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

Risk factors, prevention and treatment of weight gain associated with the use of antidepressants and antipsychotics: a state-of-the-art clinical review

INTRODUCTION

People with severe mental illness have poor cardiometabolic health. Commonly used antidepressants and antipsychotics frequently lead to weight gain, which may further contribute to adverse cardiovascular outcomes.

AREAS COVERED

We searched MEDLINE up to April 2023 for umbrella reviews, (network-)meta-analyses, trials and cohort studies on risk factors, prevention and treatment strategies of weight gain associated with antidepressants/antipsychotics. We developed 10 clinical recommendations.

EXPERT OPINION

To prevent, manage, and treat antidepressant/antipsychotic-related weight gain, we recommend i) assessing risk factors for obesity before treatment, ii) monitoring metabolic health at baseline and regularly during follow-up, iii) offering lifestyle interventions including regular exercise and healthy diet based on patient preference to optimize motivation, iv) considering first-line psychotherapy for mild-moderate depression and anxiety disorders, v)choosing medications based on medications' and patient's weight gain risk, vi) choosing medications based on acute vs long-term treatment, vii) using effective, tolerated medications, viii) switching to less weight-inducing antipsychotics/antidepressants where possible, ix) using early weight gain as a predictor of further weight gain to inform the timing of intervention/switch options, and x) considering adding metformin or glucagon-like peptide-1 receptor agonists, or topiramate(second-line due to potential adverse cognitive effects) to antipsychotics, or aripiprazole to clozapine or olanzapine.

Adherence Rates and Barriers to Second-Generation Antipsychotic Medication Use in Youth with Bipolar Spectrum Disorders Who Have Overweight/Obesity

Objective: Youth with bipolar spectrum disorders (BSD) are frequently prescribed second-generation antipsychotics (SGAs). Nonadherence to treatment often results in increased mood symptoms and diminished quality of life. We examined SGA adherence rates and adherence barriers among youth who have overweight/obesity and are diagnosed with BSD enrolled in a multisite pragmatic clinical trial. Methods: SGA adherence and adherence barriers at baseline via patient- and caregiver report was assessed. Adherence was defined as taking ≥70% of prescribed SGA doses in the past week. The weighted Kappa statistic was used to measure child-caregiver agreement about adherence rates, barriers, and caregiver assistance. Regression analyses were used to examine associations of caregiver assistance, age, sex, race, insurance status, dosing frequency, and number of concomitant medications with adherence. Barriers to adherence were analyzed separately for youth and their caregivers, using logistic regression to assess associations between informant-reported barriers and informant-reported adherence. Results: Participants included 1485 patients and/or caregivers. At baseline, 88.6% of patients self-reported as adherent; 92.0% of caregivers reported their child was adherent. Concordance between patients and caregivers was moderate (k = 0.42). Approximately, 50% of the sample reported no adherence barriers. Frequently endorsed barriers included forgetting, side effects, being embarrassed to take medications, and preferring to do something else. Concordance between informants regarding adherence barriers was weak (k = 0.05-0.36). Patients and caregivers who did not endorse adherence barriers reported higher adherence than those who endorsed barriers. Male sex and having once daily dosing of medications were associated with lower adherence. Discussion: One-week patient- and caregiver-reported adherence was high in this sample. Half of the sample reported adherence barriers. Most commonly endorsed barriers were forgetting, side effects, being embarrassed, and preferring to do something else. Caregivers and patients have unique perspectives regarding adherence barriers. Understanding and addressing treatment barriers in clinical practice may facilitate adherence.

