Options for pharmacological management of obesity in patients treated with atypical antipsychotics

Atypical Antipsychotics and Metabolic Syndrome: From Molecular Mechanisms to Clinical Differences

Atypical antipsychotics (AAPs) are commonly prescribed medications to treat schizophrenia, bipolar disorders and other psychotic disorders. However, they might cause metabolic syndrome (MetS) in terms of weight gain, dyslipidemia, type 2 diabetes (T2D), and high blood pressure, which are responsible for reduced life expectancy and poor adherence. Importantly, there is clear evidence that early metabolic disturbances can precede weight gain, even if the latter still remains the hallmark of AAPs use. In fact, AAPs interfere profoundly with glucose and lipid homeostasis acting mostly on hypothalamus, liver, pancreatic β-cells, adipose tissue, and skeletal muscle. Their actions on hypothalamic centers via dopamine, serotonin, acetylcholine, and histamine receptors affect neuropeptides and 5'AMP-activated protein kinase (AMPK) activity, thus producing a supraphysiological sympathetic outflow augmenting levels of glucagon and hepatic glucose production. In addition, altered insulin secretion, dyslipidemia, fat deposition in the liver and adipose tissues, and insulin resistance become aggravating factors for MetS. In clinical practice, among AAPs, olanzapine and clozapine are associated with the highest risk of MetS, whereas quetiapine, risperidone, asenapine and amisulpride cause moderate alterations. The new AAPs such as ziprasidone, lurasidone and the partial agonist aripiprazole seem more tolerable on the metabolic profile. However, these aspects must be considered together with the differences among AAPs in terms of their efficacy, where clozapine still remains the most effective. Intriguingly, there seems to be a correlation between AAP's higher clinical efficacy and increase risk of metabolic alterations. Finally, a multidisciplinary approach combining psychoeducation and therapeutic drug monitoring (TDM) is proposed as a first-line strategy to avoid the MetS. In addition, pharmacological treatments are discussed as well.

A dedicated nurse-led service for antipsychotic-induced weight gain

Aims and Method

To evaluate a psychosocial intervention for patients treated with antipsychotics with body mass index (BMI) > 25. A total of 44 patients (mean age (s.e.) 37.6 (1.2); 28 female, 16 male) received dietary and exercise advice with motivational interviewing. Weight and BMI were measured at baseline and monthly thereafter. Patients were offered weight monitoring for 1 year.

Results

Overall mean weight loss was 3.1 kg (mean 3.22%). Modal (range) weight change was 74.2 (719.2 kg to +8.7 kg).

Clinical Implications

Overall weight loss was not significant after 355.7 (32.5) (mean, s.e.) days. Determinants of response remain unclear. Avoiding weight gain in the first instance is critical. Further research will explore determinants of antipsychotic-induced weight gain and prevention strategies.

Individual Factors Affecting Self-esteem, and Relationships Among Self-esteem, Body Mass Index, and Body Image in Patients With Schizophrenia

The purposes of this study were to identify correlations between body mass index, body image, and self-esteem in patients with schizophrenia and to analyse the specific factors affecting self-esteem. This study had a descriptive design, utilising a cross-sectional survey. Participants were patients with schizophrenia who were admitted to a mental health facility in South Korea. A total of 180 questionnaires were distributed, and an appropriate total sample size of 167 valid questionnaires was analysed. Self-esteem was significantly correlated with body image, the subscale of appearance orientation, and body areas satisfaction. However, body mass index exhibited no significant correlation with any variable. The variables found to have a significant explanatory power of 21.4% were appearance orientation and body areas satisfaction. The explanatory power of all factors was 33.6%. The self-esteem of patients with schizophrenia was influenced by body mass index and body image. The positive symptoms of schizophrenia can be controlled by medication, whereas negative symptoms can be improved through education and nursing care with medication. Thus, psychiatric nurses should develop education and care programs that contribute to the positive body image and self-esteem of patients with schizophrenia.

Efficacy of Metformin and Topiramate in Prevention and Treatment of Second-Generation Antipsychotic–Induced Weight Gain

Objective

To review the literature describing the efficacy of metformin and topiramate for the treatment of second-generation antipsychotio–induced weight gain.

Data sources

Articles were identified by searching the MEDLINE database (from 1949 through January 2010) using the key words metformin, topiramate, antipsychotic, weight, weight gain, and obesity.

Study selection and data extraction

All randomized, place bo-controlled trials of metformin and topiramate were selected for review.

Data synthesis

Weight gain due to second-generation antipsychotic use is a concern due to the risk of long-term metabolic and cardiovascular effects with these agents. These effects include obesity, hyperglycemia, and insulin resistance, all of which may contribute to diabetes and cardiovascular disease. Second-generation antipsychotics vary in the degree to which they cause weight gain, and dietary and lifestyle changes may not be feasible or sufficient in counteracting this weight gain. Although other pharmacologic agents may be beneficial to prevent and treat antipsychotic-induced weight gain, metformin and topiramate have been the most extensively studied in this setting. Metformin acts peripherally to cause weight loss, while topiramate acts centrally. Review of 11 randomized, controlled trials demonstrates beneficial effects of metformin and topiramate in prevention and treatment of weight gain. Metformin is generally well tolerated and has been studied in pediatric patients, while topiramate is associated with more drug interactions and may possibly interfere with control of schizophrenia.

Conclusions

Data for the use of metformin and topiramate in the treatment and prevention of second-generation antipsychotio–induced weight gain are limited. Both may be effective in helping patients lose weight via mechanisms that have yet to be clearly defined. The use of metformin results in greater weight loss than topiramate, and topiramate is associated with more risks and may compromise the treatment of schizophrenia. Treatment of antipsychotic-induced weight gain with metformin may be an option after lifestyle and dietary changes have failed.

Efficacy of ranitidine in olanzapine-induced weight gain: a dose-response study

AIM

Weight gain has long been recognized as a side-effect of atypical antipsychotic drugs. Numerous new approaches have been tried for prevention of weight gain, the H2 blockers being one of them. The study was conducted with the aim to evaluate the efficacy of ranitidine in olanzapine-induced weight gain at two fixed doses of 150 and 300 mg day^-1 .

METHODS

Seventy-five inpatients with an ICD-10-DCR diagnosis of schizophrenia as their first episode were randomized into three groups of 25 patients each, receiving 150 mg day^-1 ranitidine, 300 mg day^-1 ranitidine and third group receiving only olanzapine. Their weight and body mass index (BMI) were measured at baseline and at intervals of 4 and 8 weeks.

RESULTS

All patients were comparable with respect to their weight and BMI at baseline. When a change in the weight and BMI was assessed at 4 and 8 weeks from baseline, no significant difference was observed between the three groups.

CONCLUSION

Ranitidine at doses of 150 and 300 mg day^-1 when combined with olanzapine was ineffective in attenuating olanzapine-induced weight gain. The likely reasons could be the use of low doses for a shorter period of time, or mechanisms other than H2 receptors might play an important role in weight gain.

