Dr. Bob's Psychopharmacology Tips

Weight-gain on medication

Date: Fri, 19 Jan 1996 23:45:00 +1300
From: felicity@i-max.co.nz (Dr Felicity Plunkett)
Subject: Weight-gain on medication

A colleague of mine presented a paper locally on an old & "forgotten" antipsychotic -- molindone -- which may well cause significantly less weight-gain.

Make sure that patients on Li or with dry-mouth side-effects don't drink sweet soft-drinks (in summer especially -- not that this is a problem for you all just now!).

My colleague's interested in weight-gain on meds as an under-researched area. The bottom line, she said, was that there's little one can do but sensible diet advice (delivered in a clear form & repeated for patients with negative sx) does help. The best diet seems to be as low-fat as possible, with no restriction on carbohydrates, especially simple carbs. It's easier to stick to and coupled with a little regular exercise does give gradual weight loss.

Subject: Weight-gain on medication
From: eliot.gelwan@channel1.com (Eliot Gelwan)
Date: Fri, 19 Jan 1996 22:50:00 -0640

(up onto soapbox) A much much more important weapon in combatting medication-induced weight gain is anticipating it with the patient since it's far easier to avoid pro-actively than to reverse re-actively. Yet many psychiatrists neglect to do this. It seems to me the common side effects, even if less devastating, must be topics for informed consent no less than the severe but rarer ones. And weight gain from medications has considerable morbidity associated with it. Patients' self-esteem and quality of life suffer tremendously; their alliance with their psychiatrists and trust of psychiatric medications and treatment in general are damaged; their activity level (so important to psychiatric rehabilitation) declines; and I have seen a number of sudden deaths which were, tragically, attributable mostly to weight. Enough said -- please discuss this with your patients at the outset! (down off of soapbox)

Date: Mon, 22 Jan 1996 08:09:40 -0500 (EST)
From: Elliott Richelson <richel@mayo.edu>
Subject: Less weight-gain with molindone

An old & "forgotten" antipsychotic -- molindone -- ... may well cause significantly less weight-gain.

--Dr Felicity Plunkett

Is anyone aware of what empirical data (references) support this common assertion?

From: wbennett@warren.med.harvard.edu (William Bennett)
Date: Thu, 1 Feb 1996 06:22:37 -0500
Subject: Weight-gain on medication

I don't think one can assume the existence of strategies that will successfully and consistently maintain clinically significant weight loss for very long. The published data, at least, show that most things work for the duration of a study (weeks to a few months), that some are effective until the first follow up (a year or so), and that by 5 years out, subjects are back to baseline. Granted, data of any quality are sparse indeed.

It does an incredible disservice to patients to imply that weight control is in their power, especially when we give them agents that are known to alter energy metabolism and storage. (Granted, the strategy of blaming the patient when all else fails is a time-honored one.)

Recently emerging data show that there are hitherto unrecognized transmitters (such as leptin) that may particpate in the regulation of fat storage and food intake. Energy metabolism and eating behavior are, of course, mediated by both serotonin and norepinephrine; that part is well described. But there's evidently a great deal more to the story. I think we should be pretty circumspect about anything we say to patients (or to each other) on the matter of fat.

Date: 1 Feb 1996 17:07:58 -0500
From: "Mike Johnson" <mike_johnson@smtpgw.musc.edu>
Subject: Weight-gain on medication

On 2/1/96, Stephen Nagy wrote:

Does anyone in the group know of a strategy to restore the patient's ability to feel satiated after eating?

Date: Thu, 01 Feb 1996 17:58:34 -0600
From: Stephen R Saklad <Saklad@uthscsa.edu>
Subject: Weight-gain on medication

Just a comment about encouraging water drinking. Watch out for an occasional patient developing a dilutional hyponatremia. This is a problem in several (~10) of our chronic patients that frequently results in seizures.

I haven't noticed any problem with either gastronomic insatiability, serious weight gain or excessive water drinking in our valproate (Depakote, Depakene) patients.

Date: Thu, 1 Feb 1996 22:37:25 -0500
From: bret@vnet.net (Bret Burquest)
Subject: Weight-gain on medication

I've found drinking water frequently helpful to aid satiation too... except in water bulimics. Even better is metamucil. Even before eating.