Parent Intention to Participate in an Online Intervention to Enhance Health Behavior Change Among Youth Treated with Psychotropic Medication Who are Overweight or Obese: An Application of the Theory of Planned Behavior

Youth with mental health disorders (MHD), particularly those who take psychotropic medications, are at increased risk of being overweight or obese (OW/OB) when compared to typical youth. Parents are important resources for interventions addressing OW/OB. However, parents of youth with MHD may face challenges that require interventions designed to address their needs. Prior to investing research funding in the development of interventions for this group, research is needed to understand factors associated with parents' decisions to enroll in these programs. The theory of planned behavior (TPB) provided a framework for examining parents' salient beliefs, direct attitudes, and intention to enroll in a hypothetical online healthy lifestyle intervention for their youth (ages 11-17) with OW/OB and treated with psychotropic medication. Parents who were enrolled in the study (n = 84) completed demographic questionnaires and a TPB questionnaire which was constructed for this study. A confirmatory factor analysis (CFA) of the direct attitude (i.e., attitude toward the behavior, subjective norm, perceived behavioral control) questions generally supported the three-factor model (i.e., RMSEA = .07, 90% CI .03-.11, p = .18; CFI = .96, SRMR = .06). Results from a multiple regression analysis demonstrated that direct attitudes predicted parent intention to participate in an online healthy lifestyle intervention for this sample of youth accounting for 84% of variance. In this preliminary study, the TPB appears to be a promising framework for understanding direct attitudes associated with parent intentions toward intervention participation in this population of youth. Interventions for parents of youth with OW/OB who are prescribed psychotropic medication should consider addressing these direct attitudes to improve intention.

Efficacy of topiramate in reducing second-generation antipsychotic-associated weight gain among children: A systematic review and meta-analysis

AIMS

To conduct a systematic review and meta-analysis with the aim of synthesizing existing data on the efficacy and safety of topiramate as an adjunctive treatment for reducing second-generation antipsychotic (SGA)-associated weight gain in children aged 4-18 years.

METHODS

We conducted a comprehensive search of PubMed, Embase, PsychNet and Web of Science from time of their inception up to 12 February 2024, including randomized controlled trials that compared SGA treatment with and without topiramate co-administration in children. The primary outcomes were changes in body weight and body mass index (BMI). Heterogeneity was assessed using I2 statistics.

RESULTS

This systematic review included five randomized trials, totalling 139 participants (43.9% female; mean [SD] age 11.9 [3.5] years). Four of these trials were included in the meta-analysis, comprising 116 subjects. We found that topiramate was significantly effective both in reducing SGA-associated weight gain, with a mean difference of -2.80 kg (95% confidence interval [CI] -5.28 to -0.31; p = 0.037, I2 = 86.7%) and a standardized mean difference (SMD) of -1.33 (95% CI -2.14 to -0.51; p = 0.014, I2 = 31.7%), and in reducing BMI change compared to placebo (SMD -1.90, 95% CI -3.09 to -0.70; p = 0.02, I2 = 0%). Sedation risk was lower with topiramate than with placebo (odds ratio 0.19, 95% CI 0.11-0.32; p < 0.01, I2 = 0%). No significant differences were found in dropouts, any other side effects, and metabolic parameters, such as triglycerides, total cholesterol, low-density lipoprotein, high-density lipoprotein, and glucose. None of the included studies reported assessments on cognitive side effects.

CONCLUSION

This meta-analysis suggests that topiramate is an effective and safe option for mitigating SGA-associated weight gain in children.

Modification of an Intervention to Improve Adherence in Adolescents and Young Adults With Bipolar Disorder

Objective

Managing bipolar disorder (BD) is particularly challenging for adolescents and young adults (AYAs) ages 16 to 21. Few interventions exist that address self-management in AYAs with BD. Thus, this study aimed to modify the customized adherence enhancement behavioral intervention for AYAs through an iterative, patient-centered process.

Method

The Obesity-Related Behavioral Intervention Trials (ORBIT) model was used for intervention development. In phase 1a, adherence barriers and facilitators were identified to refine intervention content. Phase 1b occurred following curriculum modification to ensure that the modified intervention was relevant and usable by the target population. Data were collected via focus groups and interviews with AYAs with BD, parents, and providers. Transcripts were analyzed using directed content analysis.

Results

Phase 1a included focus groups/interviews with AYAs (n = 10), parents (n = 4), and providers (n = 9) who described the difficulties and successes in managing BD symptoms, improving adherence, and transitioning care from caregivers. Phase 1b included an advisory board composed of 8 phase 1a participants who provided feedback on modified session activities, module delivery, and curriculum. Phase 1b involved usability testing with new participants (n = 8), revealing the need for modifiable language based on developmental level, more engaging visual images, and confirmation that topics were salient to AYAs with BD.

