Neurotransmitter receptors in the brain seem to play a part, with evidence implicating the serotonin 5-HT2C and 5-HT1A receptors, histamine H1 receptor and dopamine D2 receptor among others. Antipsychotics differ in their ability to block these receptors and this partly explains their different liability to cause weight gain. Both olanzapine and clozapine, drugs with a high risk of weight gain, bind strongly to the histamine H1 and serotonin 5-HT2C receptors.
The pharmacology of antipsychotics is not the only factor that determines their effect on weight. As already mentioned, if a group of people take the same antipsychotic there will be differences between them in their subsequent weight change. This reflects differences between people in their diet, level of activity and genetic makeup.
Variations polymorphisms in a large number of genes, including the gene that codes for the 5-HT2C receptor, have been linked to susceptibility to gain weight with antipsychotics. It is the combined effect of these genes, rather that variation in a single gene, that is relevant to weight gain.
In the future, it may be possible to conduct a simple blood test i. This could help people choose the best drug for their treatment. However, such a test is not currently available. Decisions on choosing medication and managing weight, as with other areas of treatment, should be made jointly by a patient and their doctor. The main approaches to managing weight with antipsychotics are:. Other approaches can sometimes help manage weight gain including adding certain medications to antipsychotics.
These approaches are reviewed in a recent BAP Guideline that also considers the broader issue of reducing the risk of cardiovascular disease i. Some people may consider stopping antipsychotic treatment due to weight gain. The issue of how long to continue antipsychotic treatment is complex. Space only allows some basic comments to be made here. Excess weight caused by an antipsychotic will usually be lost gradually after medication is stopped.
Weight put on for other reasons is likely to remain. The downside of stopping antipsychotics is an increased risk of becoming unwell, especially for people with schizophrenia and bipolar disorder. Sometimes relapse occurs suddenly with serious repercussions.
A person should never stop their antipsychotic, or alter the dose, without discussing this first with their psychiatrist. Together, the patient and doctor should carefully consider the advantages and disadvantages of continuing medication, stopping medication and other options for managing mental health, weight gain and other side effects.
These will differ from person to person and reflect their medical history and current circumstances. The discussion should lead to a jointly agreed management plan that is tailored to the individual. For some people stopping medication is a realistic option but for others it is inappropriate. If a decision is made to stop antipsychotic treatment, then the dose should be reduced gradually. Medication should not be stopped suddenly. A healthcare professional should monitor the person for signs and symptoms of relapse while the dose is reduced and after it is stopped.
For people with schizophrenia or psychosis, monitoring is recommended for at least two years after antipsychotics are stopped. A great deal of research is trying to improve outcomes for people with mental health problems.
This includes developing more effective medications with a lower risk of weight gain and other side effects. Lifestyle modification programmes have a modest benefit in reducing weight gain in people starting antipsychotics and helping those established on antipsychotics to lose weight. These interventions can be given to individuals or to groups or both approaches can be combined. Participants were encouraged to eat a healthier diet and spend at least 25 minutes per day doing moderate activity.
If psychosis, at least in some people, could be treated by giving antipsychotics for shorter periods than is current practice then it would reduce weight gain and other medication side effects. The RADAR trial is an ongoing randomised trial in the UK that compares a gradual and supported programme of antipsychotic reduction to maintenance antipsychotic treatment i. This approach has the advantage of avoiding antipsychotic side effects altogether.
This work is at an early stage and at the time of writing its effectiveness is not known, though initial results are promising. Nevertheless, it would widen treatment choice for some people and represent a major step forward in treating psychosis.
Antipsychotics are effective in treating schizophrenia and mania but can cause a range of side effects. Weight gain is a common and serious side effect, especially due to its impact on physical health.
Various interventions can help and a psychiatrist will be able to offer advice on these. Many people taking antipsychotics can lose some weight with simple changes to their diet and lifestyle. Losing even a small amount of weight can have important health benefits. Ongoing research is attempting to find ways to better manage or ideally avoid this problem. The BAP Guidelines on the management of weight gain, metabolic disturbances and cardiovascular risk associated with psychosis and antipsychotic drug treatment are available at: www.
An article reviewing these Guidelines is available at: www. Eur Psychiatry 24 6 BAP guidelines on the management of weight gain, metabolic disturbances and cardiovascular risk associated with psychosis and antipsychotic drug treatment. J Psychopharmacol 30 8 Efficacy and tolerability of olanzapine, quetiapine, and risperidone in the treatment of early psychosis: a randomized, double-blind week comparison.
Am J Psychiatry 7 N Engl J Med Last updated: March PLoS One 9 12 : e The STRIDE weight loss and lifestyle intervention for individuals taking antipsychotic medications: a randomized trial. Am J Psychiatry 1 Diabetes Care 34 7 : — Trials Cognitive therapy for people with schizophrenia spectrum disorders not taking antipsychotic drugs: a single-blind randomised controlled trial. The Lancet , My Sons weight more than doubled in the 5 years that he took Clozapine.
