The use of anti-obesity medications in people with mental illness as an adjunct to lifestyle interventions — Effectiveness, tolerability and impact on eating behaviours: A 52-week observational study

doi:10.1016/j.orcp.2020.11.002

Obesity Research & Clinical Practice

Volume 15, Issue 1, January–February 2021, Pages 49-57

https://doi.org/10.1016/j.orcp.2020.11.002 Get rights and content

Highlights

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People with mental illness have significant physical and metabolic co-morbidities.
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Anti-obesity medication use is just as efficacious in the mental health population.
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Weight, waist, metabolic markers and eating behaviours all improve over 52 weeks.
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There is minimal deterioration of mental health with the exception of topiramate.
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The majority are well tolerated with side effects sub-siding after 3 months.

Abstract

Objective

The increasing prevalence of obesity and metabolic syndrome in people with mental illness (MI) is a global health priority. Anti-obesity medications (AOMs) may help with reducing medication induced hunger and weight gain when lifestyle changes are insufficient. Our aim is to evaluate the effectiveness, tolerability, impact on eating behaviours and psychiatric safety of AOMs in this population.

Methods

We conducted an observational study of 244 adults with MI with at least two risk factors for metabolic syndrome attending an obesity management clinic. Participants received standardised diet, exercise and psychological care, in addition to AOMs tailored to each participant’s circumstances. Baseline and 12-month assessments encompassing physical, metabolic and psychological parameters were compared.

Results

Over the course of the study, the average weight loss was 11.79 kg (12.1%), decrease in BMI was 3.90 kg/m² and reduction in waist circumference was 12.6 cm. Participants with good glycaemic control increased from 28.6% to 80.7%, hypercholesterolaemia reduced from 85.2%–29.9% and hypertension rates reduced from 88.9%–52.0%. Depression, anxiety and stress levels for the sample decreased significantly (all p < .01). Eating behaviours improved (all p < .001) at follow-up. Psychiatric side effects including deterioration of mood (28.2%) and suicidality (30.8%) were primarily experienced by those on topiramate.

Conclusions

AOMs can be effective in achieving clinically meaningful weight loss, improved metabolic co-morbidities and eating behaviours in people living with MI, when combined with a comprehensive lifestyle program. The majority of AOMs are well tolerated but topiramate appears more likely to negatively impact mental health.

Section snippets

Participants

Participants were recruited from a specialised obesity management clinic in Melbourne, Australia between October 2016 and August 2018. All new patients presenting during this time were invited to participate and have their data included. Inclusion criteria were:

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Aged 18 years or older;
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A mental health diagnosis confirmed by a psychiatrist or general practitioner (GP);
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Prescribed at least one psychotropic medication;
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Body mass index (BMI) of 25 or higher;
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Presence of at least two risk factors for

Physical outcomes

Participants were assessed on the following outcomes at baseline and 52-week follow-up: weight (kg); waist circumference (cm); glycosylated haemoglobin (HBA1c %); lipid profile (low-density lipoproteins (LDL), high-density lipoproteins (HDL), triglycerides mmol/L) and blood pressure (BP)(mm/Hg). BP was taken three times ten minutes apart, and averaged over the three readings.

Psychological outcomes

Psychiatric safety was defined as the impact on depression, anxiety and stress levels. Participants completed the

Results

244 participants consented to participate in the study; all those who were approached provided informed consent to have their data included in the study (see Table 1 for participant characteristics).

Discussion

There is an important role that AOMs can play in managing obesity, counteracting medication-induced hunger and reducing the physiological effects of psychotropic medications when lifestyle changes alone are not enough. However their use in individuals with MI has been limited. Research in this area is especially important because treating clinicians have struggled to find medications that are both effective as well as tolerated and psychiatrically safe [35].

