25/10/2017 1 Psychotropics and Weight gain Dr Marlene Tham Director of Melbourne Weight Loss Director of Medical & Mind Weight Loss Medical & Weight Loss Practitioner for Epworth Clinic Honorary Research Fellow for Department of Psychiatry, University of Melbourne www.medicalmindweightloss.com Who am I? A Widening Gap – the stats on Mental illness • average life expectancy 50 to 59 years, 20 years less than the general population average (Lambert) - 77.7% of excess deaths are due to physical health conditions, more than suicides alone. • higher rates of physical illness: 50% reported being treated for this (Lambert) -higher deaths from cardiometabolic conditions and cancers -significant under treatment of physical illness (Ryan, Maina) • more than 50% develop metabolic syndrome (MetS) (Dickenson , 2006; Gallently, 2012) • Obesity also produces poor outcomes of mental health treatment (Lambert) Lambert, T. (2009). The medical care of people with psychosis. Medical Journal of Australia, 190(4), 171-172. Ryan MC, Flanagan S, Kinsella U, Keeling F, Thakaore The effects of atypical antipsychotics on visceral fat distribution in first episode, drug-naive patients with Scizophrenia. JG Life. 2004 Mar 5;74(16):1999-2008. Dickerson, F. B., Brown, C. H., Kreyenbuhl, J. A., Fang, L., Goldberg, R. W., Wohlheiter, K. and Dixon, L. B. (2006), Obesity among individuals with serious mental illness. Acta Psychiatrica Scandinavica, 113: 306–313. doi:10.1111/j.1600-0447.2005.00637.x What is Metabolic Syndrome (MetS)? Three main causes in people with mental illness: 1) pathophysiology of the disease 2) illness itself and 3) psychotropic treatment KEY POINT: Genetics, pathophysiology and the illness play a role, NOT JUST psychotropics MetS is a cluster of interrelated risk factors for developing cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM) 1. Pathophysiology of the disease More prevalent family histories of diabetes and CVD Genetic linkage to Type 2 DM, Hyperlipidemia, Hypertriglyceridemia • Insulin resistance has been reported in psychotic patients even in the pre- neuroleptic era. (Freeman 1946) • Increased rates of Type 2 DM observed in family members of persons with psychosis. (19-30%) (Mukherjee 1989) • 1 st episode drug naive psychosis patients have significantly increased impaired glucose tolerance and higher insulin resistance relative to healthy comparison subjects. (15%) (Ryan 2003) • Mukherjee S, Schnur DB, Reddy R: Family history of type 2 diabetes in schizophrenic patients (letter). Lancet 1989; 1:495 2. Illness itself Illness itself confers a risk Patients have a physical health profile similar to the general population that are 10 to 15 years older due to: • poor nutrition, • homelessness, • reduced access to basic health care Lifestyle and environment factors • Sedentary lifestyle/poor/low physical activity - 97% (Galletly) • Smoking, homelessness, poverty • Eating precooked/heat & eat or take away meals • High volume of unhealthy snacks, sugary drinks Symptoms • Lack of motivation • Negative symptoms Galletly, C.A; et al; Cardiometabolic risk factors in people with psychotic disorders; the 2ndNational survey of psychosis. Aust N Z J Psychiatry, 2012;46(8):753-61
Transcript
25102017
1
Psychotropics and Weight gain
Dr Marlene ThamDirector of Melbourne Weight Loss
Director of Medical amp Mind Weight Loss
Medical amp Weight Loss Practitioner for Epworth Clinic
Honorary Research Fellow for Department of Psychiatry University of Melbourne
wwwmedicalmindweightlosscom
Who am I
A Widening Gap ndash the stats on Mental illnessbull average life expectancy 50 to 59 years 20 years less than the general population average
(Lambert)
- 777 of excess deaths are due to physical health conditions more than suicides alone
bull higher rates of physical illness 50 reported being treated for this (Lambert)
-higher deaths from cardiometabolic conditions and cancers
-significant under treatment of physical illness (Ryan Maina)
bull more than 50 develop metabolic syndrome (MetS) (Dickenson 2006 Gallently 2012)
bull Obesity also produces poor outcomes of mental health treatment (Lambert)
Lambert T (2009) The medical care of people with psychosis Medical Journal of Australia 190(4) 171-172
Ryan MC Flanagan S Kinsella U Keeling F Thakaore The effects of atypical antipsychotics on visceral fat distribution in first episode drug-naive patients with Scizophrenia JG Life 2004 Mar 574(16)1999-2008
Dickerson F B Brown C H Kreyenbuhl J A Fang L Goldberg R W Wohlheiter K and Dixon L B (2006) Obesity among individuals with serious mental illness Acta Psychiatrica Scandinavica 113 306ndash313 doi101111j1600-0447200500637x
What is Metabolic Syndrome (MetS)
Three main causes in people with mental illness
1) pathophysiology of the disease 2) illness itself and 3) psychotropic treatment
KEY POINT Genetics pathophysiology and the illness play a role NOT JUST psychotropics
MetS is a cluster of interrelated risk factors for developing cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM)
1 Pathophysiology of the diseaseMore prevalent family histories of diabetes and CVD
Genetic linkage to Type 2 DM Hyperlipidemia Hypertriglyceridemia
bull Insulin resistance has been reported in psychotic patients even in the pre-neuroleptic era (Freeman 1946)
bull Increased rates of Type 2 DM observed in family members of persons with psychosis (19-30) (Mukherjee 1989)
bull 1st episode drug naive psychosis patients have significantly increased impaired glucose tolerance and higher insulin resistance relative to healthy comparison subjects (15) (Ryan 2003)
bull Mukherjee S Schnur DB Reddy R Family history of type 2 diabetes in schizophrenic patients (letter) Lancet 1989 1495
2 Illness itselfIllness itself confers a risk
Patients have a physical health profile similar to the general population that are 10 to 15 years older due to
bull poor nutrition bull homelessness bull reduced access to basic health care
bull Smoking homelessness povertybull Eating precookedheat amp eat or take away meals bull High volume of unhealthy snacks sugary drinks
Symptomsbull Lack of motivationbull Negative symptoms
Galletly CA et al Cardiometabolic risk factors in people with psychotic disorders the 2nd National survey of psychosis Aust N Z J Psychiatry 201246(8)753-61