Conclusion

Though sample sizes were small and not representative of the population of AYAs with BD, the ORBIT methodology informed the adaptation of the customized adherence enhancement intervention to improve adherence in AYAs with BD. Important next steps are to conduct a pilot randomized clinical trial of customized adherence enhancement for AYAs.

Updated strategies for the management of poor medication adherence in patients with bipolar disorder

INTRODUCTION

Suboptimal adherence is a well-established, pervasive problem in individuals with bipolar disorder (BD) causing disability, suffering, and cost.

AREAS COVERED

This review covers new research since January 2016 regarding internal (patient-centered) and external (system level) barriers and facilitators to adherence. Measures of adherence, the efficacy of psychosocial adherence enhancement interventions in individuals with BD, and, finally, novel delivery systems for BD medication are also covered. Measures of adherence continue to fall broadly into objective measures (i.e. drug levels) and more subjective, self-report measures and a combination of these likely provides the most comprehensive picture. Efficacious components of psychosocial adherence enhancement interventions include psychoeducation, motivational interviewing, and cognitive behavioral strategies, yet methods for delivery vary. Long-acting injectable (LAI) medications for BD are the drug delivery system with the most promise for BD. Combining psychosocial components with novel drug delivery systems has the potential for establishing and maintaining medication adherence.

EXPERT OPINION

Psychosocial interventions improve adherence in individuals with BD. Psychoeducation is a necessary but not sufficient component in psychosocial interventions. LAIs should be considered earlier for adherence improvement than many treatment guidelines currently suggest. Comparative studies are lacking as is research into novel systems of medication delivery.

Parental Factors Associated with Child or Adolescent Medication Adherence: A Systematic Review

Medication adherence, especially among children and adolescents with psychiatric disorders, is often seen as a major treatment challenge. The purpose of this study is to systematically review studies addressing specific aspects of parental factors that are positively or negatively associated with medication adherence among children and adolescents with psychiatric disorders. A systematic literature search of English language publications, from inception through December 2021, was conducted from PubMed, Scopus, and MEDLINE databases. This review has complied with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines. A total of 23 studies (77,188 participants) met inclusion criteria. Nonadherence rates ranged between 8% to 69%. Parents' socioeconomic background, family living status and functioning, parents' perception and attitude towards the importance of medication taking in treating psychiatric disorders, and parents' mental health status are significant parental characteristics associated with medication adherence in children and adolescents with psychiatric disorders. In conclusion, by identifying specific parental characteristics related to the medication adherence of children and adolescents with psychiatric disorders, targeted interventions on parents could be developed to guide parents in improving their child's medication adherence.

The effect of neuropsychiatric medication on pediatric nonalcoholic fatty liver disease

Obese and overweight children are at risk of developing nonalcoholic fatty liver disease (NAFLD), which can lead to steatohepatitis, cirrhosis, and liver transplantation. Neuropsychiatric conditions affect an increasing proportion of children and often require neuropsychiatric medications (NPMs) that are associated with weight gain and/or drug-induced liver injury. We sought to evaluate the role that the extended use of NPMs play in pediatric NAFLD. Medical chart review was conducted for 260 patients with NAFLD (NPM = 77, non-NPM = 183) seen in the Liver Care Center at Children's Mercy Hospital between 2000 and 2016. Outcome measures included body mass index (BMI) percentile, BMI z-score, aspartate aminotransferase (AST), alanine aminotransferase (ALT), total bilirubin, and gamma glutamyltransferase, and were collected at diagnosis, 6-18 month follow-up, and 18-36 months. Controlling for race and metformin, there was a significant increase over time in BMI z-score (p < 0.01) and total bilirubin (p = 0.03), with only initial decreases in ALT (p < 0.01) and AST (p < 0.01). Except for higher total bilirubin in the non-NPM group, no main effect of group or interaction effect was found. Similar patterns remained when subjects were analyzed by NPM drug class. Further study is needed to confirm these findings and to evaluate the effects of NPM dose and duration of exposure, by drug class, on pediatric NAFLD outcomes.

