Obesity among Patients with Schizophrenia: When we Fix One Problem and Create Another

One day I had a conversation with one of my patient with schizophrenia at his home. He was discharged from the hospital and admitted to a Community psychiatric treatment, where I worked at that time. He was stable, without symptoms. However at that moment his major problem and the main reason for his admission to a Community psychiatric treatment was social isolation. He told me: “I was admitted to a hospital because I had voices, and I was really scared, so I didn’t left the house. Psychiatrist at the ward gave me an antipsychotic medication, and symptoms slowly vanished. Now I am at home, I don’t hear voices, I am not afraid anymore, but I don’t socialize with other people and I don’t go out of the house. I am ashamed because of my obesity, I have gained 30 kilograms”.


Opinion
One day I had a conversation with one of my patient with schizophrenia at his home. He was discharged from the hospital and admitted to a Community psychiatric treatment, where I worked at that time. He was stable, without symptoms. However at that moment his major problem and the main reason for his admission to a Community psychiatric treatment was social isolation. He told me: "I was admitted to a hospital because I had voices, and I was really scared, so I didn't left the house. Psychiatrist at the ward gave me an antipsychotic medication, and symptoms slowly vanished. Now I am at home, I don't hear voices, I am not afraid anymore, but I don't socialize with other people and I don't go out of the house. I am ashamed because of my obesity, I have gained 30 kilograms".
It seems like that sometimes we fix one problem, and create another. A lot of times we treat the symptoms of the schizophrenia, and we are quite successful, but at the same time we are not aware, that we are causing another problem which can cause as harmful and devastating consequences for the patient as the symptoms of schizophrenia.
Second Generation Antipsychotics (SGAs), such as clozapine, olanzapine, risperidone and quetiapine, are among the most effective therapies to stabilize schizophrenia symptoms. In fact, SGAs have improved quality of life of billions schizophrenia patients worldwide [1].
However, despite the proven broad spectrum of efficacy and low risk of extrapyramidal symptoms compared to first generation [1] studies have linked SGA use with excessive weight gain, and the development of characteristics of the metabolic syndrome, including insulin resistance, and an atherogenic lipid profile. The major implication of SGA-induced weight gain are an increased risk of chronic health condition such as diabetes and cardiovascular disease as well as a greater risk of medication nonadherence, which may lead to lower quality of life [2]. Fatigue and weight gain are the most common side effects that affect medication adherence [3].
Reasons for weight gain include various physical and nutritional factors in a patient's life, but sometimes weight gain is iatrogenic. Many medications we prescribe in treatment of schiziophrenia are associated with weight gain, including most SGAs and antidepressants [4].
In psychiatry we are often oriented in treating "the mind" and forgeting about the body. Mentalhealth professionals asociate succesfull treatment outcome as absence of psychiatic symptoms. However patients doesn't always agree with this "definition".
Management of weight gain in patient treated SGAs can be challenging. The ideal aproach would be to provide early intervention to prevent weight gain. Nguyen and colleagues implemented a diet modification program, which is designed to reduce hunger and enhance satiety, two of the main side effects noted by patients taking SGAs. The WIN Nguyen diet includes four simple nutritional changes (1) the elimination of second servings, (2) the replacement of highcalorie snacks with fruits and vegetables, (3) the elimination of desserts, and (4) substitution of water for sodas and juices [5].
Before initiation of SGAs prescribing providers should always consider patients' current life style, health condition (diabetes, body weight, cholesterol levels,…) and also his motivation for makeing behavioural changes in his life style. Last but not least it is important to constantly monitor SGA users for weight gain and other risk factors for chronic health conditions and cardiovascular diseases.
Given the potential risks associated with weight gain among patients with schizophrenia treated with SGAs, mental health professionals should use a sheared decision making approach, explaining the potential benefits and risks of SGAs. Good therapeutic relationship between patients and mental health workers is the basis for succesfull weight management strategies (i.e., diet, exercise) that may reduce the potential risk of weight gain associated with the use of SGAs.