25102017
2
3 Psychotropic weight gain
Mechanism of antipsychotics
bulla central effect in the hypothalamic control of appetite regulation
bullBlocking of serotonin (5HT2c) and
Histamine (H-1) receptors
Psychotropic medications lsquounmaskrsquo pre-existing riskCompliance is affected by weight gain (Tham Castle et al 2007)
Marlene S P Tham Simon G Jones James A Chamberlain and Professor David J Castle The impact of psychotropic weight gain on people with psychosis ndash patient perspectives and attitudesJournal of Mental Health Vol 16 Iss 62007
Binding Properties of typical amp atypical antipsychotics
Lett et al Pharmacogenetics of antipsychotic-induced weight gain review and clinical implications Molecular Psychiatry (2012) 17 242ndash266 doi101038mp2011109 published online 6 September 2011
Which Antipsychotic
Most weight gain
1ldquopinesrdquo2ldquodonesrdquo3ldquopipsrdquo
Antidepressants
Prevalence of MetS in patients with depression and on antidepressant (AD) medications
24X higher for patients with a Major Depressive Disorder (Kahl 2012)
uarr Fasting glucose and Tryglycerides in both men and women (McIntyre 2006)
uarr Cholesterol in women
Men ndash higher rates of fasting glucose and Tryglycerides when compared to women
Kahl KG Greggersen W Schweiger U et al Eur Arch Psychiatry Clin Neurosci (2012) 262 313 doi101007s00406-011-0277-4
Roger S McIntyre Joanna K Soczynska Jakub Z Konarski and Sidney H Kennedy The effect of antidepressants on lipid homeostasis a cardiac safety concern Expert Opinion on Drug Safety Vol 5 Iss 42006
Weight Gain on Commencement
Serretti amp Mandelli Antidepressants and body weight a comprehensive review and meta-analysis The Journal of Clinical Psychiatry [01 Oct 2010 71(10)1259-1272]
1-3kg average weight gain for 10-20 of population treated by them
25102017
3
Weight Gain Long Term
Green ndash LossYellow ndash neutralRed - Gain
Serretti amp Mandelli Antidepressants and body weight a comprehensive review and meta-analysis The Journal of Clinical Psychiatry [01 Oct 2010 71(10)1259-1272]
Mood Stabilizers
Allison DB Newcomer JW Dunn AL Blumenthal JA Fabricatore AN et al (2009) Obesity among those with mental disorders a National Institute of Mental Health meeting report Am J Prev Med 36 341ndash350
1) Education about weight gain amp side effects before treatment Informed consent about this risk US law suits
2) Routine monitoring of metabolic (blood sugars serum lipids) amp physical (BP abdominal girth weight) ndash see attachments ndash see attachment in slides
3) Diet exercise education and other lifestyle advice (smoking alcohol rec drugs)
- VLCD can be effective (RENEW Study Brown et al)
4) Behavioural modification 05kg ndash 07kg per week (Umbrict et al)
5) Psychological interventions (essential as an adjunct) to manage hunger amp emotional eating
- best studied amp most effective is CBT (Mohammad et al)
Brown C Goetz J Hamera E Weight Loss Intervention for People With Serious Mental Illness A Randomized Controlled Trial of the RENEW Program Psychiatric services (Washington DC) 201162(7)800-802 doi101176appips627800
DUmbrict H Flurry amp RBridler ldquoCBT for weight gainrdquo American Journal of Psychiatry vol158 no6 pp 971-972 2001
ALIMORADI Mohammad et al Cognitive Behavioral Therapy for Treatment of Adult Obesity International Journal of Medical Reviews [Sl] v 3 n 1 p 371-379 jun 2016 ISSN 2345-525X
wwwmedicalmindweightlosscom
CBT Strategies for Weight Management
bull Normalizing eating and reducing distressbull Body image therapy altering perception
and evaluation of selfbull Overcoming overeating and chaotic eatingbull Eliminating thinking errorsbull Addressing dysfunctional thinkingbull Being in tune with emotionsbull Mindfulness
Cognitive-Behavioral Treatment of ObesityAuthor Zafra Cooper Christopher G Fairburn Deborah M Hawker
online CBT weight management program Medical amp Mind Weight Loss - wwwmedicalmindweightlosscom
25102017
4
2017 Royal Australian and New Zealand College of Psychiatrists expert consensus statement for the treatment management and monitoring of the physical health of people with an enduring psychotic illness (Lambert et al)
The RANZCP released new physical activity guidelines April 2017
Systemic approach of websites books journal articles reviewed by 3 panels of 3 panels of Australian experts (55 clinicians21 carers 20 consumers)
Aimed for mental health and medical professionals people with enduring psychotic illness families and carers
bull Initial screening checklist (see appendix figure 2)
bull Education
bull Management
bull Follow up (see appendix figure 4)
bull collaboration
Pharmacological InterventionAnti-obesity drugs in the mental health population
1) Cease any drug that is causing rapid weight gain if possible
2) KEY POINT Stop the hunger
3) Anti-obesity drug MUST be carefully monitored due to side affects
ORLISTAT (over the counter reversible fat and lipase blocker)bull Advantages does not act centrally less risk of interaction with centrally acting
medicationsbull Must take other medications 1 hour before or after orlistat (Absoption)bull Schwartz amp Bealel reported average loss of 34 over 1 year (Antidepressants)bull No difference except in men (24kg) in 146 Schizophrenia patients taking
clozapine and olanzepine (Tchoukhine et al 2011)
TL Schwarts and M Beale ldquoPsychotropic induced weight gain alleviated with Orlistat ldquoPsychoharm Bulletin Vol 37 No1 pp 5-8 2003
Tchoukhine E Takala P Hakko H Raidma M Putkonen H Rasanen P Terevnikov V Stenberg JH Eronen M Joffe G (2011) Orlistat in clozapine- or olanzapine-treated patients with overweight or obesity a 16-week open-label extension phase and both phases of a randomized controlled trial J Clin Psychiatry 72(3)326ndash330
Phentermine
Anti-obesity drugs in psychiatric populations poorly studied as mental illness is often exclusion criteria
Anorexic drugs or appetite suppressantThe evidencePhentermine - poorly studied anti-obesity drug for psychotropic weight gain
- moderate success in binge eating syndrome (Devlin et al)
Common cardiac (sympathomimetic) and psychiatric side effectsbull tachycardia bull palpitationsbull insomnia bull Anxietybull elevated blood pressure
