events related to medication use may contribute to overall improvement in the safety of AL residents living with dementia.

Factors influencing the outcome of integrated therapy approach in schizophrenia: A narrative review of the literature

The integration of pharmacotherapy with psychosocial interventions has an important role to play in the improvement of functional outcome of subjects with schizophrenia (SCZ), in all stages of the disorder. It is essential for the adequate management of unmet therapeutic needs, such as negative symptoms and cognitive dysfunctions which account for most of the functional impairment of subjects with SCZ and do not respond to available antipsychotics. Enhancing the knowledge on factors involved in the effectiveness of integrated treatment plans is an important step forward for SCZ care. This review aims to identify factors that might influence the impact of integrated treatments on functional outcome. Most studies on the impact of psychosocial treatments on functional outcome of subjects with SCZ did not control for the effect of prescribed antipsychotics or concomitant medications. However, several factors relevant to ongoing pharmacological treatment might influence the outcome of integrated therapy, with an impact on the adherence to treatment (e.g., therapeutic alliance and polypharmacotherapy) or on illness-related factors addressed by the psychosocial interventions (e.g., cognitive dysfunctions or motivational deficits). Indirect evidence suggests that treatment integration should consider the possible detrimental effects of different antipsychotics or concomitant medications on cognitive functions, as well as on secondary negative symptoms. Cognitive dysfunctions can interfere with participation to an integrated treatment plan and can be worsened by extrapyramidal or metabolic side effects of antipsychotics, or concomitant treatment with anticholinergics or benzodiazepines. Secondary negative symptoms, due to positive symptoms, sedation, extrapyramidal side effects or untreated depression, might cause early drop-out and poor adherence to treatment. Researchers and clinicians should examine all the above-mentioned factors and implement appropriate and personalized integrated treatments to improve the outcome of SCZ.

Polypharmacy prior to in-hospital cardiac arrest among patients with cardiopulmonary diseases: A pilot study

Background

Patterns of medication administration prior to in-hospital cardiac arrest (I-HCA) and the potential impact of these on patient outcomes is not well-established. Accordingly, types of medications administered in the 72 h prior to I-HCA were examined in relation to initial rhythms of I-HCA and survival.

Methods

A retrospective, pilot study was conducted among 96 patients who experienced I-HCA. Clinical characteristics and treatments including medications were extracted from electronic health records. Relative risk (RR) of medications or class of medications associated with the initial rhythms of I-HCA and return of spontaneous circulation (ROSC) were calculated.

Results

Two distinct sub-groups were identified that did not survive to hospital discharge (n = 31): 1) those who received either vasopressin/desmopressin (n = 16) and 2) those who received combinations of psychotherapeutic agents with anxiolytics, sedatives, and hypnotics (n = 15) prior to I-HCA. The risk of pulseless electrical activity and asystolic arrest was high in patients who received sympathomimetic agents alone or in combination with β-Adrenergic blocking agents, (RR = 1.40, 1.41, respectively). Vasopressin and a combination of vasopressin and fentanyl were associated with risk of unsuccessful ROSC (RR = 2.50, 2.38, respectively).

Conclusions

The types of medications administered during inpatient care may serve as a surrogate marker for identifying patients at risk of specific initial rhythms of I-HCA and survival.

Clinical validation of the self-reported Glasgow Antipsychotic Side-effect Scale using the clinician-rated UKU side-effect scale as gold standard reference

BACKGROUND

Antipsychotics are key for the treatment of psychotic and several non-psychotic disorders. Unfortunately, antipsychotic medications are associated with side effects, which may reduce quality of life and treatment adherence. Therefore, regular screening of antipsychotic side effects is essential. The Glasgow Antipsychotic Side-effect Scale is a patient self-report scale developed for this purpose. However, the Glasgow Antipsychotic Side-effect Scale has only been validated against another self-report side effect measure, which is suboptimal.

OBJECTIVE

We aimed to validate the Glasgow Antipsychotic Side-effect Scale using the clinician-rated Udvalg for Kliniske Undersøgelser side-effect rating scale as the gold standard reference.