Metformin in the management of antipsychotic-induced weight gain in adults with psychosis: development of the first evidence-based guideline using GRADE methodology

BACKGROUND

Adjunctive metformin is the most well-studied intervention in the pharmacological management of antipsychotic-induced weight gain (AIWG). Although a relatively unaddressed area, among guidelines recommending consideration of metformin, prescribing information that would facilitate its applied use by clinicians, for example, provision of a dose titration schedule is absent. Moreover, recommendations differ regarding metformin's place in the hierarchy of management options. Both represent significant barriers to the applied, evidence-based use of metformin for this indication.

OBJECTIVE

To produce a guideline solely dedicated to the optimised use of metformin in AIWG management, using internationally endorsed guideline methodology.

METHODS

A list of guideline key health questions (KHQs) was produced. It was agreed that individual recommendations would be 'adopted or adapted' from current guidelines and/or developed de novo, in the case of unanswered questions. A systematic literature review (2008-2020) was undertaken to identify published guidelines and supporting (or more recent) research evidence. Quality appraisal was undertaken using the Appraisal of Guidelines Research and Evaluation II tool, A Measurement Tool to Assess Systematic Reviews (AMSTAR) assessment,and the Cochrane Risk of Bias 2 tool, where appropriate. Assessment of evidence certainty and recommendation development was undertaken using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

FINDINGS

We confirmed that no published guideline-of appropriate quality, solely dedicated to the use of metformin to manage AIWG was available. Recommendations located within other guidelines inadequately addressed our KHQs.

CONCLUSION

All 11 recommendations and 7 supporting good practice developed here were formulated de novo.

CLINICAL IMPLICATIONS

These recommendations build on the number and quality of recommendations in this area, and facilitate the optimised use of metformin when managing AIWG.

Irritability, Anger, and Aggression in the Context of Pediatric Bipolar Disorder

Irritability, anger, and aggression, although not specific for pediatric bipolar disorder (BD), can be a common finding and an important source of distress and impairment in these patients. Over the past 2 decades the diagnostic significance of irritability in pediatric BD has been highly debated. Beyond the debate of its diagnostic significance, the clinical importance of irritability, anger, and aggression in youth with BD has been well established. In this review, the authors discuss evaluation and management strategies of irritability, anger, and aggression in youth with BD.

Effectiveness of Metformin for Weight Reduction in Children and Adolescents Treated with Mixed Dopamine and Serotonin Receptor Antagonists: A Naturalistic Cohort Study

Objectives: Mixed dopamine and serotonin receptor antagonists (DSRAs) are associated with significant weight gain and its complications. Our aim was to evaluate the effectiveness of metformin in reducing body mass index (BMI) and metabolic parameters in children treated with DSRAs. Methods: We report a naturalistic study of 49 children and adolescents (mean age 14.9 ± 3.7 years), with BMI >85 percentile for age, treated with DSRAs during 2018-2020 in a child psychiatry clinic. Clinical data, anthropometric measurements, and laboratory tests were compared between those who were (study group, n = 31) and were not (control group, n = 18) treated with metformin. Results: The mean study duration was 9.7 ± 5.9 months. The BMI standard deviation scores (BMI-SDS) of the study group declined significantly (from 2.08 ± 0.40 to 1.81 ± 0.54, p < 0.001), while the BMI-SDS of the control group did not change (from 2.03 ± 0.45 to 2.04 ± 0.47, p = 0.838). In the study group, the decline in the delta BMI-SDS/month was more robust among those with good than poor adherence to metformin (-0.047 ± 0.039 vs. -0.004 ± 0.017, p = 0.003). The decrease in BMI-SDS was greater for patients treated with risperidone and clothiapine than with other DSRAs. Fasting insulin and insulin resistance index (homeostasis model assessment of insulin resistance [HOMA-IR]) declined in the study group (from 25.4 ± 13.8 to 19.9 ± 10.7, p = 0.033 and from 5.4 ± 2.7 to 4.2 ± 2.1, p = 0.028, respectively). Conclusions: Metformin treatment was associated with significant decreases in BMI, fasting insulin, and HOMA-IR. The effect of metformin seems to be dependent on adherence and type of DSRAs.