bull Devlin M J Goldfein J A Carino J S and Wolk S L (2000) Open treatment of overweight binge eaters with phentermine and fluoxetine as an adjunct to cognitive-behavioral therapy Int J Eat Disord 28 325ndash332 doi1010021098-108X(200011)283lt325AID-EAT10gt30CO2-3
Phentermine
Application to General Practice in mental health population
bull Good appetite suppressor against psychotropic induced hunger
bull Check history of use and side effects
bull Be wary of insomnia agitation flattening of mood anti-cholinergic effects (constipation) as triggers This MUST be monitored and may be a consideration not to use
bull Start low and go slow - 15mg to 30mg
bull Limitations cannot be used for extended periods of time physical side effects must be monitored
25102017
5
Liraglutide
bull Self administered daily injection
bull glucagon-like peptide-1 (GLP-1) agonist
bull Main side effects nausea vomiting diarrhoea constipation fatigue rashes
bull Less common (but more serious) hypoglycaemia pancreatitis gallbladder disease renal impairment mood changes increased depressive behaviour suicidal thoughts
The evidence
bull Efficacy and safety in psychiatric patients yet to be demonstrated
bull Major trial major depressive disorder or suicide attempt excluded 6 out of 3384 (02) reported suicidal ideation (Pi-Sunyer et al 1995)
Pi-Sunyer X Astrup A Fujioka K et al A Randomized Controlled Trial of 30mg of Liraglutide in Weight Management N Engl J Med 2015 373 11
LiraglutideApplication to General Practice in mental health population
bull Effective appetite suppressor especially at ldquostoppingrdquo the hunger
bull Low risk of increased suicide low to moderate risk of flattening if mood ndash dose dependent
bull Low or negligible risk of ldquooverdoserdquo unless combined with insulin
bull Consider using if poorly controlled diabetes
bull Careful monitoring ndash every 2 weeks in 1st 2 months
bull Work with psychiatrist and inform of commencement
bull Clozapine and olanzapine (ldquopinesrdquo) - best outcome maybe stopping hunger
bull Other anti-psychotics (ldquodonesrdquo) ndash much slower and reduced weight loss
bull Depressants bi-polar- very effective especially combined with VLCD
bull Limitations cost () nausea with psychotropic combined (delay start)
TopiramateApproved for migraines and epilepsy NOT approved for use for obesity This is an OFF LABEL DRUG
Psychiatrists ndash sometimes used as a mood stabiliser as weight neutral
Side effects fatigue cognitive dulling ataxia glaucoma sweating depression and anxiety
bull Schizophrenia ndash sustained weight loss of 5-7kg over 16 months (Lessig et al)
bull Modest weight loss 26kg to 5kg shown (Afshar et al Hahn et al)
bull Bipolar - studies have shown 33-55 of people losing 4-7kg weight (Gordon Price)
bull Depression - increase weight loss Improved QOL
bull Severe Mental illness ndash minimal weight (Gordon Price)
MC Lessig NA Shapira and TK Murphy ldquotopiramate for reversing atypical antipsychotic weight gain ldquoJournal of the American Academy of Child and AolesecentPsychiatry Vol 40 no 12 article 1364 2001
Gordon Price et al Mood Stabilization and Weight Loss With Topiramate American Journal of Psychiatry 156(6) pp 968andash969 1999
TopiramateApplication to General Practice in mental health population
bull Good appetite suppressor
bull Build up slowly from 125mg to 100mg
bull As off-label need to clear to why prescribing
- if needle phobic
- intolerant to other agents- cost of other medications
bull Consider if have co-existing epilepsy or migraines
bull Monitor for mental cloudiness memory loss depressed mood
Drugs in the pipeline
Qsymia Phentermine and topiramateLorcaserin selective 5-HT2C receptor agonist
Contrave Naltrexone + bupropion
Very little dataresearch in the mental health population
Bulimia and binge eating
The role of the GP and allied healthWhat factors can we change 1) Lifestyle and 2) Medication
bull Patients do want us involved (Tham Young et al)
bull We know our patients well we are in best positioned to give a tailored approach
bull Ensure basic fundamentals of lifestyle change (healthy eating smoking alcohol) are encouraged
bull Be involved in psychotropic prescribing
bull Work closely with your psychiatrist and ldquodiscussrdquo possible medication change amp side effects
bull Try Anti-obesity drug prescribing Monitor closely and if one doesnrsquot work try another
bull This is a lifelong chronic issue that takes time to change
Tham Marlene amp Young Doris The role of the General Practitioner in weight management in primary care ndash a cross sectional study in General
Practice BMC Family Practice2008966 DOI 1011861471-2296-9-66
25102017
6
Contact details Dr Marlene ThamMedical amp Mind Weight Loss (Redefinetrade CBT online program)
wwwmedicalmindweightlosscom
Melbourne Weight Loss
Practice address Epworth Camberwell
888 Toorak Road Camberwell Vic 3124
Phone 03 9805 4153
wwwmelbourneweightlosscom
Email Contact mthammelbourneweightlosscom
Blog httpwwwmedicalmindweightlosscomnews
wwwmedicalmindweightlosscom
25102017
2
3 Psychotropic weight gain
Mechanism of antipsychotics
bulla central effect in the hypothalamic control of appetite regulation
bullBlocking of serotonin (5HT2c) and
Histamine (H-1) receptors
Psychotropic medications lsquounmaskrsquo pre-existing riskCompliance is affected by weight gain (Tham Castle et al 2007)
Marlene S P Tham Simon G Jones James A Chamberlain and Professor David J Castle The impact of psychotropic weight gain on people with psychosis ndash patient perspectives and attitudesJournal of Mental Health Vol 16 Iss 62007
Binding Properties of typical amp atypical antipsychotics
Lett et al Pharmacogenetics of antipsychotic-induced weight gain review and clinical implications Molecular Psychiatry (2012) 17 242ndash266 doi101038mp2011109 published online 6 September 2011
Which Antipsychotic
Most weight gain
1ldquopinesrdquo2ldquodonesrdquo3ldquopipsrdquo
Antidepressants
Prevalence of MetS in patients with depression and on antidepressant (AD) medications
24X higher for patients with a Major Depressive Disorder (Kahl 2012)
uarr Fasting glucose and Tryglycerides in both men and women (McIntyre 2006)
uarr Cholesterol in women