Adjunctive α-lipoic acid reduces weight gain compared with placebo at 12 weeks in schizophrenic patients treated with atypical antipsychotics: a double-blind randomized placebo-controlled study

α-Lipoic acid (ALA) has been reported to be effective in reducing body weight in rodents and obese patients. Our previous open trial showed that ALA may play a role in reducing weight gain in patients with schizophrenia on atypical antipsychotics. The present study evaluated the efficacy of ALA in reducing weight and BMI in patients with schizophrenia who had experienced significant weight gain since taking atypical antipsychotics. In a 12-week, double-blind randomized placebo-controlled study, 22 overweight and clinically stable patients with schizophrenia were randomly assigned to receive ALA or placebo. ALA was administered at 600-1800 mg, as tolerated. Weight, BMI, abdomen fat area measured by computed tomography, and metabolic values were determined. Adverse effects were also assessed to examine safety. Overall, 15 patients completed 12 weeks of treatment. There was significant weight loss and decreased visceral fat levels in the ALA group compared with the placebo group. There were no instances of psychopathologic aggravation or severe ALA-associated adverse effects. ALA was effective in reducing weight and abdominal obesity in patients with schizophrenia who had experienced significant weight gain since beginning an atypical antipsychotic regimen. Moreover, ALA was well tolerated throughout this study. ALA might play an important role as an adjunctive treatment in decreasing obesity in patients who take atypical antipsychotics.

Phosphorylation of hypothalamic AMPK on serine(485/491) related to sustained weight loss by alpha-lipoic acid in mice treated with olanzapine

RATIONALE

Alpha-lipoic acid (ALA) was shown to suppress atypical antipsychotic drug (AAPD)-induced weight gain. However, its mode of action has remained unidentified.

OBJECTIVE

We aimed to identify mechanisms underlying anti-obesity effects of ALA in mice treated with olanzapine.

METHODS

We compared body weight and food intake among vehicle-, olanzapine-, and olanzapine plus ALA-treated mice, and measured hypothalamic AMP-activated protein kinase (AMPK) activity by detecting levels of Thr(172) and Ser(485/491) phosphorylation, which indicate activation and inhibition of AMPK, respectively.

RESULTS

Body weights were increased by olanzapine in parallel with increased levels of Thr(172) phosphorylation of hypothalamic AMPK. Initially increased rate of weight gain was diminished as Thr(172) phosphorylation levels were decreased to control levels after 10 days of olanzapine treatment. ALA successfully not only prevented olanzapine-induced weight gain but also induced additional weight loss even relative to control levels throughout the treatment period. During the initial stage, ALA's action was indicated by both suppression of olanzapine-induced Thr(172) phosphorylation and an increase in Ser(485/491) phosphorylation levels. However, in the later stage when no more increases in Thr(172) phosphorylation and weight gain by olanzapine were observed, ALA's action was only indicated by increased levels of Ser(485/491) phosphorylation.

CONCLUSIONS

Our data suggest that anti-obesity effects of ALA may be related to modulation of both Ser(485/491) phosphorylation and Thr(172) phosphorylation of hypothalamic AMPK, while olanzapine-induced weight gain may be only associated with increase in Thr(172) phosphorylation. This might be an important mechanistic clue for the future development of anti-obesity drugs beyond control of AAPD-induced weight gain.

Behavioral interventions for antipsychotic induced appetite changes

Weight gain remains a well recognized yet difficult to treat adverse effect of many anti-psychotic drugs including agents of the first and second generation. The weight gain liabilities of antipsychotic drugs are partly associated with their ability to increase appetite. Most behavioral interventions for weight control remain of limited efficacy, possibly because they do not specifically target the neuroendocrine factors regulating appetite. Identifying new weight management interventions directly acting on the biochemical and neuroendocrine mechanisms of anti-psychotic induced weight gain may help to improve the efficacy of behavioral weight management programs. Such potentially specific strategies include (1) using diets which do not increase appetite despite calorie restriction; (2) countering thirst as an anticholinergic side-effect; (3) discouraging cannabis use and (4) adding metformin to a behavioral intervention. In view of our currently rather limited treatment repertoire it seems timely systematically to explore such novel options.

Zonisamide produces weight loss in psychotropic drug-treated psychiatric outpatients

This study examined the long-term effectiveness and tolerability of zonisamide for weight control in psychiatric outpatients using various psychotropic medications. We conducted a systematic chart review of 82 psychiatric outpatients with unwanted weight gain after the introduction of psychotropic drugs between January 2008 and September 2009 at Korea University Ansan Hospital. The primary outcome measure was the effect of zonisamide on body mass index (BMI). Additional outcome measures included safety and tolerability as assessed by the clinical global impression-severity of illness scale (CGI-S) and discontinuation rate. The mean final dose of zonisamide was 124.6±53.4 mg/day and ranged from 50mg/day to 300 mg/day. The mean BMI reduction was 0.8±1.7 kg/m(2) and ranged from -2.9 kg/m(2) to 4.7 kg/m(2) (p<0.001). We also observed a significant reduction in CGI-S scores from the baseline (3.8±0.9) to the endpoint (3.3±0.8; p<0.001). Twelve patients (14.6%) discontinued their zonisamide treatment due to its side effects. Patients treated with zonisamide showed significant weight loss. Furthermore, its treatment was generally safe and well tolerated with few negative effects on patients' overall psychiatric symptoms. Additional research is required to confirm these results and to investigate whether patients have rebound weight gains after discontinuing zonisamide.

Posttraumatic stress disorder in male military veterans with comorbid overweight and obesity: psychotropic, antihypertensive, and metabolic medications

Posttraumatic stress disorder (PTSD) is an important syndrome among military veterans. Little has been written about comorbid medical conditions of PTSD, particularly overweight and obesity. We focus on psychotropic and non-psychotropic drugs, their interactions, and metabolic issues most relevant to primary care physicians.

METHOD

Data from the recently constituted PTSD program at the Department of Veterans Affairs Medical Center in Richmond, Va., were retrospectively reviewed to assess the prevalence and severity of comorbid overweight and obesity in male veterans with PTSD. Also, our database allowed us to correlate various drugs used to treat hypertension, diabetes mellitus, and dyslipidemia with body mass index (BMI).

RESULTS

The mean BMI of 157 veterans with PTSD (DSM-IV criteria) in this sample was in the obese range (30.3 ± 5.6 kg/m²). The number of drugs a given patient was taking for treatment of hypertension, diabetes mellitus, and dyslipidemia correlated with BMI. Psychotropic drugs associated with weight gain did not explain our findings.

CONCLUSIONS

Overweight and obesity among our male veterans with PTSD strikingly exceeded national findings. The administration of psychotropic drugs associated with weight gain did not explain these findings. The number of medications used to treat hypertension, diabetes mellitus, and dyslipidemia correlated significantly with BMI. Rather than these medications explaining the high prevalence of overweight and obesity in our study population, obesity probably worsened these components of the metabolic syndrome, necessitating more aggressive treatment reflected in the high number of drugs prescribed.

The effectiveness of a non-pharmacological intervention for weight gain management in severe mental disorders: results from a national multicentric study

OBJECTIVE: To evaluate the effectiveness of a non-pharmacological intervention for weight gain management in severe mental disorders. METHOD: An open, multicentre interventional study was conducted in 93 mental health services. Patients concerned with weight gain were included in this study and received a 12-week 1-hour group intervention focused on nutrition counseling, lifestyle, physical activity and self-esteem. Weight, waist circumference and blood pressure were measured before and after the intervention. RESULTS: 1,071 patients were enrolled in the study, and 73.9% completed the 12-week intervention. Significant weight loss (Mean difference: 0.41, CI 95%: 0.18 to 0.64, p = 0.001) and a significant BMI reduction (Mean difference: 0.13, CI 95%: 0.04 to 0.22, p = 0.006) were observed. During the intervention 37 (4.4%) patients lost > 7% of their initial weight, 780 (92.5%) maintained their weight, and 26 (3.1%) of the patients had a meaningful weight gain (> 7%). There was a significant increase in the proportion of patients undertaking physical activity after the intervention (70.8%, p < 0.001). CONCLUSION: In this 3-month open study we found a small weight and waist reduction, and increased physical activity practice, suggesting a trend towards anthropometric profile improvement. However, further randomized-controlled trials are necessary to evaluate the efficacy and clinical relevance of this psychosocial intervention for weight gain.