He recently passed away and complications of obesity is noted on his death certificate. So much more work is needed in the control of weight gain in these poor souls who are already suffering enough.
I agree with you that more work is needed to manage weight gain associated with antipsychotics. I am a Special Olympic ski coach and one of my dear athletes is extremely overweight from his anti-psychotic drugs. He was recently told he could not stop his meds. I fear for him. I know his lifestyle is unhealthy too and was wondering if we just got him out walking a few times a week would help.
Walking can help to lose weight. If you increase your physical activity you will burn more calories. If you burn off more calories than you consume through food and drink, then you will lose weight. Increased activity can be achieved in many ways, for example walking, using stairs in preference to taking a lift, taking part in sport or exercising at home or in a gym.
The more intense your activity or exercise, and the longer it lasts for, then the more calories that are burnt. Walking is relatively easy to do. Many people find a walk relaxing and if done with others it can be sociable.
Regular walking can have other health benefits including lowering blood pressure and reducing your risk of heart disease. Increased activity is more effective in helping to lose weight if it is combined with changes to diet i. The weight gain from these medications is more detrimental than the illness Bipolar II I personally suffer from initially.
As you highlight both psychiatric illness and the side effects of antipsychotic medication can cause great distress. Good psychiatric care aims to ensure that people receive effective treatment, experience as few side effects as possible and are fully involved in decisions about their care. Shared decision-making by doctors and patients is recommended when choosing treatments.
This means that the patient and their doctor discuss the range of treatments available. The patient brings their experience of their illness, including symptoms they want to be treated and particular side effects they wish to avoid. A joint decision on what treatment to use can then be made. This allows treatment to be tailored to the individual.
Patients are usually more satisfied when decisions are made in this way. As antipsychotics vary in their side effects it is usually possible to reduce side effects by choosing medication carefully. Unfortunately, side effects can still occur. When this happens, the doctor and patient need to carefully consider what to do next. This will depend on how they view the trade-off between the advantages and side effects of the current medication. It may be that the antipsychotic has had clear benefits, for example in reducing or eliminating symptoms of illness and allowing the person to manage better in their everyday life.
They also need to consider how the current medication fares again any earlier medications that were used and medications and treatment approaches that have not yet been tried. If the person is well and contemplating stopping medication totally, then the risk of a recurrence of illness needs to be assessed; this will partly depend on the frequency and severity of any previous episodes of illness.
When all this information is available, the patient and their doctor can consider the options and make a joint decision about what to do next. In some cases, it may be decided that a side effect is worth accepting given the benefits of the medication. In other cases, it may be clear that the side effect is intolerable and that the medication needs to be altered.
Many side effects lessen when the dose of an antipsychotic is lowered but weight gain is an exception; the degree of weight gain is usually unrelated to the dose of an antipsychotic. Some side effects can be reduced by changing the time at which the medication is taken. For example, sedation may be less troublesome when medication is taken at bedtime rather than in the morning. Some side effects can be lessened by taking another medication to deal with them.
Sometimes the best option to manage an antipsychotic side effect is to change to a different medication with a lower risk of causing that side effect. If the person has schizophrenia or psychosis then one will need to switch to a different antipsychotic. If the person has bipolar disorder then it may be possible to switch the antipsychotic to a different type of medication, for example lithium.
A person should never stop or reduce the dose of their antipsychotic medication without discussing and agreeing this first with their psychiatrist. Stopping antipsychotics and reducing their dose are both associated with an increased risk of relapse i. A period of close monitoring by a psychiatrist, or other mental health care professional, is needed whenever an antipsychotic is reduced in dose, switched or stopped. This is to ensure that the person remains well and that support and help are promptly available should there be any problems, including side effects or early warning signs of relapse.
For those taking this kind of medication, preventable physical illnesses such as heart disease, respiratory disease and type 2 diabetes are the leading causes of death.
These illnesses appear to be indirect side effects of the medication, and they are also related to obesity. An overwhelming amount of research has found that being overweight increases the risk of conditions such as heart disease and diabetes. On average, psychiatric in-patients gain three to five pounds a month during initial treatment. Not everyone gains weight, but some others gain significantly more than others. Given the preventable illnesses listed above, it is vital to understand why these patients gain weight.
There are two different types of anti-psychotic drugs, which work in different ways. While they were and still are, in some severe cases of psychosis effective at treating psychotic symptoms, they come with high risk and substantial side effects.
For this reason, this medication is the preferred choice in modern psychiatry — although it must be noted that some patients still do experience some side effects such as dry mouth, nausea and constipation. An interesting effect of atypical anti-psychotics is that they somewhat restore the management of attention deficits which are commonly associated with symptoms of schizophrenia such as an inability to complete specific tasks.
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