RESULTS

81 antipsychotic-treated outpatients with schizophrenia-spectrum disorders (age = 42±13 years; males = 43%, schizophrenia = 77%, illness duration: median = 11 years) completed the Glasgow Antipsychotic Side-effect Scale and were subsequently scored on the Udvalg for Kliniske Undersøgelser by trained raters. Sensitivity, specificity, positive predictive value and negative predictive value were calculated for paired Glasgow Antipsychotic Side-effect Scale and Udvalg for Kliniske Undersøgelser items. Sensitivity of Glasgow Antipsychotic Side-effect Scale items ranged from 33-96%, with 19 (86%) having >75% sensitivity. Lowest sensitivity emerged for "nocturnal enuresis" (33%), "galactorrhea" (50%) and "hyperkinesia" 14-99%, with 14 items (64%) having >75% specificity, being lowest for "asthenia" (14%), "polyuria/polydipsia" (35%), "sedation" (41%), "akathisia" (53%), "dystonia" (65%), "hyperkinesia" (68%), "hypokinesia" (70%) and "accommodation" (70%). Positive predictive value ranged from 7-85%, with six items (27%) having a positive predictive value >75%. Negative predictive value ranged from 40-98%, with 21 items (95%) having a negative predictive value >75%. The mean time to complete the Glasgow Antipsychotic Side-effect Scale was 4±2 minutes.

CONCLUSION

The Glasgow Antipsychotic Side-effect Scale demonstrated satisfactory validity as a self-rated tool for antipsychotic side effects and may aid measurement-based care and decision-making.

The relationship between atypical antipsychotics drugs, QT interval prolongation, and torsades de pointes: implications for clinical use

Introduction: Increased mortality has been observed in patients with mental health disorders. Specifically, exposure to antipsychotic medications conveys a greater than 2 fold risk of sudden death, thought to be mediated through effects on QT prolongation and risk of torsades de pointes.Areas covered: We review the association between antipsychotic drugs and sudden cardiac death, the physiologic basis for these associations, assessment of patients at risk, and strategies to minimize risk of sudden cardiac death.Expert opinion: Despite the prevalence of antipsychotic medication use for many decades, there remain considerable challenges in reducing the associated risk of sudden cardiac death. A structured algorithm that incorporates patient clinical factors and antipsychotic drug factors may improve risk assessment and reduce the risk of adverse cardiac events. Future advancements in genetics and artificial intelligence may allow for enhanced risk stratification and predicting response (efficacy and adverse effects) to therapy.

The effectiveness of health behavior change interventions in managing physical health in people with a psychotic illness: A systematic review

PURPOSE

People living with psychotic illness disproportionately experience more comorbidities and have a markedly shorter life expectancy compared to the general population. This review evaluates the effectiveness of health behavior change interventions in improving health outcomes in this group.

DESIGN AND METHODS

All studies included objective physical health measures or health behaviors as the main outcome measures and experimental design with baseline and follow-up quantitative data. Only studies of moderate and strong quality were included. Narrative synthesis was undertaken.

FINDINGS

Included studies utilized a range of methodological designs and outcome measures. The majority reported significant intervention effect on most outcome measures.

PRACTICE IMPLICATIONS

Health behavior change interventions can be effective in improving health outcomes in people with psychotic illness, with the potential benefit of improved psychiatric outcomes.

Improving Access to Laboratory Monitoring in Individuals Living with Serious Mental Illness

Safe prescribing for persons with severe mental illness requires laboratory monitoring for psychotropic drug levels and metabolic side effects. Barriers to appropriate and timely monitoring increase when clients must obtain phlebotomy services at a separate facility. This quality improvement project was conducted within a program for assertive community treatment (PACT). Specific aims were to increase access to laboratory testing, improve efficiency, and lower costs by implementing on-site specimen collection. Outcomes, measured three months post-implementation, indicate that over half of all labs were obtained on-site, clients and staff were pleased with increased efficiencies, and costs were reduced by 37%.

Antipsychotic Treatment of Delirium in Critically Ill Children: A Retrospective Matched Cohort Study

OBJECTIVE

To describe the use of pharmacologic treatment in critically ill children treated according to a delirium protocol and compare those treated with antipsychotics to those treated non-pharmacologically.

METHODS>

The study included a retrospective matched cohort describing patients who were pharmacologically treated for delirium compared to those with delirium but not treated in a PICU from December 2013 to September 2015, using a delirium management protocol. Patients were matched by age, sex, diagnosis, mechanical ventilation (MV), and presence of delirium.

RESULTS

Of 1875 patients screened, 188 (10.03%) were positive for delirium. Of those, 15 patients (8%) were treated with an antipsychotic for delirium. Patients with delirium treated with antipsychotics were younger, had more delirium days (6 vs. 3, p=0.022), longer MV days (14 vs. 7, p=0.017), and longer PICU length of stay (34 vs. 16 days, p=0.029) than in the untreated group. Haloperidol, risperidone, and quetiapine were used in 9, 6, and 2 patients, respectively. Two patients were treated with multiple antipsychotics. Antipsychotic treatment was initiated on day 2 of delirium for 8 of 15 patients (53.3%). Ten patients in the treatment group had improved delirium scores by day 2 of treatment. No significant differences in sedation exposure between groups. No significant adverse effects were reported.

