Adiposity, Hepatic Triglyceride, and Carotid Intima Media Thickness During Behavioral Weight Loss Treatment in Antipsychotic-Treated Youth: A Randomized Pilot Study

A scoping review of physical activity interventions in youth attending child and adolescent mental health services

BACKGROUND

There has been an international effort to improve physical health in general and in those with mental illness. Physical activity (PA) may be beneficial as an adjunctive treatment for mental health disorders and to improve physical well-being.

AIMS

The objective of this scoping review is to understand the extent and type of evidence in relation to PA interventions offered in child and adolescent mental health services (CAMHS). Eligibility was determined using the Population, Concept, Context framework. Studies were included if the participants were under 18 years old, attending CAMHS and where PA interventions were offered.

METHODS

PubMed, MEDLINE, Embase, Cochrane Library, CINAHL, PsycINFO and SportDiscus were searched without language or date restrictions. Titles and abstracts, followed by full texts, were screened by two independent reviewers. Two reviewers carried out data extraction, and discrepancies in any of these processes were resolved in consultation with a third reviewer.

RESULTS

After 2213 non-duplicate titles and abstracts were screened, 2090 were excluded and 123 full texts were screened. Seventeen studies met inclusion criteria. Included studies demonstrated PA interventions to be effective in reducing depressive symptoms and improving psychosocial functioning. While no study reported significant changes in anthropometric measurements, 2 studies demonstrated increased aerobic fitness.

CONCLUSION

Evidence that PA interventions are being offered in CAMHS worldwide is limited. Included studies demonstrate potential benefits in depressive symptoms, psychosocial functioning, self-esteem and aerobic fitness in youth attending CAMHS. Future research should identify effective ways to incorporate exercise interventions in CAMHS and evaluate long-term benefits.

Antipsychotic-Induced Weight Gain in Severe Mental Illness: Risk Factors and Special Considerations

PURPOSE OF REVIEW

Weight gain is a disconcerting issue experienced by patients treated with antipsychotics (APs). This review summarizes current knowledge on the prevalence, etiology, and risk factors for antipsychotic-induced weight gain (AIWG), and evidence for interventions, including special considerations.

RECENT FINDINGS

Predisposing risk factors for AIWG include lack of prior AP exposure, sex, and age. AP dose and duration of exposure are additional treatment-related factors that may contribute to this issue. Among current approaches to target AIWG, metformin has the most evidence to support its use, and this is increasingly reflected in clinical guidelines. While lifestyle approaches are recommended, cost-effectiveness and scalability represent limitations. More research is needed to identify newer treatment options and inform clinical recommendations for AIWG. Concerns around scope of practice in psychiatry to address AIWG and related comorbidities will require enhanced training opportunities and interdisciplinary collaborations, as well as updated position statements/practice guidelines emphasizing prevention.

Evidence Base Update on Behavioral Treatments for Overweight and Obesity in Children and Adolescents

OBJECTIVE

This review provides an update to a previous Evidence Base Update addressing behavioral treatments for overweight and obesity in children and adolescents.

METHOD

Articles were identified through a systematic search of the biomedical literature in PubMed/MEDLINE (1946-), Elsevier EMBASE (1947-), SCOPUS (1823-), Clarivate Web of Science Core Collection (WOS, 1900-), PsycINFO (1800-), The Cochrane Library and Clinicaltrials.gov published between June 2014 and August 2022.

RESULTS

Family-based treatment (FBT) remains a well-established treatment for overweight and obesity in children and is now well-established in adolescents and toddlers. Parent-only behavioral treatment remains well-established in children and is now well-established among adolescents and children. Possibly effective treatments continue to include FBT-parent only for adolescents, and behavioral weight loss (BWL) with a family component for adolescents, children, and toddlers. Several variations of FBT and BWL can now be considered possibly effective including FBT+motivational interviewing, FBT+social facilitation maintenance, group-based FBT, low-dose FBT, BWL+stress management, and camp-based BWL. Cognitive behavioral treatment (CBT) for adolescents also met criteria for possibly effective treatments. Current research has also established that behavioral treatments can be effectively delivered in alternative settings (e.g. primary care) and through alternative mediums (e.g. telehealth).

CONCLUSIONS

Research continues to support the use of multicomponent lifestyle interventions in accordance with recent recommendations from the American Academy of Pediatrics, the American Psychological Association, and the United State Preventative Services Task Force. However, more work is needed to ensure appropriate access for children with comorbid medical and psychiatric disorders and children from socially, politically, and economically marginalized groups.