Men ndash higher rates of fasting glucose and Tryglycerides when compared to women
Kahl KG Greggersen W Schweiger U et al Eur Arch Psychiatry Clin Neurosci (2012) 262 313 doi101007s00406-011-0277-4
Roger S McIntyre Joanna K Soczynska Jakub Z Konarski and Sidney H Kennedy The effect of antidepressants on lipid homeostasis a cardiac safety concern Expert Opinion on Drug Safety Vol 5 Iss 42006
Weight Gain on Commencement
Serretti amp Mandelli Antidepressants and body weight a comprehensive review and meta-analysis The Journal of Clinical Psychiatry [01 Oct 2010 71(10)1259-1272]
1-3kg average weight gain for 10-20 of population treated by them
25102017
3
Weight Gain Long Term
Green ndash LossYellow ndash neutralRed - Gain
Serretti amp Mandelli Antidepressants and body weight a comprehensive review and meta-analysis The Journal of Clinical Psychiatry [01 Oct 2010 71(10)1259-1272]
Mood Stabilizers
Allison DB Newcomer JW Dunn AL Blumenthal JA Fabricatore AN et al (2009) Obesity among those with mental disorders a National Institute of Mental Health meeting report Am J Prev Med 36 341ndash350
1) Education about weight gain amp side effects before treatment Informed consent about this risk US law suits
2) Routine monitoring of metabolic (blood sugars serum lipids) amp physical (BP abdominal girth weight) ndash see attachments ndash see attachment in slides
3) Diet exercise education and other lifestyle advice (smoking alcohol rec drugs)
- VLCD can be effective (RENEW Study Brown et al)
4) Behavioural modification 05kg ndash 07kg per week (Umbrict et al)
5) Psychological interventions (essential as an adjunct) to manage hunger amp emotional eating
- best studied amp most effective is CBT (Mohammad et al)
Brown C Goetz J Hamera E Weight Loss Intervention for People With Serious Mental Illness A Randomized Controlled Trial of the RENEW Program Psychiatric services (Washington DC) 201162(7)800-802 doi101176appips627800
DUmbrict H Flurry amp RBridler ldquoCBT for weight gainrdquo American Journal of Psychiatry vol158 no6 pp 971-972 2001
ALIMORADI Mohammad et al Cognitive Behavioral Therapy for Treatment of Adult Obesity International Journal of Medical Reviews [Sl] v 3 n 1 p 371-379 jun 2016 ISSN 2345-525X
wwwmedicalmindweightlosscom
CBT Strategies for Weight Management
bull Normalizing eating and reducing distressbull Body image therapy altering perception
and evaluation of selfbull Overcoming overeating and chaotic eatingbull Eliminating thinking errorsbull Addressing dysfunctional thinkingbull Being in tune with emotionsbull Mindfulness
Cognitive-Behavioral Treatment of ObesityAuthor Zafra Cooper Christopher G Fairburn Deborah M Hawker
online CBT weight management program Medical amp Mind Weight Loss - wwwmedicalmindweightlosscom
25102017
4
2017 Royal Australian and New Zealand College of Psychiatrists expert consensus statement for the treatment management and monitoring of the physical health of people with an enduring psychotic illness (Lambert et al)
The RANZCP released new physical activity guidelines April 2017
Systemic approach of websites books journal articles reviewed by 3 panels of 3 panels of Australian experts (55 clinicians21 carers 20 consumers)
Aimed for mental health and medical professionals people with enduring psychotic illness families and carers
bull Initial screening checklist (see appendix figure 2)
bull Education
bull Management
bull Follow up (see appendix figure 4)
bull collaboration
Pharmacological InterventionAnti-obesity drugs in the mental health population
1) Cease any drug that is causing rapid weight gain if possible
2) KEY POINT Stop the hunger
3) Anti-obesity drug MUST be carefully monitored due to side affects
ORLISTAT (over the counter reversible fat and lipase blocker)bull Advantages does not act centrally less risk of interaction with centrally acting
medicationsbull Must take other medications 1 hour before or after orlistat (Absoption)bull Schwartz amp Bealel reported average loss of 34 over 1 year (Antidepressants)bull No difference except in men (24kg) in 146 Schizophrenia patients taking
clozapine and olanzepine (Tchoukhine et al 2011)
TL Schwarts and M Beale ldquoPsychotropic induced weight gain alleviated with Orlistat ldquoPsychoharm Bulletin Vol 37 No1 pp 5-8 2003
Tchoukhine E Takala P Hakko H Raidma M Putkonen H Rasanen P Terevnikov V Stenberg JH Eronen M Joffe G (2011) Orlistat in clozapine- or olanzapine-treated patients with overweight or obesity a 16-week open-label extension phase and both phases of a randomized controlled trial J Clin Psychiatry 72(3)326ndash330
Phentermine
Anti-obesity drugs in psychiatric populations poorly studied as mental illness is often exclusion criteria
Anorexic drugs or appetite suppressantThe evidencePhentermine - poorly studied anti-obesity drug for psychotropic weight gain
- moderate success in binge eating syndrome (Devlin et al)
Common cardiac (sympathomimetic) and psychiatric side effectsbull tachycardia bull palpitationsbull insomnia bull Anxietybull elevated blood pressure
bull Devlin M J Goldfein J A Carino J S and Wolk S L (2000) Open treatment of overweight binge eaters with phentermine and fluoxetine as an adjunct to cognitive-behavioral therapy Int J Eat Disord 28 325ndash332 doi1010021098-108X(200011)283lt325AID-EAT10gt30CO2-3
Phentermine
Application to General Practice in mental health population
bull Good appetite suppressor against psychotropic induced hunger
bull Check history of use and side effects
bull Be wary of insomnia agitation flattening of mood anti-cholinergic effects (constipation) as triggers This MUST be monitored and may be a consideration not to use
bull Start low and go slow - 15mg to 30mg
bull Limitations cannot be used for extended periods of time physical side effects must be monitored
25102017
5
Liraglutide
bull Self administered daily injection
bull glucagon-like peptide-1 (GLP-1) agonist
bull Main side effects nausea vomiting diarrhoea constipation fatigue rashes
bull Less common (but more serious) hypoglycaemia pancreatitis gallbladder disease renal impairment mood changes increased depressive behaviour suicidal thoughts
The evidence
bull Efficacy and safety in psychiatric patients yet to be demonstrated