CONCLUSIONS

No significant adverse events seen in this small cohort of critically ill pediatric patients with delirium treated with antipsychotic therapy. Patients with early-onset delirium refractory to non-pharmacologic treatment may have a more effective response to antipsychotic therapy than patients with late-onset refractory delirium.

Attitudes of Italian Psychiatrists Toward the Evaluation of Physical Comorbidities and Sexual Dysfunction in Patients With Schizophrenia. Implications for Clinical Practice

Treatment guidelines for patients with schizophrenia recommend evaluating their risk of physical comorbidities, especially since these patients are known to have decreased life expectancy due to comorbidities. Therefore, to the authors' knowledge, this is the first national survey conducted to investigate how Italian psychiatrists deal with the risk of physical comorbidities and sexual dysfunction in patients with schizophrenia. A sample of 750 psychiatrists completed an ad hoc online survey investigating their decision making about performing blood tests, clinical and instrumental examinations, and scheduling follow-up appointments in relation to the different phases of the illness and possible pharmacological side effects. Compared to patients in therapeutic continuation, those diagnosed for the first time and those who received a therapeutic change were visited more frequently (every 15 to 17 days vs. every 40 days, respectively), and were more regularly prescribed blood tests and instrumental examinations (every 4.2 to 4.4 months vs. every 9 months, respectively). There was a high interest in the surveillance of cardiometabolic risk. In 54% of patients, prolactin testing was not requested before starting an antipsychotic. In terms of specialist referrals, only 5% of surveyed psychiatrists "never" sought for additional counseling. There was little attention given to sexual functioning assessment based on the survey results about patients' daily life and with regard to deciding to prescribe additional examinations. In fact, only up to 3% of psychiatrists reported assessing sexual functioning using specific psychometric tests. In summary, Italian psychiatrists describes themselves as careful healthcare providers for the physical illnesses of patients with schizophrenia but with several shortcomings. For instance, clinical attention toward patients' sexual and reproductive healthcare needs remains a challenge. Psychiatrists should take the lead for the integrated education, assessment, and care of medical needs of their patients with mental illness. Based on the results of this survey, the authors also believe that a future challenge for the management of patients with mental illness will be the classification of patients based on their risk of comorbidities, to help ensure optimal healthcare provision for those at greater risk of other illnesses.

A phenotypic Caenorhabditis elegans screen identifies a selective suppressor of antipsychotic-induced hyperphagia

Antipsychotic (AP) drugs are used to treat psychiatric disorders but are associated with significant weight gain and metabolic disease. Increased food intake (hyperphagia) appears to be a driving force by which APs induce weight gain but the mechanisms are poorly understood. Here we report that administration of APs to C. elegans induces hyperphagia by a mechanism that is genetically distinct from basal food intake. We exploit this finding to screen for adjuvant drugs that suppress AP-induced hyperphagia in C. elegans and mice. In mice AP-induced hyperphagia is associated with a unique hypothalamic gene expression signature that is abrogated by adjuvant drug treatment. Genetic analysis of this signature using C. elegans identifies two transcription factors, nhr-25/Nr5a2 and nfyb-1/NFYB to be required for AP-induced hyperphagia. Our study reveals that AP-induced hyperphagia can be selectively suppressed without affecting basal food intake allowing for novel drug discovery strategies to combat AP-induced metabolic side effects.

Synthesis and Biological Evaluation of Fused Tricyclic Heterocycle Piperazine (Piperidine) Derivatives As Potential Multireceptor Atypical Antipsychotics

Herein, a novel series of multireceptor ligands was developed as polypharmacological antipsychotic agents using the designed multiple ligand approach between dopamine receptors and serotonin receptors. Among them, compound 47 possessed unique pharmacological features, exhibiting high affinities for D₂, D₃, 5-HT_1A, 5-HT_2A, and 5-HT₆ receptors and low efficacy at the off-target receptors (5-HT_2C, histamine H₁, and adrenergic α₁ receptor). Compound 47 showed dose-dependent inhibition of apomorphine- and MK-801-induced motor behavior, and the conditioned avoidance response with low cataleptic effect. Moreover, compound 47 resulted nonsignificantly serum prolactin levels and weight gain change compared with risperidone. Additionally, compound 47 possessed a favorable pharmacokinetic profile with oral bioavailability of 58.8% in rats. Furthermore, compound 47 displayed procognition properties in a novel object recognition task in rats. Taken together, compound 47 may constitute a novel class of atypical antipsychotic drugs for schizophrenia.