Changes in body weight, body composition and cardiovascular risk factors after long-term nutritional intervention in patients with severe mental illness: an observational study

BACKGROUND

Compared with the general population, individuals with severe mental illness (SMI) have increased prevalence rates of obesity and greater risk for cardiovascular disease. This study aimed to investigate the effects of a long term nutritional intervention on body weight, body fat and cardiovascular risk factors in a large number of patients with SMI.

METHODS

Nine hundred and eighty-nine patients with a mean ± S.D age of 40 ± 11.7 yrs participated in a 9 mo nutritional intervention which provided personalised dietetic treatment and lifestyle counselling every two weeks. Patients had an average body mass index (BMI) of 34.3 ± 7.1 kg x m(-2) and body weight (BW) of 94.9 ± 21.7 kg. Fasted blood samples were collected for the measurement of glucose, total cholesterol, triglycerides and HDL-cholesterol. All measurements were undertaken at baseline and at 3 mo, 6 mo and 9 mo of the nutritional intervention.

RESULTS

Four hundred and twenty-three patients of 989 total patients' cases (42.8%) dropped out within the first 3 months. Two hundred eighty-five completed 6 months of the program and 145 completed the entire 9 month nutritional intervention. There were progressive statistically significant reductions in mean weight, fat mass, waist and BMI throughout the duration of monitoring (p < 0.001). The mean final weight loss was 9.7 kg and BMI decreased to 30.7 kg x m(-2) (p < 0.001). The mean final fat mass loss was 8.0 kg and the mean final waist circumference reduction was 10.3 cm (p < 0.001) compared to baseline. Significant and continual reductions were observed in fasting plasma glucose, total cholesterol and triglycerides concentrations throughout the study (p < 0.001).

CONCLUSION

The nutritional intervention produced significant reductions in body weight, body fat and improved the cardiometabolic profile in patients with SMI. These findings indicate the importance of weight-reducing nutritional intervention in decreasing the cardiovascular risk in patients with SMI.

Safety and tolerability of antipsychotics: focus on amisulpride

The introduction of the atypical antipsychotic drugs represents an important advance in the treatment of schizophrenia, because the therapeutic efficacy, tolerability, and safety profiles of these agents seem to be superior to that of the classical neuroleptics. As would be predicted from the pharmacologic profile of a pure D(2)/D(3) receptor blocker, amisulpride is an atypical antipsychotic agent, effective for positive and negative symptoms, which can bring about additional improvement in the social functioning and quality of life of patients with schizophrenia. Amisulpride is effective in acute schizophrenia as determined by Clinical Global Impression scores. The major concern regarding the safety of the atypical antipsychotics is related to their propensity to induce weight gain and alter glucose and lipid metabolism. Amisulpride has one of the lowest potentials for weight gain of all the antipsychotic agents, and is associated with clearly lower use of antiparkinsonian medication and with fewer dropouts due to adverse events than conventional antipsychotics. Amisulpride is well tolerated with regard to anxiety and insomnia, and not notably different from placebo. Amisulpride has a pronounced prolactin-elevating effect which appears to be independent of dosage and duration of administration. Hyperprolactinemia rapidly reverses following amisulpride discontinuation. Amisulpride benefits patients with negative symptoms, and is the only antipsychotic to demonstrate efficacy in patients with predominantly negative symptoms. Amisulpride maintains its efficacy when used for medium/long-term treatment, as demonstrated in studies of up to 12 months. In terms of relevance of the effects, superiority is observed for quality of life, social adaptation, and functioning, as measured by the Quality of Life and Functional Status Questionnaire scales. In conclusion, amisulpride is an antipsychotic agent with proven efficacy and good tolerability. Moreover, this drug can help people with schizophrenia to attain social reinsertion.

Adverse endocrine and metabolic effects of psychotropic drugs: selective clinical review

The article critically reviews selected, clinically significant, adverse endocrine and metabolic effects associated with psychotropic drug treatments, including hyperprolactinaemia, hyponatraemia, diabetes insipidus, hypothyroidism, hyperparathyroidism, sexual dysfunction and virilization, weight loss, weight gain and metabolic syndrome (type 2 diabetes mellitus, dyslipidaemia and hypertension). Such effects are prevalent and complex, but can be managed clinically when recognized. They encourage continued critical assessment of benefits versus risks of psychotropic drugs and underscore the importance of close coordination of psychiatric and general medical care to improve long-term health of psychiatric patients. Options for management of hyperprolactinaemia include lowering doses, switching to agents such as aripiprazole, clozapine or quetiapine, managing associated osteoporosis, carefully considering the use of dopamine receptor agonists and ruling out stress, oral contraceptive use and hypothyroidism as contributing factors. Disorders of water homeostasis may include syndrome of inappropriate antidiuretic hormone (SIADH), managed by water restriction or slow replacement by hypertonic saline along with drug discontinuation. Safe management of diabetes insipidus, commonly associated with lithium, involves switching mood stabilizer and consideration of potassium-sparing diuretics. Clinical hypothyroidism may be a more useful marker than absolute cut-offs of hormone values, and may be associated with quetiapine, antidepressant and lithium use, and managed by thyroxine replacement. Hyper-parathyroidism requires comprehensive medical evaluation for occult tumours. Hypocalcaemia, along with multiple other psychiatric and medical causes, may result in decreased bone density and require evaluation and management. Strategies for reducing sexual dysfunction with psychotropics remain largely unsatisfactory. Finally, management strategies for obesity and metabolic syndrome are reviewed in light of the recent expert guidelines, including risk assessment and treatments, such as monoamine transport inhibitors, anticonvulsants and cannabinoid receptor antagonists, as well as lifestyle changes.

Improved body weight and metabolic outcomes in overweight or obese psychiatric patients switched to amisulpride from other atypical antipsychotics

Switching to a different second-generation antipsychotic (SGA) with a lower risk of weight gain is recommended for overweight or obese psychiatric patients undergoing SGA treatment. However, there have been no complete reports regarding the long-term metabolic effects of switching to amisulpride. In this open-label 1-year study, we investigated the effects on body weight and other metabolic profiles when psychiatric patients treated with another SGA were switched to amisulpride treatment. Forty-six schizophrenia or schizoaffective inpatients with a body mass index greater than 27 kg/m were enrolled in the switch group. These patients were cross-titrated to amisulpride treatment and followed up for 1 year prospectively. Another 46 inpatients matched with the baseline body mass index of those in the switch group were enrolled as the control group retrospectively. The results showed that the switch group had greater weight loss than the control group (7.80 +/- 6.67 vs 2.60 +/- 6.23 kg, respectively; repeated-measure analysis of variance, P < 0.0005). During the treatment course, the amisulpride-treated patients showed significantly decreased fasting triglyceride, total cholesterol, glucose, and insulin resistance levels; decreased diastolic blood pressure and pulse rate; and a significant increase in high-density lipoprotein cholesterol levels after switching to amisulpride (all with a P < 0.05). The prevalence of metabolic syndrome in amisulpride-treated patients also decreased significantly from 65.2% to 30.4% (McNemar test, P < 0.0005). These findings suggest that switching to amisulpride could be an effective treatment of overweight or obese psychiatric patients treated previously with other SGAs.