bull Major trial major depressive disorder or suicide attempt excluded 6 out of 3384 (02) reported suicidal ideation (Pi-Sunyer et al 1995)
Pi-Sunyer X Astrup A Fujioka K et al A Randomized Controlled Trial of 30mg of Liraglutide in Weight Management N Engl J Med 2015 373 11
LiraglutideApplication to General Practice in mental health population
bull Effective appetite suppressor especially at ldquostoppingrdquo the hunger
bull Low risk of increased suicide low to moderate risk of flattening if mood ndash dose dependent
bull Low or negligible risk of ldquooverdoserdquo unless combined with insulin
bull Consider using if poorly controlled diabetes
bull Careful monitoring ndash every 2 weeks in 1st 2 months
bull Work with psychiatrist and inform of commencement
bull Clozapine and olanzapine (ldquopinesrdquo) - best outcome maybe stopping hunger
bull Other anti-psychotics (ldquodonesrdquo) ndash much slower and reduced weight loss
bull Depressants bi-polar- very effective especially combined with VLCD
bull Limitations cost () nausea with psychotropic combined (delay start)
TopiramateApproved for migraines and epilepsy NOT approved for use for obesity This is an OFF LABEL DRUG
Psychiatrists ndash sometimes used as a mood stabiliser as weight neutral
Side effects fatigue cognitive dulling ataxia glaucoma sweating depression and anxiety
bull Schizophrenia ndash sustained weight loss of 5-7kg over 16 months (Lessig et al)
bull Modest weight loss 26kg to 5kg shown (Afshar et al Hahn et al)
bull Bipolar - studies have shown 33-55 of people losing 4-7kg weight (Gordon Price)
bull Depression - increase weight loss Improved QOL
bull Severe Mental illness ndash minimal weight (Gordon Price)
MC Lessig NA Shapira and TK Murphy ldquotopiramate for reversing atypical antipsychotic weight gain ldquoJournal of the American Academy of Child and AolesecentPsychiatry Vol 40 no 12 article 1364 2001
Gordon Price et al Mood Stabilization and Weight Loss With Topiramate American Journal of Psychiatry 156(6) pp 968andash969 1999
TopiramateApplication to General Practice in mental health population
bull Good appetite suppressor
bull Build up slowly from 125mg to 100mg
bull As off-label need to clear to why prescribing
- if needle phobic
- intolerant to other agents- cost of other medications
bull Consider if have co-existing epilepsy or migraines
bull Monitor for mental cloudiness memory loss depressed mood
Drugs in the pipeline
Qsymia Phentermine and topiramateLorcaserin selective 5-HT2C receptor agonist
Contrave Naltrexone + bupropion
Very little dataresearch in the mental health population
Bulimia and binge eating
The role of the GP and allied healthWhat factors can we change 1) Lifestyle and 2) Medication
bull Patients do want us involved (Tham Young et al)
bull We know our patients well we are in best positioned to give a tailored approach
bull Ensure basic fundamentals of lifestyle change (healthy eating smoking alcohol) are encouraged
bull Be involved in psychotropic prescribing
bull Work closely with your psychiatrist and ldquodiscussrdquo possible medication change amp side effects
bull Try Anti-obesity drug prescribing Monitor closely and if one doesnrsquot work try another
bull This is a lifelong chronic issue that takes time to change
Tham Marlene amp Young Doris The role of the General Practitioner in weight management in primary care ndash a cross sectional study in General
Practice BMC Family Practice2008966 DOI 1011861471-2296-9-66
25102017
6
Contact details Dr Marlene ThamMedical amp Mind Weight Loss (Redefinetrade CBT online program)
wwwmedicalmindweightlosscom
Melbourne Weight Loss
Practice address Epworth Camberwell
888 Toorak Road Camberwell Vic 3124
Phone 03 9805 4153
wwwmelbourneweightlosscom
Email Contact mthammelbourneweightlosscom
Blog httpwwwmedicalmindweightlosscomnews
wwwmedicalmindweightlosscom
25102017
3
Weight Gain Long Term
Green ndash LossYellow ndash neutralRed - Gain
Serretti amp Mandelli Antidepressants and body weight a comprehensive review and meta-analysis The Journal of Clinical Psychiatry [01 Oct 2010 71(10)1259-1272]
Mood Stabilizers
Allison DB Newcomer JW Dunn AL Blumenthal JA Fabricatore AN et al (2009) Obesity among those with mental disorders a National Institute of Mental Health meeting report Am J Prev Med 36 341ndash350
1) Education about weight gain amp side effects before treatment Informed consent about this risk US law suits
2) Routine monitoring of metabolic (blood sugars serum lipids) amp physical (BP abdominal girth weight) ndash see attachments ndash see attachment in slides
3) Diet exercise education and other lifestyle advice (smoking alcohol rec drugs)
- VLCD can be effective (RENEW Study Brown et al)
4) Behavioural modification 05kg ndash 07kg per week (Umbrict et al)
5) Psychological interventions (essential as an adjunct) to manage hunger amp emotional eating
- best studied amp most effective is CBT (Mohammad et al)
Brown C Goetz J Hamera E Weight Loss Intervention for People With Serious Mental Illness A Randomized Controlled Trial of the RENEW Program Psychiatric services (Washington DC) 201162(7)800-802 doi101176appips627800
DUmbrict H Flurry amp RBridler ldquoCBT for weight gainrdquo American Journal of Psychiatry vol158 no6 pp 971-972 2001
ALIMORADI Mohammad et al Cognitive Behavioral Therapy for Treatment of Adult Obesity International Journal of Medical Reviews [Sl] v 3 n 1 p 371-379 jun 2016 ISSN 2345-525X
wwwmedicalmindweightlosscom
CBT Strategies for Weight Management
bull Normalizing eating and reducing distressbull Body image therapy altering perception
and evaluation of selfbull Overcoming overeating and chaotic eatingbull Eliminating thinking errorsbull Addressing dysfunctional thinkingbull Being in tune with emotionsbull Mindfulness
Cognitive-Behavioral Treatment of ObesityAuthor Zafra Cooper Christopher G Fairburn Deborah M Hawker
online CBT weight management program Medical amp Mind Weight Loss - wwwmedicalmindweightlosscom
25102017
4
2017 Royal Australian and New Zealand College of Psychiatrists expert consensus statement for the treatment management and monitoring of the physical health of people with an enduring psychotic illness (Lambert et al)
The RANZCP released new physical activity guidelines April 2017