CYP2D6 genotypes in revolving door patients with bipolar disorders: A case series

RATIONALE

In psychiatric disorders, interindividual differences in cytochrome P450 (CYP)2D6 (CYP2D6) enzymatic activity could be responsible of adverse drug reactions (ADRs) and therapeutic failures (TFs) for CYP2D6-metabolized drugs, contributing to the periodical hospital readmissions of the revolving door (RD) condition.

PATIENT CONCERNS

We investigated CYP2D6 genotypes in a controlled series of 5 consecutive RD patients with Bipolar Disorder (BD).

DIAGNOSES

Psychiatric patients affected by Bipolar Disorder.

INTERVENTIONS

We defined TFs as a difference at the Brief Psychiatric Rating Scale score ΔBPRS < 25% at each 1-week of stable treatment, and ADRs as the onset of extrapyramidal symptoms and/or metabolic impairment with weight gain.

OUTCOMES

At 3 months, a mean number of 2.75 ± 1.26 ADR and a mean ΔBPRS score of 16.07 ± 0.05% were observed. At 6 months of follow-up, compared to the only patient without BD (ΔBPRS < 32.10%), BD patients (n = 4) showed TFs (ΔBPRS < 25%). CYP2D6 genotyping revealed intermediate metabolizer phenotypes for BD patients and an extensive metabolizer phenotype for the patient without BD. In BD patients, the ratio of drugs maintained/discontinued for TFs or ADRs was 1.75 for non-CYP2D6 versus 0.33 for CYP2D6 interacting drugs, while the proportion of ADR:TF was 0:4 versus 6:3.

LESSONS

Our findings may suggest that CYP2D6 clinically relevant genotypes may be involved in the unwanted outcomes observed in RD patients with BD.

ADHD is associated with migraine: a systematic review and meta-analysis

An association between primary headaches and attention-deficit/hyperactivity disorder (ADHD) has long been suggested. Moreover, headache is regarded as a common side effect of stimulants, the most effective treatment for ADHD. So far, no systematic review has evaluated the potential association between ADHD and headache. We performed a systematic review of the literature and a meta-analysis of all reported studies on ADHD and primary headaches. Our analysis showed a positive association between ADHD and migraine (OR 1.322, 95% CI 1.018-1717, p value 0.036), but not with tension-type headache. There is a significant association between migraine and ADHD. The mechanisms underlying this association remain to be elucidated, warranting further studies.

A 6-Month Prospective Trial of a Personalized Behavioral Intervention + Long-Acting Injectable Antipsychotic in Individuals With Schizophrenia at Risk of Treatment Nonadherence and Homelessness

PURPOSE

Long-acting injectable antipsychotics (LAI) can optimize adherence for high-risk serious mental illness (SMI). This customized adherence-enhancement approach delivered by social worker interventionists was combined with LAI (CAE-L) of paliperidone palmitate for homeless, poorly adherent individuals with SMI.

METHODS

This 6-month prospective, uncontrolled trial of CAE-L in 30 recently homeless individuals with SMI assessed adherence using the Tablets Routine Questionnaire, injection frequency, and SMI symptoms measured by the Positive and Negative Syndrome Scale, Brief Psychiatric Rating Scale, and Clinical Global Impressions. The Social and Occupational Functioning Assessment Scale measured social function. Standardized scales assessed extrapyramidal effects.

FINDINGS

Patients' mean age was 43.6 (SD, 9.53) years, and they were mainly minorities (86.7% African American) and single/never married (72.4%). Rate of substance abuse within the past year was 40.0%, and rate of incarceration within the past 6 months was 32.1%. Four participants (13.3%) terminated the study prematurely. Customized adherence enhancement + LAI was associated with good adherence to LAI (92.9%) and improved adherence with oral drug as measured by Tablets Routine Questionnaire (P = 0.02). There were significant improvements in Positive and Negative Syndrome Scale (P < 0.01), Brief Psychiatric Rating Scale (P < 0.001), Clinical Global Impressions (P = 0.003), and Social and Occupational Functioning Assessment Scale (P = 0.005). There were no significant extrapyramidal effects.

IMPLICATIONS

While findings must be tempered by the methodological limitations, CAE-L seems associated with multiple domains of improvement in homeless/recently homeless individuals with SMI. Adverse effects limit tolerability in some individuals, and not all will remain engaged. However, LAI combined with a patient-centered behavioral approach can improve outcomes for some high-risk individuals with SMI.