Date: Wed, 03 Jul 1996 15:56:27 -0400
From: Bonnie Szarek <Bszarek@harthosp.org>
Subject: Antidepressant-induced weight gain

In a retrospective comparison of weight changes in hospitalized patients treated with fluoxetine, desipramine, and amitriptyline (J Nerv Ment Dis 181: 702-704, 1991), Doug Brandt and I found that at 4 weeks and 8 weeks, both desipramine- and amitriptyline-treated patients gained significantly more weight than fluoxetine-treated patients. At 4 weeks, there was no significant difference in weight change between desipramine- and amitriptyline-treated patients, but at 8 weeks, amitriptyline-treated patients had gained significantly more weight than desipramine-treated patients.

In a review of the literature, Garland, Remick, and Zis (J Clin Psychopharmacology, 8: 323-330, 1988) found that the amount of weight gain with TCAs appeared to be related to both dose and duration of treatment.

Fernstrom and Kupfer (Psychiatry Research, 26: 256-271, 1988) compared weight change in patients treated with amitriptyline, nortriptyline, desipramine, and zimelidine. They reported weight gain in 89% of patients treated with amitriptyline, 67% of patients treated with nortriptyline, 58% of patients treated with desipramine, and 8% of those treated with zimelidine. They found a positive correlation between amitriptylilne dose and weight gain.

From: LHSQ76A@prodigy.com (Dr Valerie D Raskin)
Date: Wed, 3 Jul 1996 15:23:42, -0500
Subject: Antidepressant-induced weight gain

Since I have an almost all woman practice, many of whom are especially concerned about weight gain in the context of being heavier than usual following recent childbirth, I struggle with this issue quite commonly. My unscientific observations are as follows:

• Yes, it is definitely dose and blood level related. If there is a clinical reason to prefer TCAs to SSRIs, I check a level and drop the dose if that's acceptable clinically. Unfortunately, it's often like anorgasmia and SSRIs: drop low enough to get rid of the side effect, and you often lose the clinical effect. Increasingly, I reserve TCAs for panic disorder and augmentation, since typically effective dosages for these conditions don't result in weight gain.

• Exercise and diet rarely help. I think it may be an issue of resetting the weight "set point." Many patients have sworn up and down that they aren't eating enough more; others clearly experience an appetite increase and/or specific food cravings.

• The rich get richer and the poor stay poor. Not always, but typically, thin women get this side effect less than women who have been moderately or severely overweight, or who have struggled hard to stay within a healthy weight range.

• It is easy to underestimate the cultural and personal significance of even 10 lb weight gains, and, like it or not, this is a bigger issue for most women than it is for most men. Always keep in mind that we have an extremely thin-obsessive culture, which getting more so by the hour, and few women will find this a tolerable effect. We may not weigh the risks and benefits of treatment of depression vs. weight gain from the same vantage point as our patients do.

• Concern about weight spans the life cycle, i.e., it may be as important to our geriatric patients as to our adolescent patients.

Date: 03 Jul 96 18:42:21 EDT
From: Leslie Gise <76106.413@compuserve.com>
Subject: Antidepressant-induced weight gain

SSRIs also seem associated with weight gain long term. Weight gain is a most difficult problem to treat and, I agree, generally quite treatment resistant. But in the context of a PMS program in the Ob-Gyn department, which I ran for 10 years, with group follow-up visits, women showed an amazing ability to modify health behaviors, eating, weight, exercise, smoking, caffeine, etc. We were somewhat less effective with alcohol. Group support seemed to be a critical factor.

From: LJGROLD@aol.com (L.James Grold M.D.)
Date: Sat, 6 Jul 1996 06:32:50 -0400
Subject: Antidepressant-induced weight gain

I have had a number of patients gain prodigious amounts of weight on sertraline and not lose the extra pounds until they were shifted off the SSRI.

Date: Tue, 9 Jul 1996 18:27:27 -0700 (PDT)
From: Jonathan Nye <jpn@itsa.ucsf.edu>
Subject: Antidepressant-induced weight gain

I had a pt who gained many lbs on fluoxetine. At the time, I received advice in this forum that sertraline produces a "predicable anorexiant effect" at doses of 150 mg or greater/d. (I can't remember who offered it.) That patient was lost to follow-up, but I had the opportunity later to see a woman who had gained about 30 lbs on sertraline 50 mg/d. When I increased her dose to 150 and later to 200 mg/d, she began to lose the added pounds. The power of suggestion aside, I was quite impressed.

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