Is There A New Approach to Antipsychotic-Related Weight Gain? A Brief Journal Club With Rakesh Jain, MD

In this installment of the 7 in 7 journal review, Rakesh Jain, MD, MPH, reviews an article from The Lancet Psychiatry, entitled "Psychotropic Medicines Increased Appetite Rather Than Weight Gain." Dr Jain includes his review of this research article and weighs in on the question: Is there a different way to approach antipsychotic-related weight gain?

Read the transcript:

Dr. Rakesh Jain: Weight gain is a significant challenge in clinical practice, particularly with psychiatric medications. The question I wanted to ask myself was the following. Is it time to look at this issue of weight gain with psychiatric medications differently?

Towards this goal, I found a recent wonderful article worthy of inclusion in our Journal Article Review, where I review 7 of the most important journals in psychiatry, pick 1 article, and within 7 minutes, offer you an in-depth review with information that we clinicians can take to our practices and make a difference for our patients.

My favorite 7 journals, which I consider essential in my development as a mental health clinician, are the following: the American Journal of Psychiatry, Molecular Psychiatry, Translational Psychiatry.

The other journals are The Lancet Psychiatry, The Journal of Positive Psychology, The Journal of the American Academy of Child and Adolescent Psychiatry, and then The Journal of Wellness.

My name is Rakesh Jain. I'm a clinical professor of psychiatry at Texas Tech School of Medicine in Permian Basin. I also have a private practice in Austin, Texas. I'm a proud member of the Steering Committee at Psych Congress 2022.

Today's featured article is the following. It appeared in The Lancet Psychiatry February 2022 issue, and it is a correspondence from 2 of the best-known thought leaders in the world of international psychiatry.

This correspondence directly addresses the issue of psychotropic medicines and increased appetite rather than weight gain being of primary interest to us. Here is the title. By the way, the direct link to it is posted here on the bottom right.

The authors are 2 people who together have perhaps 80-some years of clinical experience as well as research abilities, Leonardo Tondo from Italy and Ross Baldessarini from Harvard.

Here is the full article citation. This article, by the way, is available as a free PDF download for your review. I strongly encourage you to read this for yourself.

The relevant background is as follows. We do know weight gain is a common adverse reaction with lots of psychiatric medications but particularly antipsychotic medications. The effect of psychotropic medications on body weight is different between medications and between different drugs.

Amongst antipsychotics, they often are a significant problem that lead to profound morbidity, mortality, and adherence challenges for our patients. Now, let's examine the issue in a bit more detail using a graphic. The question is, appetite increase, weight increase, what is the relationship?

This article makes a very clear link by stating that the weight gain appears to be primarily because of appetite increase, particularly with carbohydrate-rich foods, and a decrease in exercise. They do not support the notion that the weight gain is independent of appetite increase. I'll tell you more about that in just a second or so.

The authors are asserting the following, that one of the first questions asked by many patients is whether a prescribed medication will lead to weight gain. What they're stating is, this is the wrong question for the clinician and the patient to be discussing.

What they're suggesting is, instead of talking about weight gain to start with, we clinicians should be thinking about and talking about increased appetite and to encourage our patients to act assertively to counter this adverse effect in order to reduce the risk of weight gain. Let's move on to the article further.

By examining the full article, we realize that they are recommending a 3-step set of recommendations. The first one is, focus on increased appetite. Let's offer our patients direct information on this, the time course, the degree of it, and encourage our patients to act assertively to counter the adverse effects of increased appetite. I'll tell you more about that in just a second.

Number 2, clinicians should always discuss dietary issues, particularly carbohydrate issues, and to stress the importance of physical exercise. These authors with their tremendous experience focus deeply on these two issues. They are recommending that, in some cases, a referral to an expert nutritionist may be appropriate for the patient.

These are their recommendations, but what are the results that they have from following their own advice? They analyzed their data sets, which is a pretty impressive 687 patients with motor anxiety disorders who were being treated with various psychotropic agents.

They followed these patients for prolonged periods of time, on average about 8.5 years but some of them for 40-some years. These authors do know what they're talking about.

About 6 out of 10 of their patients are women. The average age of the patients is about 41 with a body mass index at the beginning of about 24. Let's see what results did they have based on their focus on increased appetite rather than increased weight.

They found, by following their own advice, they only had a modest mean increase in body mass index of about 4.5 percentage points. This increase is substantially lower than the typical reported values. What does this article teach us practicing clinicians? Let me break their teachings into three parts.

Part 1 is, the authors are recommending that patients be informed about the possibility of an increased appetite first rather than increased weight that is often associated with psychotropic medications.

This is a profound shift in my own thinking. They are right. I tend to focus much more on body weight and not increase appetite. As a result of this article, I will most likely change my own recommendations.

Number 2 is, authors propose that the effect of adverse changes on body weight and metabolic status should be countered and can be offset by an adequate diet, which is both lower in calories, but particularly low in carbohydrates, and increase in physical exercise. This is exceptionally good advice from both the authors.

The third deep learning for us is that reporting of adverse metabolic effects of medicines that the FDA uses and the other regulatory bodies use should emphasize an increase in appetite as an adverse event and not necessarily weight gain. Weight gain should be seen as a secondary outcome to this challenge of increased appetite.

One more time, let's review it graphically. The relationship between appetite increase and weight gain is unidirectional. That's what the authors are proposing and that focusing too much on weight gain ultimately is counterproductive.

We should be focusing on increased appetite as our primary target. Of course, as the authors have suggested before, countering increased appetite with good nutritional information and exercise would be important.

If you want to read this article in its entirety, worry not, here is the link.

By the way, thank you all for joining me for this issue of the "7 Journals in 7 Minutes." I hope you found it useful, and I'll see you with the next issue. Goodbye for now.