'Mind and Body': a lifestyle programme for people on antipsychotic medication

RATIONALE

Psychiatric illnesses such as schizophrenia and their treatments have consequences in terms of lifestyle, diet and weight.

AIMS AND OBJECTIVES

'Mind and Body' is a 10-week programme of weekly sessions aimed to improve the health status of people treated with second generation antipsychotic medications.

METHODS

The programme focuses on a range of lifestyle strategies including diet and exercise and was conducted at a Community Health Centre by professionally qualified staff. Between 2002 and 2006, 50 participants enrolled in, and 30 completed the programme. Measures of body weight, health status (Short Form-36) and blood markets (plasma glucose, haemoglobin A1c and lipid profile) were collected at commencement and completion of the programme. Results A modest improvement was demonstrated in mean values for the majority of measures collected.

CONCLUSIONS

A lifestyle program for people treated with antipsychotic medications is achievable and may be worthwhile although gains may be modest.

Topiramate add-on treatment in schizophrenia: a randomised, double-blind, placebo-controlled clinical trial

Glutamate antagonists such as topiramate have been proposed based on the glutamate hypothesis of schizophrenia because its properties encourage its exploration and possible development as a medication for the treatment of schizophrenia. A randomised, double-blind, placebo-controlled clinical trial was performed on 18- to 45-year-old patients with schizophrenia. Baseline information including vital signs, height, weight, smoking status, demographic characteristics, (past) psychiatric history, medication history and medication-related adverse effects were collected. Patients were randomly assigned to a topiramate or placebo group. Efficacy of medication was measured by administering Positive and Negative Syndrome Scale (PANSS), and tolerability of treatment was recorded on day 0 (baseline), day 28 and day 56. PANSS values (95% confidence interval) at baseline, day 28 and day 56 in the topiramate group were 96.87 (85.37-108.37), 85.68 (74.67-96.70) and 76.87 (66.06-87.69), respectively; compared with 101.87 (90.37-113.37), 100.31 (89.29-111.32) and 100.56 (89.74-111.37) in the placebo group. General linear model for repeated measures analysis showed that topiramate has lowered PANSS values significantly compared with the placebo group. Similar significant decline patterns were found in all three subscales (negative, positive and psychopathology sign). Clinical response (more than 20% reduction in PANSS) was significantly higher in topiramate-treated subjects than controls (50% vs 12.5%). Topiramate can be an effective medication in controlling schizophrenic symptoms, considering its effect on negative symptoms and controlling antipsychotic-associated weight gain.

Drug-induced hyperphagia: what can we learn from psychiatric medications?

This brief review examines hyperphagia and associated weight gain as undesirable side effects of psychiatric medications; exploring the scope of the problem, proposed mechanisms, and potential interventions. Mechanisms of action appear to include drug-mediated effects on hypothalamic appetite pathways that have been implicated in other etiologies of obesity. There is great individual variation in response to these medications as well as variation in the degree of weight gain within drug classes. Gene polymorphisms may be a key factor in determining individual variations in response. Better understanding of the underlying mechanisms can guide useful interventions. Medication selection and dosing appear to be important strategies to minimize adverse weight gain.

Weight management in a cohort of Irish inpatients with serious mental illness (SMI) using a modular behavioural programme. A preliminary service evaluation

BACKGROUND

Weight gain is commonly observed during psychotropic treatments for chronic forms of severe mental illness and is most rapid during the early treatment phases. All formats of behavioural weight intervention programmes have suggested that weight gain can be prevented or reversed in some patients. There is no data on these programmes in acutely unwell inpatients whom may be the major beneficiaries.

METHODS

A modular behavioural intervention programme (Solutions for Wellness) used in SMI outpatients since 2002 in Ireland has been adapted for inpatient use. Preliminary data is reported from 5 centres in Ireland.

RESULTS

In 47 inpatients the mean weight change was +0.26 kg (SD 2.02) with a median change of 0 kg. Mean follow-up was 23.7 (SD 21.6) days, and median 14 days (range 6-98 days). There was no difference in mean weight change in those patients involved for > 35 days compared with < 35 days (+0.26 kg; 0.25 kg; p = 0.5). Weight loss or maintenance was seen in 70% of patients.

CONCLUSION

These preliminary data are supportive of the concept that acutely unwell inpatients with SMI may engage with a behavioural weight programme. Weight change observed contrasts with the significant weight gain often seen in most subjects. Further clinical trials are warranted.

Psychotropic drug considerations in depressed patients with metabolic disturbances

Depression, obesity, diabetes mellitus, and the metabolic syndrome are conditions commonly treated in primary care. The prevalence of each condition separately does not explain the frequency of their co-occurrence. Depression may lead to or exacerbate these endocrine and metabolic conditions. Conversely, these medical conditions may lead to or exacerbate depression. Psychotropic drugs that treat depression may increase appetite with resultant weight gain. Rarely, such agents may be associated with weight loss. We review the potential for psychotropic drugs to alter body weight and provide a table as a guide to drug selection. Unless circumstances dictate otherwise, clinicians should select psychotropic drugs least likely to induce weight gain when treating depressed patients with obesity, diabetes mellitus, or the metabolic syndrome. Even drugs generally thought to be "weight neutral" may occasionally be associated with weight gain. Thus, alerting patients to this potential and due diligence form the cornerstone of weight management in the depressed patient.

BDNF levels and genotype are associated with antipsychotic-induced weight gain in patients with chronic schizophrenia

Recent evidence suggests that centrally released brain-derived neurotrophic factor (BDNF) modulates eating behavior and metabolism that is responsible for body weight fluctuation. BDNF also may play an important role in the therapeutic action of antipsychotic medications. We investigated whether the Val66Met polymorphism of the BDNF gene affected weight gain after long-term antipsychotic treatment in schizophrenia. The polymorphism was genotyped in 196 Chinese patients with schizophrenia on long-term antipsychotic medication. Serum BDNF was measured in all patients and 50 normal controls. Mean body mass index (BMI) change was evaluated retrospectively by means of clinical records. The results showed that there was a significant relationship between the three BDNF Val/Met genotypes and mean BMI gain, with genotype having a strong effect on BMI gain in male but not female patients. BDNF levels were significantly lower in patients than normal controls, and negatively correlated with BMI gain in female but not male patients. Our results suggest that variation in the BDNF gene may be a risk factor for weight gain in male patients with schizophrenia on long-term antipsychotic treatment, and decreased BDNF levels may be associated with weight gain in females.

Antipsychotic drug and body weight set-point

OBJECTIVE

Antipsychotic (AP) drugs frequently induce weight gain. The present study aimed at exploring a potential association between antipsychotic-induced weight gain and delayed negative alliesthesia for sweet stimuli.

RESEARCH METHODS AND PROCEDURES

The study aimed at recruiting patients undergoing AP treatment, half of them with stable weight and the other half with documented weight gain. Negative alliesthesia to sweet stimuli was assessed through a specific procedure.

RESULTS

A multivariate regression of the data obtained from the entire sample was performed to establish the relationship between alliesthesia dependent variables and weight gain as a predictor. The overall F statistic shows that there was a significant association between delayed negative alliesthesia for sweet stimuli and weight gain.