Systemic approach of websites books journal articles reviewed by 3 panels of 3 panels of Australian experts (55 clinicians21 carers 20 consumers)
Aimed for mental health and medical professionals people with enduring psychotic illness families and carers
bull Initial screening checklist (see appendix figure 2)
bull Education
bull Management
bull Follow up (see appendix figure 4)
bull collaboration
Pharmacological InterventionAnti-obesity drugs in the mental health population
1) Cease any drug that is causing rapid weight gain if possible
2) KEY POINT Stop the hunger
3) Anti-obesity drug MUST be carefully monitored due to side affects
ORLISTAT (over the counter reversible fat and lipase blocker)bull Advantages does not act centrally less risk of interaction with centrally acting
medicationsbull Must take other medications 1 hour before or after orlistat (Absoption)bull Schwartz amp Bealel reported average loss of 34 over 1 year (Antidepressants)bull No difference except in men (24kg) in 146 Schizophrenia patients taking
clozapine and olanzepine (Tchoukhine et al 2011)
TL Schwarts and M Beale ldquoPsychotropic induced weight gain alleviated with Orlistat ldquoPsychoharm Bulletin Vol 37 No1 pp 5-8 2003
Tchoukhine E Takala P Hakko H Raidma M Putkonen H Rasanen P Terevnikov V Stenberg JH Eronen M Joffe G (2011) Orlistat in clozapine- or olanzapine-treated patients with overweight or obesity a 16-week open-label extension phase and both phases of a randomized controlled trial J Clin Psychiatry 72(3)326ndash330
Phentermine
Anti-obesity drugs in psychiatric populations poorly studied as mental illness is often exclusion criteria
Anorexic drugs or appetite suppressantThe evidencePhentermine - poorly studied anti-obesity drug for psychotropic weight gain
- moderate success in binge eating syndrome (Devlin et al)
Common cardiac (sympathomimetic) and psychiatric side effectsbull tachycardia bull palpitationsbull insomnia bull Anxietybull elevated blood pressure
bull Devlin M J Goldfein J A Carino J S and Wolk S L (2000) Open treatment of overweight binge eaters with phentermine and fluoxetine as an adjunct to cognitive-behavioral therapy Int J Eat Disord 28 325ndash332 doi1010021098-108X(200011)283lt325AID-EAT10gt30CO2-3
Phentermine
Application to General Practice in mental health population
bull Good appetite suppressor against psychotropic induced hunger
bull Check history of use and side effects
bull Be wary of insomnia agitation flattening of mood anti-cholinergic effects (constipation) as triggers This MUST be monitored and may be a consideration not to use
bull Start low and go slow - 15mg to 30mg
bull Limitations cannot be used for extended periods of time physical side effects must be monitored
25102017
5
Liraglutide
bull Self administered daily injection
bull glucagon-like peptide-1 (GLP-1) agonist
bull Main side effects nausea vomiting diarrhoea constipation fatigue rashes
bull Less common (but more serious) hypoglycaemia pancreatitis gallbladder disease renal impairment mood changes increased depressive behaviour suicidal thoughts
The evidence
bull Efficacy and safety in psychiatric patients yet to be demonstrated
bull Major trial major depressive disorder or suicide attempt excluded 6 out of 3384 (02) reported suicidal ideation (Pi-Sunyer et al 1995)
Pi-Sunyer X Astrup A Fujioka K et al A Randomized Controlled Trial of 30mg of Liraglutide in Weight Management N Engl J Med 2015 373 11
LiraglutideApplication to General Practice in mental health population
bull Effective appetite suppressor especially at ldquostoppingrdquo the hunger
bull Low risk of increased suicide low to moderate risk of flattening if mood ndash dose dependent
bull Low or negligible risk of ldquooverdoserdquo unless combined with insulin
bull Consider using if poorly controlled diabetes
bull Careful monitoring ndash every 2 weeks in 1st 2 months
bull Work with psychiatrist and inform of commencement
bull Clozapine and olanzapine (ldquopinesrdquo) - best outcome maybe stopping hunger
bull Other anti-psychotics (ldquodonesrdquo) ndash much slower and reduced weight loss
bull Depressants bi-polar- very effective especially combined with VLCD
bull Limitations cost () nausea with psychotropic combined (delay start)
TopiramateApproved for migraines and epilepsy NOT approved for use for obesity This is an OFF LABEL DRUG
Psychiatrists ndash sometimes used as a mood stabiliser as weight neutral
Side effects fatigue cognitive dulling ataxia glaucoma sweating depression and anxiety
bull Schizophrenia ndash sustained weight loss of 5-7kg over 16 months (Lessig et al)
bull Modest weight loss 26kg to 5kg shown (Afshar et al Hahn et al)
bull Bipolar - studies have shown 33-55 of people losing 4-7kg weight (Gordon Price)
bull Depression - increase weight loss Improved QOL
bull Severe Mental illness ndash minimal weight (Gordon Price)
MC Lessig NA Shapira and TK Murphy ldquotopiramate for reversing atypical antipsychotic weight gain ldquoJournal of the American Academy of Child and AolesecentPsychiatry Vol 40 no 12 article 1364 2001
Gordon Price et al Mood Stabilization and Weight Loss With Topiramate American Journal of Psychiatry 156(6) pp 968andash969 1999
TopiramateApplication to General Practice in mental health population
bull Good appetite suppressor
bull Build up slowly from 125mg to 100mg
bull As off-label need to clear to why prescribing
- if needle phobic
- intolerant to other agents- cost of other medications
bull Consider if have co-existing epilepsy or migraines
bull Monitor for mental cloudiness memory loss depressed mood
Drugs in the pipeline
Qsymia Phentermine and topiramateLorcaserin selective 5-HT2C receptor agonist
Contrave Naltrexone + bupropion
Very little dataresearch in the mental health population
Bulimia and binge eating
The role of the GP and allied healthWhat factors can we change 1) Lifestyle and 2) Medication
bull Patients do want us involved (Tham Young et al)
bull We know our patients well we are in best positioned to give a tailored approach
bull Ensure basic fundamentals of lifestyle change (healthy eating smoking alcohol) are encouraged
bull Be involved in psychotropic prescribing
bull Work closely with your psychiatrist and ldquodiscussrdquo possible medication change amp side effects
