Obesity in Patients with Schizophrenia

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In the pre-antipsychotic era, Kraepelin noted that some patients with schizophrenia exhibited bizarre eating habits, and not uncommonly were obese. "The taking of food fluctuates from complete refusal to the greatest voracity. The body weight usually falls at first often to a considerable degree. (. . .) Later, on the contrary we see the weight not infrequently rise quickly in the most extraordinary way, so that the patients in a short time acquire an uncommonly well-nourished turgid appearance" (Kraepelin 1919, p. 125).

It is worth noting that this tendency to weight loss during more active phases of the illness has been borne out by results from a recent meta-analysis of multiple antipsychotic drug trials, which noted that placebo-treated patients on average lost weight (Allison et al. 1999a). Nevertheless, there are a number of reasons that patients with schizophrenia might be prone to obesity, including the effect of symptoms such as paranoia and negative symptoms such as apathy and social withdrawal, which may independently contribute to schizophrenic patients' lack of adherence to proper diet and their overall sedentary lifestyle (Davidson et al. 2001).

Weight Monitoring for Schizophrenia

The effects of antipsychotic-related weight gain have both medical and psychiatric components. In particular, medication compliance is adversely affected by excessive weight gain, with weight gain being a wellknown cause of treatment nonadherence (Bernstein 1988; Silverstone et al. 1988) and subsequent psychotic relapse (Rockwell et al. 1983).

During the 2000 American Psychiatric Association meeting, investigators at the Columbia­St. Luke's Obesity Research Center released survey data examining this link between obesity and antipsychotic medication compliance. They found that obese patients were 13 times as likely to request discontinuation of their current antipsychotic agent because of concerns about weight gain and 3 times as likely to be noncompliant with treatment compared with nonobese individuals (Weiden et al. 2000).

Patients who gain weight on antipsychotics also utilize health care resources more than patients who do not experience weight gain (Allison and Mackell 2000).

Behavioral Treatment

Behavioral interventions such as calorie restriction, exercise, and behavioral modification are key elements to successful, sustained weight loss (NHLBI 2000; NHLBI also has posted on its Web site a practical guide for obesity evaluation and management: www.nhlbi.nih.gov/guidelines/ obesity/practgd_c.pdf). There is little in the way of published data on behavioral interventions for weight loss in psychotic patients, and the few studies tend to be methodologically weak. In one small (n = 14) 14-week study, patients in a residential setting achieved, on average, 10 pounds more weight loss when given behavioral interventions compared with a control group (Rotatori 1980).

Work by Wirshing and colleagues demonstrated that simple stepwise behavioral interventions were modestly successful in risperidone- and olanzapine-treated subjects, but had little effect in clozapine-treated subjects (Wirshing et al. 1999).

The Effects of Antipsychotic Medications on Weight

Obesity as a risk factor for antipsychotic noncompliance. Weight gain is a common side effect of antipsychotic medications and is of particular concern with most of the newer "atypical" antipsychotics. It is, therefore, increasingly important to understand the impact of obesity and perceived weight problems on compliance with these medications.

Antipsychotic medications have been the mainstay of treatment for schizophrenia for over half a century. A link between weight gain and treatment with chlorpromazine and other low-potency conventional antipsychotic agents, such as thioridazine, was noted in early studies of the metabolic effects of these agents. (Bernstein 1988; Rockwell et al. 1983). A recent study by Allison et al. (1999b) based on 1989 National Health Interview Survey data revealed that a significantly greater proportion of female patients with schizophrenia had BMI distributions in the overweight and obese spectrum compared with their counterparts in the general medical population, with a trend toward greater BMI seen among male schizophrenic patients. 


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