CONCLUSION

Atypical antipsychotic drug-induced weight gain seems to result from a raised body weight set-point.

A preliminary investigation of alpha-lipoic acid treatment of antipsychotic drug-induced weight gain in patients with schizophrenia

Weight gain and other metabolic disturbances have now become discouraging, major side effects of atypical antipsychotic drugs (AAPDs). The novel strategies required to counteract these serious consequences, however, should avoid modulating the activities of the neurotransmitter receptors involved because those receptors are the therapeutic targets of AAPDs. Adenosine monophosphate-activated protein kinase is an enzyme that plays a pivotal role in energy homeostasis. We hypothesized that alpha-lipoic acid (ALA), which is known to modulate adenosine monophosphate-activated protein kinase activity in the hypothalamus and peripheral tissues, would ameliorate AAPD-induced weight gain. We describe the case series of a 12-week ALA trial in schizophrenia patients treated with AAPDs. Two of 7 enrolled subjects were dropped from the study because of noncompliance and demand for new medication to treat depressive symptoms, respectively. The mean (SD) weight loss was 3.16 (3.20) kg (P = 0.043, last observation carried forward; median, 3.03 kg; range, 0-8.85 kg). On average, body mass index showed a significant reduction (P = 0.028) over the 12 weeks. During the same period, a statistically significant reduction was also observed in total cholesterol levels (P = 0.042), and there was a weak trend toward the reduction in insulin resistance (homeostasis model assessment of insulin resistance) (P = 0.080). Three subjects reported increased energy subjectively. The total scores on the Brief Psychiatric Rating Scale and the Montgomery-Asberg Depression Rating Scale did not vary significantly during the study. These preliminary data suggest the possibility that ALA can ameliorate the adverse metabolic effects induced by AAPDs. To confirm the benefits of ALA, more extended study is warranted.

Use of low-dose topiramate in substance use disorder and bodyweight control

In recent years topiramate has been used for psychiatric patients, mainly for controlling substance use and food intake. A total of 46 patients who received topiramate treatment during the study period were identified from a computer database. Nineteen had received topiramate for at least 1 month. Twelve patients received topiramate for anticraving effects (alcohol, n = 9; heroin/amphetamine, n = 1; meperidine, n = 1; and nicotine, n = 1). On an average dosage of 112.5 mg/day, nine of the 12 patients (excluding three alcoholic patients) achieved complete or partial remission from the substance use disorders. The present results show that six of the nine patients achieved full or partial remission from alcohol use disorder on a dosage of 100 mg/day. Topiramate was also used to control seven patients' bodyweight (mean bodyweight change, 1.53 kg). Four of them achieved bodyweight loss in the 1-month follow up, with an average change of 2.65 kg. Based on the present findings topiramate <100 mg/day may be effective in treating patient with alcohol use disorder, and that topiramate has not shown remarkable benefit of bodyweight loss.

Long-term topiramate treatment of psychotropic drug-induced weight gain: a retrospective chart review

OBJECTIVE

The objective of this study was to determine the efficacy and tolerability of long-term topiramate treatment of psychotropic drug-induced weight gain.

METHOD

We conducted a retrospective review of the charts of patients treated with add-on topiramate in order to control weight gain induced by psychotropic drugs (antipsychotic drugs, lithium or valproate).

RESULTS

The case series consisted of 100 patients. The mean final dose of topiramate was 186.8+/-138.3 mg/day, whereas the median dose was 200 mg/day for a total treatment duration of 41+/-38 weeks. Adverse events led to topiramate discontinuation in 22% of the sample. A significant reduction in body mass index was observed between the first and last measures, from 29.7+/-3.6 to 28+/-3.3 (t=5.82, P<.0005). The reduction in body mass index was greater in patients treated with antipsychotic drugs than in those treated with lithium or valproate alone. No difference was found between subjects with and those without comorbid active substance abuse or dependence.

CONCLUSIONS

In this retrospective case series, topiramate was found to be effective in reversing weight gain associated with antipsychotic drugs, lithium or valproate. Tolerability of topiramate was an issue in some patients.

Metabolic side effects of antipsychotic medication

The use of second-generation antipsychotics (SGAs) is associated with metabolic side effects including weight gain, diabetes mellitus and an atherogenic lipid profile. These adverse effects are not only the risk factors for cardiovascular disease, insulin resistance and diabetes mellitus leading to increased morbidity and mortality but may also impair the patient's adherence to treatment. SGAs in particular are associated with significant weight gain with clozapine and olanzapine carrying the highest risk, whereas newer agents, such as risperidone and aripiprazole, are considered to be less prone to cause weight gain. Consequently, a consensus development conference convened issuing recommendations on patient monitoring when treated with SGAs. The metabolic effects of antipsychotic drugs should be of concern when planning a patient's treatment strategy. Baseline screening and regular follow-up monitoring whose intervals should depend on the individual predisposition are advised. Possible therapeutical strategies for the management of drug-induced obesity include therapeutic approaches, such as life style change and pharmaceutical intervention. Drugs with a weight reducing effect become more important because of the lack of compliance with behavioural intervention. Topiramate, histamine-antagonists, dopaminergic- and serotoninergic agents have shown positive results in the management of psychotropic medication induced weight gain. However, further trials are required to support a specific therapeutical approach as well as studies to investigate the underlying mechanisms for future drug development.

Association of clozapine-induced weight gain with a polymorphism in the leptin promoter region in patients with chronic schizophrenia in a Chinese population

Weight gain is a problem commonly encountered with antipsychotic treatment and has become more apparent with increasing use of the newer atypical antipsychotics. The adipocyte-derived hormone, leptin, has been associated with body weight and energy homeostasis, and abnormal regulation of leptin could play a role in weight gain induced by antipsychotics. We investigated whether a leptin gene promoter variant affected weight gain after long-term treatment with clozapine in chronic schizophrenia. Leptin G2548A polymorphism was genotyped in 102 Chinese Han inpatients with chronic schizophrenia treated with clozapine. Weight gains, expressed as change in body mass index (BMI), were monitored after long-term clozapine treatment. We found a significant relationship between the 3 leptin G/A genotypes and mean BMI gain (F(2,99) = 3.35, P = 0.039, r(2) = 0.09). Moreover, genotype had a strong effect on BMI gain in male (P = 0.004, r(2) = 0.16), but not in female patients (P > 0.05). Thus, variation in the leptin gene may be a risk factor for weight gain in male patients with schizophrenia on long-term clozapine treatment.

Cognitive behavioural therapy for weight gain associated with antipsychotic drugs

BACKGROUND

Overweight and obesity are common concerns in individuals with severe mental disorders. In particular, antipsychotic drugs (AP) frequently induce weight gain. This phenomenon lacks current management and no previous controlled studies seem to use cognitive therapy to modify eating and weight-related cognitions. Moreover, none of these studies considered binge eating or eating and weight-related cognitions as possible outcomes.

AIM

The main aim of this study is to assess the effectivity of cognitive and behavioural treatment (CBT) on eating and weight-related cognitions, binge eating symptomatology and weight loss in patients who reported weight gain during AP treatment.

METHOD

A randomized controlled study (12-week CBT vs. Brief Nutritional Education) was carried out on 61 patients treated with an antipsychotic drug who reported weight gain following treatment. Binge eating symptomatology, eating and weight-related cognitions, as well as weight and body mass index were assessed before treatment, at 12 weeks and at 24 weeks.

