Obesity in Patients With Psychiatric Conditions

People with mental illness face the harsh reality that they may die decades earlier than people without mental illness. Much of the increased morbidity and mortality in this population is due to preventable medical conditions. Lifestyle choices, adverse effects of psychotropic medication, disparities in living and working conditions, and lack of access to and use of health care contribute to poor physical health outcomes. Obesity-one of the most common physical health comorbidities with psychiatric disorders-is a major contributor to medical morbidity and mortality, and is the focus of this article. To address the multitude of factors that influence obesity in patients with psychiatric conditions adequately, a confluence of patient, provider, and system factors is highlighted.

Obesity is a significant and growing health crisis that affects both developed and developing countries. Nearly 70% of adults in the United States are overweight or obese.¹ Projections are that this percentage might increase to 75% by 2015. Excess body weight increases the risk for many medical problems, including diabetes, heart disease, osteoarthritis, hypertension, and many cancers. Obesity rates are higher in people with psychiatric conditions and vary by psychiatric diagnosis. Individuals with schizophrenia have a 2.8 to 3.5 increased likelihood of being obese, and those with MDD or bipolar disorder have a 1.2 to 1.5 increased risk.^2,3 An expert panel identified obesity and mental illness as an “. . . epidemic within an epidemic, which requires a public health perspective, including prevention and early intervention across the lifespan.”⁴

What new information does this article provide?

This article provides information about new strategies and approaches at the patient, provider, and system levels that address obesity in individuals with psychiatric conditions. It highlights how promising lifestyle interventions and collaboration with primary care providers can reduce obesity in these individuals. New research about patient awareness of having a weight problem and how this relates to psychiatric intervention is discussed.

What are the implications for psychiatric practice?

Obesity is a major contributor to excess medical morbidity and mortality in individuals with psychiatric conditions. The selection of medication and monitoring of weight and other health factors as well as collaboration between psychiatrists, patients, and primary care providers can affect psychotropic-associated weight gain and obesity, which may improve both physical and psychiatric outcomes.

An unhealthy lifestyle, the effects of psychotropic medications, insufficient income for a healthy diet and/or exercise program, and inadequate knowledge and life skills contribute to weight problems in persons with psychiatric conditions. Obesity also affects self-esteem and is associated with stigma and discrimination. Research suggests that persons with psychiatric disorders are less likely to know that they have a weight problem.⁵ Unawareness and motivation are key factors that require assessment and implementation of stage-appropriate interventions.

The role of the psychiatrist/prescriber

Medications are often the mainstay of behavioral health treatment, especially for psychotic disorders. However, since the advent of the atypical antipsychotics, obesity has become more prevalent. Efficacy may differ from drug to drug, and patient to patient, as may the degree of weight change, making medication selection and monitoring for weight gain a complex issue. Moreover, weight gain and metabolic disturbances are major adverse effects of several classes of psychotropic medications, including antidepressants, antipsychotics, and mood stabilizers. Psychiatrists are increasingly aware that weight gain and its complications may cause significant distress among patients. This can complicate medication selection, medication adherence, and medication management.

Monitoring body weight is essential, and weight gain early in treatment may predict those at risk for substantial weight gain. Showing a patient his or her BMI on a BMI chart can help the patient understand the health risks of weight gain (Table 1). Waist measurement also helps screen for possible health risks related to overweight and obesity in adults. The risk of coronary artery disease and diabetes increases with a waist size greater than 35 inches in women or greater than 40 inches in men. An elevated BMI and waist circumference help in diagnosing obesity, which should be documented on Axis III (under general medical conditions) of the multiaxial system of DSM.

Many clinicians feel that in addition to monitoring weight, monitoring blood pressure, glucose and lipid levels, and waist circumference also falls within the scope of psychiatric practice. Practice guidelines and expert consensus urge behavioral health care providers to play a larger role in the detection and intervention of medical conditions such as metabolic disturbances.^6,7 A multidisciplinary team approach, including monitoring support, allowing the patient an active role, and collaborating with a primary care provider (PCP), may help meet practice guidelines, facilitate the integration of physical health into behavioral health care, and improve weight and other outcomes.

