Improving Weight and Related Improving Weight and Related Side-Effects of Antipsychotic Side-Effects of Antipsychotic

MedicationMedication

Alexander S. Young, MD, MSHSAmy N. Cohen, PhD

VISN-22 Mental Illness Research, Education, and Clinical Center (MIRECC)UCLA Department of Psychiatry

OverviewOverview

• Antipsychotic medications & weight gain• Management of weight gain• Quality of usual care• EQUIP: options for improving care

CATIE Results: CATIE Results: Weight Gain Per Month of Treatment Weight Gain Per Month of Treatment

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olanzapineolanzapine risperidonerisperidone perphenizineperphenizinequetiapinequetiapine ziprasidoneziprasidone

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Risk of Death Increases with BMIRisk of Death Increases with BMI

Waist Circumference and BMI IncreaseWaist Circumference and BMI Increasethe Risk of Diabetes, Hypertension,the Risk of Diabetes, Hypertension,

and Cardiovascular Diseaseand Cardiovascular Disease

BMI Waistmen ≤ 40 inches

women ≤ 35 inches

Waist> 40 inches> 35 inches

Underweight < 18.5 - -

Normal 18.5 – 24.9 - -

Overweight 25.0 – 29.9 Increased High

Obese 30.0 – 34.9

35.0 – 39.9

High

Very High

Very High

Very High

Extremely Obese ≥ 40 Extremely High Extremely High

Weight Management Programs Are EffectiveWeight Management Programs Are Effective

• Group and individual psychoeducation improves weight in people with psychotic disorders– these are specialized programs– numerous controlled research trials

• Weight loss is modest: average 5 lbs• Modest weight loss is associated with

health benefits

EQUIP Weight Management ProgramEQUIP Weight Management Program

• Located in specialty mental health– led by mental health clinician– tailored for learning disabilities

• 16 sessions– each focused on one nutrition or exercise topic

• Handouts for every session– large font– room for patients’ notes

• Food models• Fast food guide

Weight ManagementWeight ManagementSession ContentSession Content

1. Poor diet and health problems

2. Food pyramid and portion sizes

3. Food pyramid and portion sizes (continued)

4. Increasing fiber intake

5. Increasing water intake

6. Importance of exercise

7. Decreasing fat and cholesterol

8. Starting to exercise

Weight ManagementWeight ManagementSession Content (cont’d)Session Content (cont’d)

9. Limiting sugar intake

10. Walking as exercise

11. Controlling hunger

12. Limiting salt; fast food

13. Expected lifestyle changes

14. Avoiding alcohol

15. Making exercise a daily routine

16. Review and summary

Changing Antipsychotic MedicationChanging Antipsychotic MedicationCan Cause Weight LossCan Cause Weight Loss

• CATIE study• Among patients who gained more than 7%

of weight in Phase 1• When switched to the following, how many

lost more than 7%– olanzapine: 0%– quetiapine: 7%– risperidone: 20%– ziprasidone: 42%

Changing from Olanzapine toChanging from Olanzapine toAripiprazole Causes Weight LossAripiprazole Causes Weight Loss

• Newcomer et al 2008• Overweight patients on olanzapine• Switch to aripiprazole vs. remain on olanzapine

– randomized controlled trial, n=173, 16 weeks

• Results– weight change (pounds): -4.0 vs. +3.1– lost more than 7%: 11.1% vs. 2.6%– lipids improved– CGI-Improvement: no change - minimal improvement

How Are We Doing? How Are We Doing?

• Most research on quality of care for schizophrenia was performed in 1990s– 1st generation antipsychotic medications

• Newer 2nd generation antipsychotics – fewer neurologic side-effects– more weight gain (varies by agent)

• Change in– frequency of clinical problems?– appropriateness of treatment?

MethodsMethods

• Random sample of patients with schizophrenia– 3 VA mental health clinics (n=398)

• Patient interviews– symptoms: psychosis, depression– side-effects: parkinsonism, akathisia, tardive

dyskinesia, weight gain

• Prescription data• Use explicit criteria to evaluate appropriateness

– derived from national guidelines

ResultsResults

• Clinical problems– few patients had depression without psychosis

(3%), parkinsonism (2%), or akathisia (1%)– 44% had severe psychosis– 11% had tardive dyskinesia– 46% were substantially overweight

• Appropriate medication changes– 27% of patients with psychosis– 2% of patients with elevated weight

ConclusionsConclusions

• Problems in care were equally common at all 3 clinics

• Compared with the 1990s– patients more likely to have severe psychosis

• quality of care for psychosis is unchanged

– weight is now the most important side-effect• treatment rarely changed in response to weight

Improving Care: OptionsImproving Care: Options

• Routine monitoring of weight• Clinician education• Patient education• Make services available

Enhancing QUality of care In Psychosis Enhancing QUality of care In Psychosis (EQUIP)(EQUIP)

• 3-year clinic-level controlled trial– funded by VA HSR&D QUERI– 4 VISNs: 3, 16, 17, 22– 320 providers, 900 patients

• intervention: evidence-based quality improvement, improved patient information, care reorganization– weight– employment

EQUIP Leadership Team

VISN 16Anna Teague, MD (PI: Houston)

Dean Robinson, MD (PI: Shreveport)Kathy Henderson, MD

Avila Steele, PhD

VISN 3Eran Chemerinski, MD (PI: Bronx)

Charlene Thomesen, MD (PI: Northport) Deborah Kayman, PhD

VISN 22Christopher Reist, MD (PI: Long Beach)

Larry Albers, MDDavid Franklin, PsyD, MPH

VISN 17Max Shubert, MD (PI: Central Texas)

Wendell Jones, MDStaley Justice, MSW

Alexander S. Young, MD, MSHS (PI)Jennifer Pope, BS

Patricia Parkerton, PhDPaul Jung

Youlim Choi

Amy N. Cohen, PhD (co-PI)Alison Hamilton, PhD

Katy Oksas, MFTStone ShihPaul Jung

Los Angeles (Coordinating Site)

Routine Monitoring of WeightRoutine Monitoring of Weight

• In specialty mental health• Challenges

– purchase scales– check weight at every visit

Patient Education

Make Services Available: Make Services Available: Wellness GroupsWellness Groups

• Challenges– services not currently provided– few clinicians believe weight is a high priority– patient motivation– patient transportation

• Facilitators– clinicians like providing the groups– audio (VANTS) or video– PRRC’s

Make Services Available: Make Services Available: Medication ChangeMedication Change

• Challenges– psychiatrists are not changing medications– few psychiatrists believe this is a high priority– “It’s too hard for patients to lose weight.”– “Symptom management is more important.”– medication changes require early follow-up

• Facilitators– start with ziprasidone and aripiprazole– next try risperidone or quetiapine– provide patient-specific feedback

SummarySummary

• Individuals with psychotic disorders are at a high risk for weight gain and related medical problems

• Monitoring– weight: at every visit & at home

• Implementation– weight management groups– medication change