Improving Weight and Related Side-Effects of Antipsychotic Medication

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Improving Weight and Related Side-Effects of
Antipsychotic Medication

• Alexander S. Young, MD, MSHS
• Amy N. Cohen, PhD
• VISN-22 Mental Illness Research, Education, and
  Clinical Center (MIRECC)
• UCLA Department of Psychiatry

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Overview

• Antipsychotic medications weight gain
• Management of weight gain
• Quality of usual care
• EQUIP options for improving care

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CATIE Results Weight Gain Per Month of
Treatment
Weight gain (lb) per month
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Risk of Death Increases with BMI
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Waist Circumference and BMI Increasethe Risk of
Diabetes, Hypertension,and Cardiovascular Disease
BMI Waist men 40 inches women 35 inches Waist gt 40 inches gt 35 inches
Underweight lt 18.5 - -
Normal 18.5 24.9 - -
Overweight 25.0 29.9 Increased High
Obese 30.0 34.9 35.0 39.9 High Very High Very High Very High
Extremely Obese 40 Extremely High Extremely High
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Weight Management Programs Are Effective

• Group and individual psychoeducation improves
  weight in people with psychotic disorders
• these are specialized programs
• numerous controlled research trials
• Weight loss is modest average 5 lbs
• Modest weight loss is associated with health
  benefits

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EQUIP Weight Management Program

• Located in specialty mental health
• led by mental health clinician
• tailored for learning disabilities
• 16 sessions
• each focused on one nutrition or exercise topic
• Handouts for every session
• large font
• room for patients notes
• Food models
• Fast food guide

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Weight ManagementSession Content

1. Poor diet and health problems
2. Food pyramid and portion sizes
3. Food pyramid and portion sizes (continued)
4. Increasing fiber intake
5. Increasing water intake
6. Importance of exercise
7. Decreasing fat and cholesterol
8. Starting to exercise

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Weight ManagementSession Content (contd)

1. Limiting sugar intake
2. Walking as exercise
3. Controlling hunger
4. Limiting salt fast food
5. Expected lifestyle changes
6. Avoiding alcohol
7. Making exercise a daily routine
8. Review and summary

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Changing Antipsychotic MedicationCan Cause
Weight Loss

• CATIE study
• Among patients who gained more than 7 of weight
  in Phase 1
• When switched to the following, how many lost
  more than 7
• olanzapine 0
• quetiapine 7
• risperidone 20
• ziprasidone 42

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Changing from Olanzapine toAripiprazole Causes
Weight Loss

• Newcomer et al 2008
• Overweight patients on olanzapine
• Switch to aripiprazole vs. remain on olanzapine
• randomized controlled trial, n173, 16 weeks
• Results
• weight change (pounds) -4.0 vs. 3.1
• lost more than 7 11.1 vs. 2.6
• lipids improved
• CGI-Improvement no change - minimal improvement

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How Are We Doing?

• Most research on quality of care for
  schizophrenia was performed in 1990s
• 1st generation antipsychotic medications
• Newer 2nd generation antipsychotics
• fewer neurologic side-effects
• more weight gain (varies by agent)
• Change in
• frequency of clinical problems?
• appropriateness of treatment?

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Methods

• Random sample of patients with schizophrenia
• 3 VA mental health clinics (n398)
• Patient interviews
• symptoms psychosis, depression
• side-effects parkinsonism, akathisia, tardive
  dyskinesia, weight gain
• Prescription data
• Use explicit criteria to evaluate appropriateness
• derived from national guidelines

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Results

• Clinical problems
• few patients had depression without psychosis
  (3), parkinsonism (2), or akathisia (1)
• 44 had severe psychosis
• 11 had tardive dyskinesia
• 46 were substantially overweight
• Appropriate medication changes
• 27 of patients with psychosis
• 2 of patients with elevated weight

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Conclusions

• Problems in care were equally common at all 3
  clinics
• Compared with the 1990s
• patients more likely to have severe psychosis
• quality of care for psychosis is unchanged
• weight is now the most important side-effect
• treatment rarely changed in response to weight

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Improving Care Options

• Routine monitoring of weight
• Clinician education
• Patient education
• Make services available

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Enhancing QUality of care In Psychosis (EQUIP)

• 3-year clinic-level controlled trial
• funded by VA HSRD QUERI
• 4 VISNs 3, 16, 17, 22
• 320 providers, 900 patients
• intervention evidence-based quality improvement,
  improved patient information, care reorganization
• weight
• employment

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EQUIP Leadership Team
VISN 16 Anna Teague, MD (PI Houston) Dean
Robinson, MD (PI Shreveport)Kathy Henderson,
MDAvila Steele, PhD
VISN 3Eran Chemerinski, MD (PI Bronx) Charlene
Thomesen, MD (PI Northport) Deborah Kayman, PhD
VISN 22Christopher Reist, MD (PI Long
Beach)Larry Albers, MD David Franklin, PsyD, MPH
VISN 17Max Shubert, MD (PI Central
Texas)Wendell Jones, MDStaley Justice, MSW
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Routine Monitoring of Weight

• In specialty mental health
• Challenges
• purchase scales
• check weight at every visit

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Patient Education
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Make Services Available Wellness Groups

• Challenges
• services not currently provided
• few clinicians believe weight is a high priority
• patient motivation
• patient transportation
• Facilitators
• clinicians like providing the groups
• audio (VANTS) or video
• PRRCs

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Make Services Available Medication Change

• Challenges
• psychiatrists are not changing medications
• few psychiatrists believe this is a high priority
• Its too hard for patients to lose weight.
• Symptom management is more important.
• medication changes require early follow-up
• Facilitators
• start with ziprasidone and aripiprazole
• next try risperidone or quetiapine
• provide patient-specific feedback

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Summary

• Individuals with psychotic disorders are at a
  high risk for weight gain and related medical
  problems
• Monitoring
• weight at every visit at home
• Implementation
• weight management groups
• medication change