bull Try Anti-obesity drug prescribing Monitor closely and if one doesnrsquot work try another
bull This is a lifelong chronic issue that takes time to change
Tham Marlene amp Young Doris The role of the General Practitioner in weight management in primary care ndash a cross sectional study in General
Practice BMC Family Practice2008966 DOI 1011861471-2296-9-66
25102017
6
Contact details Dr Marlene ThamMedical amp Mind Weight Loss (Redefinetrade CBT online program)
wwwmedicalmindweightlosscom
Melbourne Weight Loss
Practice address Epworth Camberwell
888 Toorak Road Camberwell Vic 3124
Phone 03 9805 4153
wwwmelbourneweightlosscom
Email Contact mthammelbourneweightlosscom
Blog httpwwwmedicalmindweightlosscomnews
wwwmedicalmindweightlosscom
25102017
4
2017 Royal Australian and New Zealand College of Psychiatrists expert consensus statement for the treatment management and monitoring of the physical health of people with an enduring psychotic illness (Lambert et al)
The RANZCP released new physical activity guidelines April 2017
Systemic approach of websites books journal articles reviewed by 3 panels of 3 panels of Australian experts (55 clinicians21 carers 20 consumers)
Aimed for mental health and medical professionals people with enduring psychotic illness families and carers
bull Initial screening checklist (see appendix figure 2)
bull Education
bull Management
bull Follow up (see appendix figure 4)
bull collaboration
Pharmacological InterventionAnti-obesity drugs in the mental health population
1) Cease any drug that is causing rapid weight gain if possible
2) KEY POINT Stop the hunger
3) Anti-obesity drug MUST be carefully monitored due to side affects
ORLISTAT (over the counter reversible fat and lipase blocker)bull Advantages does not act centrally less risk of interaction with centrally acting
medicationsbull Must take other medications 1 hour before or after orlistat (Absoption)bull Schwartz amp Bealel reported average loss of 34 over 1 year (Antidepressants)bull No difference except in men (24kg) in 146 Schizophrenia patients taking
clozapine and olanzepine (Tchoukhine et al 2011)
TL Schwarts and M Beale ldquoPsychotropic induced weight gain alleviated with Orlistat ldquoPsychoharm Bulletin Vol 37 No1 pp 5-8 2003
Tchoukhine E Takala P Hakko H Raidma M Putkonen H Rasanen P Terevnikov V Stenberg JH Eronen M Joffe G (2011) Orlistat in clozapine- or olanzapine-treated patients with overweight or obesity a 16-week open-label extension phase and both phases of a randomized controlled trial J Clin Psychiatry 72(3)326ndash330
Phentermine
Anti-obesity drugs in psychiatric populations poorly studied as mental illness is often exclusion criteria
Anorexic drugs or appetite suppressantThe evidencePhentermine - poorly studied anti-obesity drug for psychotropic weight gain
- moderate success in binge eating syndrome (Devlin et al)
Common cardiac (sympathomimetic) and psychiatric side effectsbull tachycardia bull palpitationsbull insomnia bull Anxietybull elevated blood pressure
bull Devlin M J Goldfein J A Carino J S and Wolk S L (2000) Open treatment of overweight binge eaters with phentermine and fluoxetine as an adjunct to cognitive-behavioral therapy Int J Eat Disord 28 325ndash332 doi1010021098-108X(200011)283lt325AID-EAT10gt30CO2-3
Phentermine
Application to General Practice in mental health population
bull Good appetite suppressor against psychotropic induced hunger
bull Check history of use and side effects
bull Be wary of insomnia agitation flattening of mood anti-cholinergic effects (constipation) as triggers This MUST be monitored and may be a consideration not to use
bull Start low and go slow - 15mg to 30mg
bull Limitations cannot be used for extended periods of time physical side effects must be monitored
25102017
5
Liraglutide
bull Self administered daily injection
bull glucagon-like peptide-1 (GLP-1) agonist
bull Main side effects nausea vomiting diarrhoea constipation fatigue rashes
bull Less common (but more serious) hypoglycaemia pancreatitis gallbladder disease renal impairment mood changes increased depressive behaviour suicidal thoughts
The evidence
bull Efficacy and safety in psychiatric patients yet to be demonstrated
bull Major trial major depressive disorder or suicide attempt excluded 6 out of 3384 (02) reported suicidal ideation (Pi-Sunyer et al 1995)
Pi-Sunyer X Astrup A Fujioka K et al A Randomized Controlled Trial of 30mg of Liraglutide in Weight Management N Engl J Med 2015 373 11
LiraglutideApplication to General Practice in mental health population
bull Effective appetite suppressor especially at ldquostoppingrdquo the hunger
bull Low risk of increased suicide low to moderate risk of flattening if mood ndash dose dependent
bull Low or negligible risk of ldquooverdoserdquo unless combined with insulin
bull Consider using if poorly controlled diabetes
bull Careful monitoring ndash every 2 weeks in 1st 2 months
bull Work with psychiatrist and inform of commencement
bull Clozapine and olanzapine (ldquopinesrdquo) - best outcome maybe stopping hunger
bull Other anti-psychotics (ldquodonesrdquo) ndash much slower and reduced weight loss
bull Depressants bi-polar- very effective especially combined with VLCD
bull Limitations cost () nausea with psychotropic combined (delay start)
TopiramateApproved for migraines and epilepsy NOT approved for use for obesity This is an OFF LABEL DRUG
Psychiatrists ndash sometimes used as a mood stabiliser as weight neutral
Side effects fatigue cognitive dulling ataxia glaucoma sweating depression and anxiety
bull Schizophrenia ndash sustained weight loss of 5-7kg over 16 months (Lessig et al)
bull Modest weight loss 26kg to 5kg shown (Afshar et al Hahn et al)
bull Bipolar - studies have shown 33-55 of people losing 4-7kg weight (Gordon Price)
bull Depression - increase weight loss Improved QOL
bull Severe Mental illness ndash minimal weight (Gordon Price)
MC Lessig NA Shapira and TK Murphy ldquotopiramate for reversing atypical antipsychotic weight gain ldquoJournal of the American Academy of Child and AolesecentPsychiatry Vol 40 no 12 article 1364 2001
Gordon Price et al Mood Stabilization and Weight Loss With Topiramate American Journal of Psychiatry 156(6) pp 968andash969 1999