The Place of Antipsychotics in the Therapy of Anxiety Disorders and Obsessive-Compulsive Disorders

PURPOSE OF REVIEW

The purpose of this review was to assess and present the findings up to this date on the efficacy of antipsychotics in the treatment of generalized anxiety disorders (GAD), social anxiety disorders (SAD), panic disorders (PD), and obsessive-compulsive disorders (OCD), mostly based on published randomized controlled trials (RCTs) or on open-label studies when RCT were lacking.

RECENT FINDINGS

Quetiapine could be recommended in patients with GAD. The efficacy of aripiprazole in two open-label studies on patients with antidepressant-refractory GAD should be assessed in RCTs. Despite preliminary positive results in open studies, there are currently no strong evidence for the effectiveness of antipsychotics in refractory SAD and in refractory PD. Conversely, risperidone and aripiprazole can be used for the treatment of refractory OCD as augmentation agents to antidepressants. Contrary to SAD and PD, this review found evidence for the use of second-generation antipsychotics in GAD and OCD. Otherwise, first-generation antipsychotics cannot be recommended in anxiety disorders and OCD.

Pharmacotherapy for Weight Management in the VHA

Weight management medications (WMM) are underutilized as an adjunct to behavioral and lifestyle interventions. In fiscal years 2014-2015, a total of approximately 2500 veterans-a mere 2% of veterans receiving care from the Veterans Health Administration (VHA)-eligible for a WMM received a prescription for one. A State of the Art Conference on Weight Management workgroup, focused on pharmacotherapy, developed evidence-based recommendations and strategies to foster the appropriate use of WMM in the VHA. The workgroup identified patient, prescriber, and health system barriers to and facilitators for prescribing WMM. Barriers included patient and provider concerns about medication safety and efficacy, limited involvement of primary care, restrictive medication criteria for use (CFU), and skepticism among providers regarding the safety and efficacy of WMM and the perception of obesity as a disease. Potential facilitators for removing barriers included patient and provider education about WMM and the health benefits of weight loss, increased engagement of primary care providers in weight management, relaxation of the CFU, and creation of a system to help patients navigate through weight management treatment options. Several research questions were framed with regard to WMM in general, and specifically to the care of obese veterans. While some of the workgroup's conclusions reflect issues specific to the VHA, many are likely to be applicable to other health organizations.

A Randomized, Controlled Multisite Study of Behavioral Interventions for Veterans with Mental Illness and Antipsychotic Medication-Associated Obesity

BACKGROUND

Weight gain and other metabolic sequelae of antipsychotic medications can lead to medication non-adherence, reduced quality of life, increased costs, and premature mortality. Of the approaches to address this, behavioral interventions are less invasive, cost less, and can result in sustained long-term benefits.

OBJECTIVE

We investigated behavioral weight management interventions for veterans with mental illness across four medical centers within the Veterans Affairs (VA) Healthcare System.

DESIGN

We conducted a 12-month, multi-site extension of our previous randomized, controlled study, comparing treatment and control groups.

PARTICIPANTS

Veterans (and some non-veteran women) diagnosed with mental illness, overweight (defined as having a BMI over 25), and required ongoing antipsychotic therapy.

INTERVENTIONS

One group received "Lifestyle Balance" (LB; modified from the Diabetes Prevention Program) consisting of classes and individual nutritional counseling with a dietitian. A second group received less intensive "Usual Care" (UC) consisting of weight monitoring and provision of self-help.

MAIN MEASURES

Participants completed anthropometric and nutrition assessments weekly for 8 weeks, then monthly. Psychiatric, behavioral, and physical assessments were conducted at baseline and months 2, 6, and 12. Metabolic and lipid laboratory tests were performed quarterly.

KEY RESULTS

Participants in both groups lost weight. LB participants had a greater decrease in average waist circumference [F(1,1244) = 11.9, p < 0.001] and percent body fat [F(1,1121) = 4.3, p = 0.038]. Controlling for gender yielded statistically significant changes between groups in BMI [F(1,1246) = 13.9, p < 0.001]. Waist circumference and percent body fat decreased for LB women [F(1,1243) = 22.5, p < 0.001 and F(1,1221) = 4.8, p = 0.029, respectively]. The majority of LB participants kept food and activity journals (92%), and average daily calorie intake decreased from 2055 to 1650 during the study (p < 0.001).

CONCLUSIONS

Behavioral interventions specifically designed for individuals with mental illness can be effective for weight loss and improve dietary behaviors. "Lifestyle Balance" integrates well with VA healthcare's patient-centered "Whole Health" approach. ClinicalTrials.gov identifier NCT01052714.