RESULTS

The CBT group showed some improvement with respect to binge eating symptomatology and weight-related cognitions, whereas the control group did not. Weight loss occurred more progressively and was greater in the CBT group at 24 weeks.

CONCLUSION

The proposed CBT treatment is particularly interesting for patients suffering from weight gain associated with antipsychotic treatment.

Interventions to reduce weight gain in schizophrenia

BACKGROUND

Weight gain is common for people with schizophrenia and this has serious implications for health and well being.

OBJECTIVES

To determine the effects of both pharmacological (excluding medication switching) and non pharmacological strategies for reducing or preventing weight gain in people with schizophrenia.

SEARCH STRATEGY

We searched key databases and the Cochrane Schizophrenia Group's trials register (April 2006), reference sections within relevant papers, hand searched key journals, and contacted the first author of each relevant study and other experts to collect further information.

SELECTION CRITERIA

We included all clinical randomised controlled trials comparing any pharmacological or non pharmacological intervention for weight gain (diet and exercise counselling) with standard care or other treatments for people with schizophrenia or schizophrenia-like illnesses.

DATA COLLECTION AND ANALYSIS

We reliably selected, quality assessed and extracted data from studies. As weight is a continuous outcome measurement, weighted mean differences (WMD) of the change from baseline were calculated. The primary outcome measure was weight loss.

MAIN RESULTS

Twenty-three randomised controlled trials met the inclusion criteria for this review. Five trials assessed a cognitive/behavioural intervention and eighteen assessed a pharmacological adjunct. In terms of prevention, two cognitive/behavioural trials showed significant treatment effect (mean weight change) at end of treatment (n=104, 2 RCTs, WMD -3.38 kg CI -4.2 to -2.0). Pharmacological adjunct treatments were significant with a modest prevention of weight gain (n=274, 6 RCTs, WMD - 1.16 kg CI -1.9 to -0.4). In terms of treatments for weight loss, we found significantly greater weight reduction in the cognitive behavioural intervention group (n=129, 3 RCTs, WMD -1.69 kg CI -2.8 to -0.6) compared with standard care.

AUTHORS' CONCLUSIONS

Modest weight loss can be achieved with selective pharmacological and non pharmacological interventions. However, interpretation is limited by the small number of studies, small sample size, short study duration and by variability of the interventions themselves, their intensity and duration. Future studies adequately powered, with longer treatment duration and rigorous methodology will be needed in further evaluating the efficacy and safety of weight loss interventions for moderating weight gain. At this stage, there is insufficient evidence to support the general use of pharmacological interventions for weight management in people with schizophrenia.

Nutritional approach to metabolic changes arising out of schizophrenia therapy: case report

The case of a 35-year-old female patient who was diagnosed as schizophrenia treated with psychotrophic drugs nearly for 15 years is presented here. After the disease was diagnosed, the patient quit her university education and began to live inactively far from her social environment, usually spending lazy time at home. During this period, due to either the effects of drugs which have to be used on hormones affecting appetite and body weight or her decreased physical activity, her body weight increased by nearly 30 kg. Anthropometric measurements, biochemical parameters and food diaries were evaluated at the beginning of the nutritional counseling and then repeated periodically. Upon obtaining biochemical findings, collaboration with other units started. The patient was educated on nourishing healthy and controlling body weight, also to bring about lasting behavioral changes. At the beginning of the therapy, among the biochemical measurements, insulin resistance was defined and metformin treatment was begun. Metformin therapy contributed to the patient's adaptation to the diet and improved glucose tolerance. In this way, it was possible to cope with the insulin resistance caused by anti-psychotic pharmacotherapy (clozapine) and the obesity which had developed as a result of clozapine. During the 18-month therapy the patient lost 27 kg, her body fat was reduced by 10% (18 kg) and BMI returned to normal levels. It is known that, many medications used in psychiatric disorders affect appetite and body weight. As seen in our patient metformin therapy causes weight loss and decreases insulin resistance. Both the illness and the medications used for treatment could affect the hormones which play a part in controlling body weight and the cytokines, as a result could change food preference and eating behavior which ultimately pave the way to obesity.

Antidepressants and sexual dysfunction

OBJECTIVE

Many patients with depression suffer from sexual dysfunction and sexual dysfunction is a recognized side-effect of antidepressants. The aim of this review was to examine the prevalence of psychosexual dysfunction associated with antidepressants, and to review treatment options which are specific to the affected component of sexual functioning and antidepressants.

METHOD

Comprehensive literature review using Medline and Cochrane databases.

RESULTS

Up to 70% of patients with depression may have sexual dysfunction. Tricyclic antidepressants, selective-serotonin reuptake inhibitors and venlafaxine are most and the non-serotonergic antidepressants and duloxetine least likely to produce sexual dysfunction. Pharmacological treatment options include antidepressants less likely associated or 'antidotes' to reverse sexual dysfunction.

CONCLUSION

Sexual dysfunction may be a preventable or treatable side-effect of antidepressants. Patients need routinely to be asked about sexual function to identify problems early. If sexual dysfunction is ignored it may maintain the depression, compromise treatment outcome and lead to non-compliance.

Effects of an educational intervention on weight gain in patients treated with antipsychotics

BACKGROUND

Increasing numbers of reports have raised concerns about significant increases in weight and adiposity over both short- and long-term treatment in patients treated with antipsychotics (APs). The management of overweight and obesity in patients treated with APs has included pharmacological interventions, dietary suggestions, and behavioral strategies. Nevertheless, current evidence does not support the use of pharmacological management of this specific type of obesity, and only a limited number of studies have been published regarding prevention and treatment of weight gain with other strategies.

OBJECTIVE

The aim of this study was to evaluate the effectiveness of an educational intervention (EI) that combines low-calorie diet with increased physical activity to prevent and treat weight gain in patients treated with APs.

METHOD

Data were from 53 subjects whose body mass index (BMI) had increased by more than 7% after starting an AP therapy and who consented to participate in a 12-week educational intervention study aimed at preventing further weight gain and, when possible, at inducing a weight loss. Weight and BMI were measured at baseline (at each of the monthly follow-up visits) and at study completion 12 weeks from entry in the study.

RESULTS

Twenty-six patients completed the 12-week program. Completers showed a significant mean body weight decrease of 3.15 kg, with a mean BMI reduction of 1.2 (kg/m) at the end of the 3-month period.

CONCLUSIONS

Educational intervention can be an important tool for the management of weight increase in patients treated with APs. A larger prospective and controlled study is now needed to confirm our findings.

Excessive weight gain after remission of depression in a schizophrenic patient treated with risperidone: case report

BACKGROUND

The use of atypical antipsychotics in schizophrenic patients has been associated with a risk of weight gain. Similarly, recovery from depression is often followed by improved appetite, greater food intake and potential increase in weight.

CASE PRESENTATION

A Caucasian 33-year-old schizophrenic female patient was being treated with 6 mg/day of risperidone and 15 mg/day of clorazepate. She developed depressive symptomatology and 40 mg/day of fluoxetine was gradually added to her treatment regimen for about 9 months. After the remission of depression, and the discontinuation of fluoxetine, she experienced an increase in appetite and subsequently excessive weight gain of 52 kg. Re-administration of fluoxetine did not reverse the situation. The patient developed diabetes mellitus, which was successfully controlled with metformin 1700 mg/day. The addition at first of orlistat 360 mg/day and later of topiramate 200 mg/day has helped her to lose a significant part of the weight gained (30 kg).