Many weight management interventions, such as using a scale and BMI chart, selecting medications with lower risk of weight gain, and assessing the patient’s awareness of a weight problem, can be easily implemented in most psychiatric settings. During the initial appointment, obtain a baseline height and weight, then ask: “Do you consider yourself underweight, normal weight, or overweight?” This simple question provides invaluable information about awareness of having a weight problem. If a person is overweight or obese, using a motivational approach such as asking permission to discuss the persons’ weight and its health effects can initiate a discussion: “Is it okay if we discuss whether your weight is in a healthy range for your height?”

CASE VIGNETTE

Tyler is a 29-year-old man with schizoaffective disorder and obesity (BMI = 35). When weight gain was observed in medication sessions, Tyler was given brief nutritional and physical activity counseling for losing weight. Because Tyler looked confused, his psychiatrist assessed Tyler’s awareness of the problem. Tyler knew that he had gained weight since high school, but he believed his body weight was normal.

According to the Transtheoretical Model of Change, Tyler was in the precontemplation stage (unaware of the problem); the appropriate stage-based intervention at this point is to raise awareness of the problem. It was too soon to offer advice on weight loss strategies; however, showing Tyler his health risk on a BMI chart (high risk of health problems), discussing his weight-related health problems (hyperlipidemia and elevated blood pressure), and offering to make a referral to a PCP helped move him toward action-oriented interventions. Within 2 months, Tyler had lost 5 lb.

A discussion with the patient on the need to self-monitor weight and “small steps” for maintaining healthy weight (Table 2) is essential when initiating psychotropic medication. More intensive nonpharmacological therapies that combine education about nutrition, behavior change, and physical activity should be implemented if the initial steps do not work and there is an ongoing or emerging weight problem.

Solutions for Wellness (SFW) is a science-based, no-cost, lifestyle program, designed specifically for persons with mental illness.⁸ SFW is copyrighted by Eli Lilly and Company and in 2013 was added to the Substance Abuse and Mental Health Services Administration’s national registry of evidence-based practices and programs. SFW groups have been implemented in hundreds of behavioral health organizations across the US and other countries.⁹ Research suggests that adults with psychiatric conditions who participate in SFW experience significant improvement in BMI, blood pressure, and waist circumference.^10-12

Findings indicate that weight reduction is enhanced by using behavioral strategies combined with diet and exercise strategies.^13,14 Although medications and bariatric surgery can be considered in cases of obesity refractory to lifestyle modifications, there is insufficient evidence to support the general use of medications for weight loss in people with serious mental illness. Caution is warranted when prescribing the newer weight loss drugs (eg, lorcaserin and phentermine hydrochloride/topiramate extended-release) because they have potential serious interactions with several classes of psychiatric medications.^15,16 Bariatric surgery has also not been systematically studied in patients with psychiatric disorders, and uncontrolled psychiatric illness is a contraindication to surgery.^4,14 Individual risks and benefits of pharmacological or surgical interventions should be explored carefully only after nonpharmacological interventions have failed.

Organizational change

Organizational change can be challenging, but when it is strategically planned, the process can be successful and rewarding. University of Medicine and Dentistry of New Jersey-University Behavioral HealthCare (UBHC) began integrating physical and mental health nearly a decade ago after a review showed greater morbidity and mortality in patients with excess weight. A physical health committee was charged with promoting the physical health of patients. The committee’s goal is improved documentation of Axis III diagnoses (including obesity) and better access to and use of primary care. Obesity and tobacco use are the primary targets.

Quarterly health status monitoring was introduced in 2004, and documentation of height, weight, BMI, blood pressure, and waist circumference became standard practice. Recently, “wellness stations” were implemented that allow patients to self-monitor health measures. The wellness stations provide educational materials. In addition, patients can weigh themselves, consult BMI charts, use tape measures to check their waist circumference, and check their blood-pressure. Self-monitoring of weight and other health measures empowers patients and may help prevent or minimize weight gain and/or foster weight loss. The facility also provides “Wellness Trackers” so that patients can track their medications as well as self-monitor health measures. Two integrated health centers have recently been created that provide improved access, use, and collaboration with primary care.