This observational study demonstrated

Declaration of conflicting interests

MT and TC established and run the specialised obesity management clinic in Melbourne where the study took place. Both are also the creator of the Medical & Mind Weight Loss (www.medicalmindweightloss.com) and the online Redefine CBT Weight Loss program that all patients undertake. MT includes a small fee which makes up a small component of her initial consultation fee for patients’ use of the online program which goes towards IT services and web maintenance. TC has no other conflicts.

MT has

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Ethical agreement

I have read and have abided by the statement of ethical standards for manuscripts submitted to the Obesity Research & Clinical Practice.

CRediT authorship contribution statement

Marlene Tham: Conceptualization, Methodology, Validation, Investigation, Writing - original draft, Visualization. Terence W.H. Chong: Methodology, Validation, Visualization, Writing - review & editing, Supervision. Zoe M. Jenkins: Formal analysis, Data curation, Writing - review & editing, Visualization. David J. Castle: Writing - review & editing, Supervision.

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Schizophrenia and antipsychotic use are associated with clinically significant weight gain and subsequent increased mortality. Despite weight loss medications (WLMs) licensed by regulatory bodies (FDA, EMA, and MHRA) being available, current psychiatric guidelines recommend off-label alternatives, which differ from non-psychiatric guidelines for obesity.
Evaluate the efficacy of licensed WLMs on treating antipsychotic-induced weight gain (AIWG) and obesity in schizophrenia and psychosis (OSP).
A literature search was conducted using Medline, EMBASE, PsycINFO and Cochrane Library online databases for human studies using licensed WLMs to treat AIWG and OSP.
Three RCTs (two liraglutide, one naltrexone-bupropion), one unpublished open-label trial (naltrexone-bupropion), and seven observational studies (five liraglutide, one semaglutide, one multiple WLMs) were identified. Results for liraglutide showed statistically significant improvement in weight, BMI, waist circumference, HbA1c, cholesterol, and LDL readings on meta-analysis. Evidence was mixed for naltrexone-bupropion with no detailed studies conducted for setmelanotide, or stimulants.
Evidence is strongest for liraglutide compared to other licensed WLMs. The findings, particularly the inclusion of human trial data, provide evidence for liraglutide use in treating AIWG and OSP, which would better align psychiatric practice with non-psychiatric practices around obesity. The findings also identify continued literature gaps regarding other licensed WLMs.
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View full text

The use of anti-obesity medications in people with mental illness as an adjunct to lifestyle interventions — Effectiveness, tolerability and impact on eating behaviours: A 52-week observational study

Highlights

Abstract

Objective

Methods

Results

Conclusions

Section snippets

Participants

Physical outcomes

Psychological outcomes

Results

Discussion

Declaration of conflicting interests

Funding

Ethical agreement

CRediT authorship contribution statement

Lancet Psychiatry

Lancet Psychiatry

Lancet Diabetes Endocrinol

Can J Diabetes

Schizophr Res

Schizophr Res

Behav Res Ther

Excess mortality in persons with severe mental disorders: a multilevel intervention framework and priorities for clinical practice, policy and research agendas

World Psychiatry

The impact of psychotropic weight gain on people with psychosis – patient perspectives and attitudes

J Ment Health

Pathways from dieting to weight regain, to obesity and to the metabolic syndrome: an overview

Obes Rev

Effects of antipsychotics, antidepressants and mood stabilizers on risk for physical diseases in people with schizophrenia, depression and bipolar disorder

World Psychiatry

Systematic review and meta-analysis of pharmacological interventions for weight gain from antipsychotics and mood stabilizers

Curr Psychiatry Rev

Advances in the science, treatment, and prevention of the disease of obesity: reflections from a Diabetes Care editors’ expert forum

Diabetes Care

Long-term drug treatment for obesity: a systematic and clinical review

JAMA

Long-term persistence of hormonal adaptations to weight loss

N Engl J Med

Evaluation of an online cognitive behavioural therapy weight loss programme as an adjunct to anti-obesity medications and lifestyle interventions

Australas Psychiatry

Pharmacotherapy for obesity

Aust Fam Phys