Use of an Interactive Obesity Treatment Approach in Individuals With Severe Mental Illness: Feasibility, Acceptability, and Proposed Engagement Criteria

BACKGROUND

Digital and mobile health interventions are increasingly being used to support healthy lifestyle change, including in certain high-risk populations such as those with severe mental illnesses (SMIs). Life expectancy in this population lags 15 years behind counterparts in the general population, primarily due to obesity-related health conditions.

OBJECTIVE

We tested the feasibility and usability of a 12-week interactive obesity treatment approach (iOTA) to adults with chronic SMIs (depression, bipolar disorder and schizophrenia spectrum disorder) receiving treatment in community settings. The iOTA incorporates short message service (SMS) text messages to supplement monthly in-person health coaching.

METHODS

Factors hypothesized to be associated with weight change were illness severity and treatment engagement. Severe psychiatric symptoms were defined as baseline Clinical Global Impression severity score of >5. Criterion engagement was defined as a text messaging response rate >80% during the first 4 weeks of treatment. Disordered eating, assessed with the Loss of Control Over Eating Scores, was also evaluated. Participants provided qualitative data, further informing assessment of intervention feasibility, usability, and acceptability.

RESULTS

A total of 26 participants were enrolled. The mean age was 48.5 (SD 15.67) years; 40% (10/26) were Black and 60% (15/26) female. Participants with lower symptom severity and adequate engagement demonstrated significantly decreased weight (F1,16=22.54, P<.001). Conversely, high symptom severity and lower text message response rates were associated with trend-level increases in weight (F1,7=4.33, P=.08). Loss-of-control eating was not observed to impact treatment outcome. Participants voiced preference for combination of live health coaching and text messaging, expressing desire for personalized message content.

CONCLUSIONS

These results demonstrate the feasibility of delivering an adapted iOTA to SMI patients receiving care in community settings and suggest testable criteria for defining sufficient treatment engagement and psychiatric symptom severity, two factors known to impact weight loss outcomes. These important findings suggest specific adaptations may be needed for optimal treatment outcomes in individuals with SMI.

Weight management interventions that include dietary components for young people with chronic health care needs: A systematic review

AIMS

To identify and describe weight management interventions that include a dietary component for young people with chronic healthcare needs and overweight or obesity and their effect on body mass index (BMI) or weight.

METHODS

Six databases were searched in 2017 and 2020 for experimental studies in English: Ovid MEDLINE, Ovid Embase, Ovid AMED, EBSCO CINAHL, Scopus and Cochrane Central Register of Controlled Trials and Database of Systematic Reviews. Two independent reviewers conducted data extraction and quality assessment using the Cochrane Risk of Bias tool. Eligible studies included young people with chronic healthcare needs ≤18 years with overweight or obesity with an intervention that included a dietary component. Eligible outcomes were BMI or weight. Data were synthesised narratively.

RESULTS

The search identified 15 293 references, 12 studies were included (randomised controlled trials n = 5, before-after comparisons n = 7). Participant diagnoses were neurodevelopmental disabilities (n = 5) and mental illness (n = 1); survivors of cancers or tumours (n = 4); congenital heart disease (n = 1) and; migraine (n = 1). No studies addressed weight management in physical disabilities. Eight studies demonstrated a significant reduction in BMI or weight. Of these, most interventions used dietary counselling or an energy deficit, were family-focused, multicomponent and delivered by a multidisciplinary team including dietitians. A high risk of bias was detected across studies.

CONCLUSIONS

There is limited high-quality evidence about effective dietary solutions for the management of overweight and obesity for young people with chronic healthcare needs. While more research is required, dietary management appears to be important to manage weight in these populations.

Improving the physical health of young people with early psychosis with lifestyle interventions: Scoping review

People with mental illness experience a shorter life expectancy compared to the general population. Poor physical health trajectory emerges following the onset of psychosis and is further compounded by the initiation of antipsychotic treatment. Young people are particularly at risk as the onset of mental illness mostly occurs between the age of 12 and 25 years. This represents a crucial period for early intervention to prevent a physical ill health trajectory. Furthermore, those who are at ultra-high risk for psychosis should also be targeted for early intervention. Lifestyle interventions have been identified as the first-line physical health promotion practice for improving the physical health of people with severe mental illness. The aim of this study was to conduct a scoping review following the JBI methodological guidance on scoping reviews to explore the current literature on lifestyle intervention trialled for early psychosis, including first-episode psychosis and those who are at ultra-high risk for psychosis. This review also explores the extent of literature examining physical health literacy in this specific population. The literature search was conducted on Medline, Embase, PsycINFO and Scopus. Twenty-two studies were included for the purpose of this scoping review, 21 of which examined the effects of lifestyle interventions and one of which reported on physical health literacy. This scoping review indicates the need for co-designed lifestyle interventions with the involvement of service users, families and carers and a focus on promoting physical health literacy, social support, and an incorporation of a health behaviour change model focus on promoting autonomous motivation. The findings of this study can inform future development of a novel co-designed lifestyle intervention for the targeted population.