Collaboration between behavioral health and primary care

Many individuals with psychiatric conditions have difficulty in accessing medical care and frequently rely on the use of emergency department services for their health care needs. A meta-analysis revealed that 35% of persons with a serious mental illness had at least one undiagnosed medical disorder in addition to having higher rates of physical health problems.¹⁷ Psychiatric practitioners may be the primary source of contact with the individual. Therefore, to improve access and quality of care, a holistic approach that forms a partnership between primary care and behavioral health is recommended. The best outcomes are seen when behavioral health providers and PCPs collaborate in an organized way.

Person-centered health care homes that take a care management team approach to support patients in self-management goals are evolving. At the most integrated level, this model would co-locate PCPs with psychiatrists to optimize patient outcomes. There is strong evidence that integrated care programs for patients with comorbid chronic mental and medical conditions generally have positive outcomes in regard to control of chronic conditions and cost. Components of integrated care models include a multidisciplinary team, support for patient self-management, patient education, care management, and feedback to clinicians. Care management that helps link individuals to a variety of services and that provides assistance and support to better manage health conditions is a key component of the health home.

CASE VIGNETTE

Now 33, Margaret received a diagnosis of bipolar II disorder in her early 20s. Morbidly obese with multiple comorbidities (type 2 diabetes mellitus, hypertension, hyperlipidemia, asthma, and polycystic ovary syndrome), she is being treated by a psychiatrist and a PCP in an integrated health program.

Through sustained effective transfer of clinical information between providers regarding medication changes, laboratory results, and changes in BMI, it became apparent that Margaret’s worsening diabetes control and 20-lb weight gain were directly correlated to treatment with olanzapine, which had been selected, in part, because Margaret did not have a prescription plan and medication samples were readily available. The treating providers worked together to switch from olanzapine to aripiprazole, with continued monitoring of blood sugar and weight, and adjustment of diabetes medication as appropriate. Consequently, Margaret experienced mood stabilization, reduction in BMI, and marked improvement in diabetes control. These results are similar to those seen when a medication associated with a higher risk of diabetes and weight gain was switched to one of lower risk in the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study.¹⁸

Group medical visits are a novel collaborative approach for PCPs and psychiatric providers to treat obesity together and have been successfully implemented by the UBHC’s integrated health program. Consumers participating in group medical visits divide their time between an educational interactive group using motivational and behavioral techniques, and a brief individual medical visit with a PCP to review control of obesity-related comorbidities. Group medical visits have been shown to improve patient and physician satisfaction and quality of care and quality of life, as well as decrease health care use, particularly visits to the emergency department.¹⁹

Summary

Obesity is one of the most common physical health problems in individuals with psychiatric conditions and contributes to excess medical morbidity and mortality. Several classes of psychotropic medications, particularly atypical antipsychotics, cause weight gain. Therefore, selection of medication and monitoring of weight and other health indicators are important factors for prescribers and patients to consider. While these issues pose challenges to optimal health, the good news is that there are solutions and emerging strategies. Lifestyle interventions that incorporate nutrition, physical activity, and behavioral strategies are the most promising.

Disclosures:

Ms Vreeland is Advanced Practice Nurse at the University of Medicine and Dentistry of New Jersey (UMDNJ)–University Behavioral HealthCare (UBHC) in Voorhees, NJ, and Clinical Assistant Professor, department of psychiatry, at UMDNJ–Robert Wood Johnson Medical School in Piscataway, NJ. Dr Sharma is a psychiatrist at UMDNJ–UBHC and Instructor at UMDNJ–Robert Wood Johnson Medical School. Ms Miller is Vice President, Acute and Nursing Services, at UMDNJ-UBHC. Dr Mravcak is Assistant Professor, department of family and community medicine, at UMDNJ–Robert Wood Johnson Medical School, Eric B. Chandler Health Center, in New Brunswick, NJ. Ms Vreeland reports that she is coauthor of Solutions for Wellness; Ms Miller and Drs Sharma and Mravcak report no conflicts of interest concerning the subject matter of this article.

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