CONCLUSION

The case suggests a probable association between the remission of depressive symptomatology and weight gain in a schizophrenic patient.

Long-term treatment with atypical antipsychotics and the risk of weight gain : a literature analysis

The aim of this review is to analyse and summarise the literature data about the incidence of weight gain in patients exposed to atypical antipsychotics during long-term (>or=1 year) treatment regimens. Despite the clinical relevance of the topic, the vast majority of reviewed studies showed methodological limitations. Some trials had retrospective analysis, and concomitant medications also associated with an increased risk of weight gain, such as antidepressants and mood stabilisers, were often prescribed. Results were obtained from clinical trials conducted using flexible dosages; thus, the relationship between dosage and weight change was not explored adequately. Also, in a large number of studies, the average antipsychotic daily dose was lower than the usual dosage in clinical practice. Moreover, weight gain was evaluated by different measures, such as mean weight gain in the enrolled population, percentage of patients who gained >7% of basal weight or body mass index (BMI) variations from baseline. In short-term studies, a definite rank order of weight-gain potential among atypical antipsychotics has been demonstrated: clozapine is related to the highest risk of weight gain, followed in decreasing order of magnitude by olanzapine, quetiapine, risperidone, amisulpride, aripiprazole and ziprasidone. However, in long-term studies, except for clozapine at one end of the scale and ziprasidone at the other, the differences in weight-gain liability showed by the other atypical antipsychotics became less intense. Differences between short-term and long-term treatment could be due to a complex overlapping of different factors, both drug-specific (relative receptorial affinity; timing of weight change plateau; and drug-specific/dose-dependent weight gain), and patient-specific (genetic vulnerability; sex; age; BMI; weight before starting antipsychotic treatment; type of psychiatric disorder; and individual lifestyle). There is an urgent need for well designed, randomised controlled trials to assess firmly both the differential effects of atypical antipsychotics on weight and the role of other factors in contributing to iatrogenic unwanted weight changes. Meanwhile, the well known benefits shown by some atypical antipsychotics in reducing akathisia and other extrapyramidal adverse effects and improving cognition should be carefully balanced with the problems of weight gain, other metabolic complications and higher health care costs.

A psychiatric rehabilitation approach to weight loss

Obesity is a major problem nationwide and even more prevalent among people with psychiatric disabilities. This study examined the efficacy of a psychiatric rehabilitation weight loss program. Twenty-one individuals participated in the 12-week intervention. Another 15 individuals served as matched controls. Results indicate the intervention group improved more than the control group for weight, body mass index, waist circumference and physical activity. The intervention group lost 2.7 kg (6 lbs) and the control group gained 0.5 kg (1 lb). A weight loss program incorporating psychiatric rehabilitation principles was effective for people with psychiatric disabilities at a community based program.

The role of lifestyle interventions and weight management in schizophrenia

The recognition that schizophrenia is associated with metabolic comorbidity and a subsequent greater risk of cardiovascular events compared to the general population has led to attempts to reduce this metabolic burden. Increased weight, and smoking rates combined with less exercise and poor dietary choices, have led to a variety of behavioural programmes and pharmacological agents being evaluated with the aim of improving lifestyle and managing weight. Adjunctive pharmacological strategies for weight management have not been shown to be consistently effective and remain contraindicated in many schizophrenia subjects. However some novel compounds with recent promising data suggest that research should not be abandoned. In contrast a variety of behavioural interventions have shown a consistent degree of success not only with weight management but also in achieving lifestyle changes. Many reported data-sets are naturalistic or open-label indicating that there is a difficulty in performing traditional randomized controlled studies in this area. The long-term naturalistic studies and holistic approaches show that weight management and significant lifestyle changes are attainable goals in schizophrenia patients. Weight management and lifestyle advice should be routinely offered to all schizophrenia subjects.

Management of atypical antipsychotic-induced weight gain in schizophrenic patients with topiramate

Patients treated with atypical antipsychotic drugs commonly gain excess weight. Because obesity is associated with considerable morbidity and decreased life expectancy, treatment of weight gain in these patients is critical. Topiramate, a fairly new anticonvulsant, promotes bodyweight loss in healthy obese subjects, patients with bipolar disorder, and patients with eating disorder. However, there are very few reports about the efficacy of topiramate for weight management in schizophrenic patients. We present the cases of three Taiwanese patients with schizophrenia whose bodyweight increased as a result of atypical antipsychotics treatment, then was controlled by topiramate without aggravation of their psychotic symptoms.

Influence of topiramate on olanzapine-related adiposity in women: a random, double-blind, placebo-controlled study

The aim of this study was to compare the efficacy of topiramate versus a placebo in the treatment of adiposity in women undergoing olanzapine therapy. We also assessed changes health-related quality of life, the patient's actual state of health, and psychologic impairments. The 10-week, random, double-blind, placebo-controlled study included 43 women who had been treated with olanzapine (mean dose 7.8 +/- 3.6 in the topiramate group and 7.2 +/- 3.1 in the placebo group) and had gained weight as a side effect. The subjects were randomly assigned to topiramate (n = 25) or a placebo (n = 18). Primary outcome measures were weight checks and self-reported changes on the scales of the SF-36 Health Survey, Bf-S Scale of Well-Being, and the Adjective Checklist EWL-60-S. Weight loss was observed and was significantly more pronounced in the topiramate-treated group (difference in weight loss between the 2 groups: 5.6 kg, 95% CI = -8.5, -3.0, P < 0.001). In comparison with the placebo group, significant changes on 7 (7/8) scales of SF-36 Health Survey (all P < 0.001), on all 6 scales of the EWL-60-S, and on the Bf-S were observed in the topiramate-treated subjects after 10 weeks. All patients tolerated topiramate well. Topiramate appears to be a safe and effective agent in the treatment of weight gain that occurred during olanzapine treatment. Significantly positive changes in health-related quality of life, the patient's actual state of health, and psychologic impairments were observed.

Differential effects of topiramate in patients with traumatic brain injury and obesity--a case series

RATIONALE

Topiramate is an antiepileptic drug known to have effects on weight. In order to use this as a tool to treat eating disorders, it is useful to examine whether these effects can be predicted in certain patients.

OBJECTIVES

To report the effects of topiramate, initiated for the treatment of epilepsy, on top of ongoing treatment, on eating patterns and weight of 17 patients with traumatic brain injury (TBI) with post-traumatic epilepsy and weight gain of various etiologies.

METHODS

Patients were followed up according to their usual treatment plan. Topiramate was added on top of current and stable treatment. Dose was titrated based on the patients' neurological status. Patients were asked to report side effects. No other changes were made.

RESULTS

Of the 17 patients included, one patient dropped out. Six patients with binge eating disorder (BED) demonstrated the most pronounced effects, with marked attenuation of binges and normalizing body mass index. Less noticeable were the effects in patients with mood disorders. Topiramate was ineffective in patients whose overweight was a side effect of their medication. Side effects were rated as mild and included somnolence, paresthesias, mild cognitive disturbances and some gastrointestinal disturbances.

CONCLUSIONS

In this report of the actual effects of topiramate in a clinical setting on weight and eating habits of 17 patients with TBI and obesity of various etiologies, topiramate seemed to be a safe intervention. Topiramate appeared to be differentially effective, with particular effects on primary pathological eating patterns.