The Burden of Antipsychotic-Induced Weight Gain and Metabolic Syndrome in Children

Antipsychotic medications are critical to child and adolescent psychiatry, from the stabilization of psychotic disorders like schizophrenia, bipolar disorder, and psychotic depression to behavioral treatment of autism spectrum disorder, tic disorders, and pediatric aggression. While effective, these medications carry serious risk of adverse events-most commonly, weight gain and cardiometabolic abnormalities. Negative metabolic consequences affect up to 60% of patients and present a major obstacle to long-term treatment. Since antipsychotics are often chronically prescribed beginning in childhood, cardiometabolic risk accumulates. An increased susceptibility to antipsychotic-induced weight gain (AIWG) has been repeatedly documented in children, particularly rapid weight gain. Associated cardiometabolic abnormalities include central obesity, insulin resistance, dyslipidemia, and systemic inflammation. Lifestyle interventions and medications such as metformin have been proposed to reduce risk but remain limited in efficacy. Furthermore, antipsychotic medications touted to be weight-neutral in adults can cause substantial weight gain in children. A better understanding of the biological underpinnings of AIWG could inform targeted and potentially more fruitful treatments; however, little is known about the underlying mechanism. As yet, modest genetic studies have nominated a few risk genes that explain only a small percentage of the risk. Recent investigations have begun to explore novel potential mechanisms of AIWG, including a role for gut microbiota and microbial metabolites. This article reviews the problem of AIWG and AP metabolic side effects in pediatric populations, proposed mechanisms underlying this serious side effect, and strategies to mitigate adverse impact. We suggest future directions for research efforts that may advance the field and lead to improved clinical interventions.

A Smartphone-Based Technique to Detect Dynamic User Preferences for Tailoring Behavioral Interventions: Observational Utility Study of Ecological Daily Needs Assessment

BACKGROUND

Mobile health apps are promising vehicles for delivering scalable health behavior change interventions to populations that are otherwise difficult to reach and engage, such as young adults with psychiatric conditions. To improve uptake and sustain consumer engagement, mobile health interventions need to be responsive to individuals' needs and preferences, which may change over time. We previously created an ecological daily needs assessment to capture microprocesses influencing user needs and preferences for mobile health treatment adaptation.

OBJECTIVE

The objective of our study was to test the utility of a needs assessment anchored within a mobile app to capture individualized, contextually relevant user needs and preferences within the framework of a weight management mobile health app.

METHODS

Participants with an iOS device could download the study app via the study website or links from social media. In this fully remote study, we screened, obtained informed consent from, and enrolled participants through the mobile app. The mobile health framework included daily health goal setting and self-monitoring, with up to 6 daily prompts to determine in-the-moment needs and preferences for mobile health-assisted health behavior change.

RESULTS

A total of 24 participants downloaded the app and provided e-consent (22 female; 2 male), with 23 participants responding to at least one prompt over 2 weeks. The mean length of engagement was 5.6 (SD 4.7) days, with a mean of 2.8 (1.1) responses per day. We observed individually dynamic needs and preferences, illustrating daily variability within and between individuals. Qualitative feedback indicated preferences for self-adapting features, simplified self-monitoring, and the ability to personalize app-generated message timing and content.

CONCLUSIONS

The technique provided an individually dynamic and contextually relevant alternative and complement to traditional needs assessment for assessing individually dynamic user needs and preferences during treatment development or adaptation. The results of this utility study suggest the importance of personalization and learning algorithms for sustaining app engagement in young adults with psychiatric conditions. Further study in broader user populations is needed.

Psychopharmacologic Treatment of Schizophrenia in Adolescents and Children

An increasing number of antipsychotic medications have demonstrated efficacy in randomized placebo-controlled trials in the treatment of children and adolescents with schizophrenia. This review summarizes and synthesizes relevant antipsychotic medication studies, with particular emphasis on second-generation agents, and discusses other clinical considerations that may influence medication selection. With the exception of clozapine demonstrating superior efficacy in the improvement of psychotic symptoms in treatment-resistant patients, many antipsychotic agents have been shown to be similarly efficacious, including first-generation medications. Consideration of the side-effect profile, which can differ substantially from medication to medication, is essential when choosing treatment options.