TopiramateApplication to General Practice in mental health population
bull Good appetite suppressor
bull Build up slowly from 125mg to 100mg
bull As off-label need to clear to why prescribing
- if needle phobic
- intolerant to other agents- cost of other medications
bull Consider if have co-existing epilepsy or migraines
bull Monitor for mental cloudiness memory loss depressed mood
Drugs in the pipeline
Qsymia Phentermine and topiramateLorcaserin selective 5-HT2C receptor agonist
Contrave Naltrexone + bupropion
Very little dataresearch in the mental health population
Bulimia and binge eating
The role of the GP and allied healthWhat factors can we change 1) Lifestyle and 2) Medication
bull Patients do want us involved (Tham Young et al)
bull We know our patients well we are in best positioned to give a tailored approach
bull Ensure basic fundamentals of lifestyle change (healthy eating smoking alcohol) are encouraged
bull Be involved in psychotropic prescribing
bull Work closely with your psychiatrist and ldquodiscussrdquo possible medication change amp side effects
bull Try Anti-obesity drug prescribing Monitor closely and if one doesnrsquot work try another
bull This is a lifelong chronic issue that takes time to change
Tham Marlene amp Young Doris The role of the General Practitioner in weight management in primary care ndash a cross sectional study in General
Practice BMC Family Practice2008966 DOI 1011861471-2296-9-66
25102017
6
Contact details Dr Marlene ThamMedical amp Mind Weight Loss (Redefinetrade CBT online program)
wwwmedicalmindweightlosscom
Melbourne Weight Loss
Practice address Epworth Camberwell
888 Toorak Road Camberwell Vic 3124
Phone 03 9805 4153
wwwmelbourneweightlosscom
Email Contact mthammelbourneweightlosscom
Blog httpwwwmedicalmindweightlosscomnews
wwwmedicalmindweightlosscom
25102017
5
Liraglutide
bull Self administered daily injection
bull glucagon-like peptide-1 (GLP-1) agonist
bull Main side effects nausea vomiting diarrhoea constipation fatigue rashes
bull Less common (but more serious) hypoglycaemia pancreatitis gallbladder disease renal impairment mood changes increased depressive behaviour suicidal thoughts
The evidence
bull Efficacy and safety in psychiatric patients yet to be demonstrated
bull Major trial major depressive disorder or suicide attempt excluded 6 out of 3384 (02) reported suicidal ideation (Pi-Sunyer et al 1995)
Pi-Sunyer X Astrup A Fujioka K et al A Randomized Controlled Trial of 30mg of Liraglutide in Weight Management N Engl J Med 2015 373 11
LiraglutideApplication to General Practice in mental health population
bull Effective appetite suppressor especially at ldquostoppingrdquo the hunger
bull Low risk of increased suicide low to moderate risk of flattening if mood ndash dose dependent
bull Low or negligible risk of ldquooverdoserdquo unless combined with insulin
bull Consider using if poorly controlled diabetes
bull Careful monitoring ndash every 2 weeks in 1st 2 months
bull Work with psychiatrist and inform of commencement
bull Clozapine and olanzapine (ldquopinesrdquo) - best outcome maybe stopping hunger
bull Other anti-psychotics (ldquodonesrdquo) ndash much slower and reduced weight loss
bull Depressants bi-polar- very effective especially combined with VLCD
bull Limitations cost () nausea with psychotropic combined (delay start)
TopiramateApproved for migraines and epilepsy NOT approved for use for obesity This is an OFF LABEL DRUG
Psychiatrists ndash sometimes used as a mood stabiliser as weight neutral
Side effects fatigue cognitive dulling ataxia glaucoma sweating depression and anxiety
bull Schizophrenia ndash sustained weight loss of 5-7kg over 16 months (Lessig et al)
bull Modest weight loss 26kg to 5kg shown (Afshar et al Hahn et al)
bull Bipolar - studies have shown 33-55 of people losing 4-7kg weight (Gordon Price)
bull Depression - increase weight loss Improved QOL
bull Severe Mental illness ndash minimal weight (Gordon Price)
MC Lessig NA Shapira and TK Murphy ldquotopiramate for reversing atypical antipsychotic weight gain ldquoJournal of the American Academy of Child and AolesecentPsychiatry Vol 40 no 12 article 1364 2001
Gordon Price et al Mood Stabilization and Weight Loss With Topiramate American Journal of Psychiatry 156(6) pp 968andash969 1999
TopiramateApplication to General Practice in mental health population
bull Good appetite suppressor
bull Build up slowly from 125mg to 100mg
bull As off-label need to clear to why prescribing
- if needle phobic
- intolerant to other agents- cost of other medications
bull Consider if have co-existing epilepsy or migraines
bull Monitor for mental cloudiness memory loss depressed mood
Drugs in the pipeline
Qsymia Phentermine and topiramateLorcaserin selective 5-HT2C receptor agonist
Contrave Naltrexone + bupropion
Very little dataresearch in the mental health population
Bulimia and binge eating
The role of the GP and allied healthWhat factors can we change 1) Lifestyle and 2) Medication
bull Patients do want us involved (Tham Young et al)
bull We know our patients well we are in best positioned to give a tailored approach
bull Ensure basic fundamentals of lifestyle change (healthy eating smoking alcohol) are encouraged
bull Be involved in psychotropic prescribing
bull Work closely with your psychiatrist and ldquodiscussrdquo possible medication change amp side effects
bull Try Anti-obesity drug prescribing Monitor closely and if one doesnrsquot work try another
bull This is a lifelong chronic issue that takes time to change
Tham Marlene amp Young Doris The role of the General Practitioner in weight management in primary care ndash a cross sectional study in General
Practice BMC Family Practice2008966 DOI 1011861471-2296-9-66
25102017
6
Contact details Dr Marlene ThamMedical amp Mind Weight Loss (Redefinetrade CBT online program)
wwwmedicalmindweightlosscom
Melbourne Weight Loss
Practice address Epworth Camberwell
888 Toorak Road Camberwell Vic 3124
Phone 03 9805 4153
wwwmelbourneweightlosscom
Email Contact mthammelbourneweightlosscom
Blog httpwwwmedicalmindweightlosscomnews
wwwmedicalmindweightlosscom
25102017
6
Contact details Dr Marlene ThamMedical amp Mind Weight Loss (Redefinetrade CBT online program)