Nutritional intervention to prevent weight gain in patients commenced on olanzapine: a randomized controlled trial

OBJECTIVE

Olanzapine is the most commonly prescribed atypical antipsychotic medication in Australia. Research reports an average weight gain of between 4.5 and 7 kg in the 3 months following its commencement. Trying to minimize this weight gain in a population with an already high prevalence of obesity, mortality and morbidity is of clinical and social importance. This randomized controlled trial investigated the impact of individual nutrition education provided by a dietitian on weight gain in the 3 and 6 months following the commencement of olanzapine.

METHOD

Fifty-one individuals (29 females, 22 males) who had started on olanzapine in the previous 3 months (mean length of 27 days +/- 20) were recruited through Peninsula Health Psychiatric Services and were randomly assigned to either the intervention (n = 29) or the control group (n = 22). Individuals in the intervention group received six 1 hour nutrition education sessions over a 3-month period. Weight, waist circumference, body mass index (BMI) and qualitative measures of exercise levels, quality of life, health and body image were collected at baseline at 3 and 6 months.

RESULTS

After 3 months, the control group had gained significantly more weight than the treatment group (6.0 kg vs 2.0 kg, p < or = 0.002). Weight gain of more than 7% of initial weight occurred in 64% of the control group compared to 13% of the treatment group. The control group's BMI increased significantly more than the treatment group's (2 kg/m(2)vs 0.7 kg/m(2), p < or = 0.03). The treatment group reported significantly greater improvements in moderate exercise levels, quality of life, health and body image compared to the controls. At 6 months, the control group continued to show significantly more weight gain since baseline than the treatment group (9.9 kg vs 2.0 kg, p < or = 0.013) and consequently had significantly greater increases in BMI (3.2 kg/m(2)vs 0.8 kg/m(2), p < or = 0.017).

CONCLUSION

Individual nutritional intervention provided by a dietitian is highly successful at preventing olanzapine-induced weight gain.

Body mass index (BMI) in newly admitted child and adolescent psychiatric inpatients

INTRODUCTION

Obesity is a major problem among children and adolescents suffering from chronic mental illness. State-of-the-art measures such as body mass index (BMI) and growth-related weight charts are now readily available to clinicians and investigators interested in psychotropic drug-associated weight gain in the pediatric population. However, no reports that utilize such measures in large series of children and adolescents with psychiatric disorders are available.

METHODS

The authors employed the Nutstat module of the Centers for Disease Control and Prevention (CDC) Epi Info software to assess BMI in a psychiatry inpatient child and adolescent population in Central Virginia. The authors also developed a scoring system to relate psychotropic administration to BMI.

RESULTS

Children and adolescents with chronic mental illness had greater BMI measurements than the general pediatric population. Our scoring system found a relationship between antipsychotic drug administration and increased BMI that almost reached a level of significance (p=0.062).

CONCLUSIONS

The present methodology using absolute weight to assess psychotropic drug-associated increase in body weight for children and adolescents is unsatisfactory. The authors offer a new and convenient methodology to correct this problem.

Short- and long-term efficacy and safety of risperidone in adults with disruptive behavior disorders

RATIONALE

Function in society can be severely affected by disruptive behaviors in adults.

OBJECTIVES

To examine the efficacy and safety of risperidone in the treatment of disruptive behavior disorders in intellectually disabled adults.

METHODS

Intellectually disabled patients with disruptive behavior disorder were randomly assigned to receive risperidone (n = 39) in a flexible dosage ranging from 1 to 4 mg/day (mean dosage, 1.45+/-0.08 mg/day) or placebo (n = 38) for 4 weeks of double-blind treatment. Efficacy at endpoint was measured primarily by using the Aberrant Behavior Checklist (ABC); secondary efficacy measures included the Behavior Problems Inventory and Clinical Global Impressions scales. After this 4-week period, patients could enter open-label treatment with risperidone for 48 weeks.

RESULTS

Risperidone was well tolerated, and patients treated with risperidone demonstrated significantly greater improvement at endpoint on the ABC than those who received placebo [-27.3 points (52.8% improvement) versus -14.9 points (31.3% improvement); P = 0.036] and also improved on Behavior Problems Inventory and Clinical Global Impressions ratings. Over the 48-week, open-label follow-up period, there was a further decrease of 6.3 points (P < or = 0.05) on the ABC for patients who initially received risperidone and a decrease of 11.3 points (P < or = 0.05) for patients who initially received placebo and were switched to open-label risperidone. These results were achieved with a mean modal dosage of 1.8 mg/day.

CONCLUSION

Risperidone is efficacious and well tolerated in managing disruptive behavior disorders in adults with intellectual disability.

Clinical experience with Topiramate to counteract neuroleptic induced weight gain in 10 individuals with autistic spectrum disorders

Children and adolescents with autistic spectrum disorders are treated with neuroleptics to limit behavioral disturbances such as aggression, hyperactivity and self-injury. They may experience substantial weight gain when undergoing treatment with atypical antipsychotics actually employed. Topiramate (TPM) is an antiepileptic medication that is being progressively demonstrating a wider spectrum of action, mainly as an agent for weight control and as a mood stabilizer. It was administered to a group of children and adolescents with autistic spectrum disorders with the aim of reversing weight gain. This is an open study over an observation period of 18 months of 10 children and adolescents, eight males and two females, mean age 13 years, SD+/-3.6, range 8-19 years with a diagnosis of autistic disorder or pervasive developmental disorder not otherwise specified according to DSM-IV. Starting dosage of TPM was 0.5 mg/kg followed by titration of 0.5 mg/kg on a weekly basis, up to 1-3 mg/kg/day as the maintenance dosage. Eight subjects were undergoing long-term treatment with risperidone, one with pimozide and one was temporarily not on antipsychotics. Six patients took TPM on a regular basis and four dropped out. Variable degrees of weight reduction were observed in four patients, two subjects showed weight increase. Behavioral adverse effects were observed in three patients causing rapid withdrawal of the medication. TPM should be used with caution in autistic spectrum disorders because this population has a high risk of behavioral disruption.

Current Options in the Management of Olanzapine-Associated Weight Gain

OBJECTIVE:

To evaluate options for the management of weight gain associated with olanzapine therapy.

DATA SOURCES:

MEDLINE (1966–May 2004), International Pharmaceutical Abstracts (1970–August 2003), The Cochrane Library, and EMBASE (1974–August 2003) databases were searched using the key words antipsychotics, atypical antipsychotics, olanzapine, and weight gain. Bibliographies of cited articles were reviewed.

STUDY SELECTION AND DATA EXTRACTION:

All articles identified from the data sources were evaluated and all information deemed relevant was included for this review.

DATA SYNTHESIS:

Weight gain is a common adverse effect of olanzapine, a member of the atypical antipsychotic class. Data are limited supporting a specific therapeutic approach to the management of weight gain with olanzapine treatment. Reversal of weight gain with lifestyle modifications and adjunctive pharmacologic therapies such as nizatidine and amantadine has been modest. Experience with adjunctive pharmacologic treatment has been limited to small, observational studies and case reports. Although data are limited, weight reduction has been observed in select patients switching from olanzapine to an alternative atypical antipsychotic.

CONCLUSIONS:

At this time, targeting lifestyle modifications provides the most reasonable approach to minimize weight gain observed with olanzapine therapy. Preliminary evidence evaluating adjunctive pharmacologic treatment for this indication has demonstrated minimal clinical benefit. Switching to an alternative atypical antipsychotic agent associated with less significant weight gain may be appropriate in select patients. Further clinical trials are needed to support a specific therapeutic approach to managing weight gain with olanzapine.