Narrator: Welcome to the E-View Series “Strategies to Integrate Physical Health Care Into Mental Health,” chaired by John W. Newcomer, MD, from the Department of Psychiatry, Washington University School of Medicine in St. Louis, Missouri. This E-View, entitled “Monitoring and Managing Weight Gain in the Mentally Ill,” includes presentations by Rohan Ganguli, MD, and Betty Vreeland MSN, APRN, NP-C, BC.
Narrator: Dr. Ganguli, from the Department of Psychiatry at the University of Pittsburgh Medical Center and the Western Psychiatric Institute and Clinic in Pittsburgh, Pennsylvania, will now present “Weight Reduction and Prevention of Weight Gain in Patients With Schizophrenia.” Dr. Ganguli: I will talk about interventions with patients, focusing primarily on lifestyle. I'll also talk about both weight reduction and preventing weight gain because clearly the latter is the direction in which we want to point people and give them some tools.
Narrator: Think about your answer.
Dr. Ganguli: I've been treating really overweight people for many, many years without paying much attention to it at all. Then, one of my research fellows did a survey, and, as you can see, only about 20% of our patients are actually in the normal weight range. 80% of them are overweight or obese, and actually the majority of them, 60%, are obese. So this is a serious problem for the population of people with schizophrenia that we were treating. I think that among the various excuses that were made for why we were neglecting this problem was that people with schizophrenia—and this is unfortunately a very pejorative and stigmatizing attitude—do not care. I often heard clinicians and families state that obesity is the least of these patients’ problems. I also heard that patients have negative symptoms and poor insight, leading them to be unaware of their own weight problems. In other words, it has been assumed that people with schizophrenia are socially unaware and that, unlike the rest of us, this really does not matter to them.
Dr. Ganguli: Dr. Strassnig actually asked patients with schizophrenia, "Do you believe that you're overweight? Do you want to weigh less? Have you tried to lose weight?" We found that the majority of people in fact believed that they were overweight and would like to lose weight and had tried to lose weight. When we divided the sample by how badly they needed to lose weight, for health reasons—so you had the obese people here who urgently need to lose weight, the overweight people who should lose weight, and the normal weight people who do not really need to lose weight for health reasons—we found that, just like in the general population, you had people who do not necessarily need to lose weight for health reasons, but who wanted to and were trying to lose weight. At the other end, we found that almost everybody believed that they were overweight, and a surprisingly large number claimed that they had actually tried to lose weight.
Dr. Ganguli: The next question, of course, was what do patients themselves attribute their weight gain to. As most people would guess, many patients attribute their weight gain to the effects of medication. This was reinforced by this survey of community dwelling patients, conducted in the U.K. The respondents were asked about the 5 worst things about taking medicine, and weight gain came out as the most frequently cited “worst thing”.
Dr. Ganguli: So we decided to go into the business of weight reduction. We obviously went out to look for things that had already been done, and we have obviously added to this list since we started out. Even though there are relatively few studies that have some form of a control group, the results were relatively reassuring. All methodologically-rigorous studies found clinically significant weight loss as a result of behavioral interventions, so people with schizophrenia did not seem to be any less suitable for behavioral interventions than other obese or overweight people.
Dr. Ganguli: In developing a behavioral intervention for weight loss in schizophrenia, we had to take into account a lot of the practical difficulties of implementing these interventions in the “real world” as opposed to just with the most enthusiastic providers and the most enthusiastic patients. One of the things that we recognized is that many of our patients do not have control over the quantity of food that they are actually served. They do not actually serve themselves. They do not cook for themselves. They use fast food restaurants like many of the other poor people in this country because it is cheap and tasty. Unfortunately, the only solution to the excessive portion sizes being served is to waste food, so you really have to leave some food behind in order to do that. The same thing with energy—we had to work strategies into their lives where they would waste energy, as well. We also recognized that, to be practical, the intervention had to be cheap, not require education, not require very extensive travel, and should be deliverable by mental health clinicians. The mental health center has way too much on its plate already, so, if there is a significant financial investment, they are not going to be able to do it.
Dr. Ganguli: This is what we came up with: a random assignment, short-term intervention. We did it in groups because this is the most familiar way and the most economical way for mental health centers to deliver treatment. We used standard behavioral treatments. We rehearsed in the groups; we gave them homework to do. A major confound with many of these studies prior to this one was the varieties of medications patients were taking and the potential that treatment was confounded by that. Consequently, for this particular study, we chose a sample of patients who had been switched to risperidone, so basically the medication treatment was uniform across the group. Then we randomized them, and they went into our treatment.
Dr. Ganguli: This is how the 14 weeks were laid out, into 7 separate steps, and you can see that there is a different focus in each of the steps. We manualized the intervention so that we could put it in the hands of the clinicians.
Dr. Ganguli: This was just one top line level of results here. We have taken patients and put them into 3 different strata: those who lost 3% of weight, 4%, or 5%. As you can see, about 50% of the patients would succeed in losing at least up to 4% of body weight. Now, many of them starting out were extremely obese and are still not in the normal healthy range at this point. Nevertheless, in a short-term intervention this is reasonable and compares very favorably with any expensive commercial weight loss program.
Dr. Ganguli: The conclusions reinforced that patients with schizophrenia are in fact capable of participating in these interventions—they do lose weight—and that mental health clinicians delivered the interventions in an efficacious manner. However, I think maintenance of weight loss remains the challenge, as it does for weight loss research in general.
Dr. Ganguli: This is a woman who has really been sick for many years, been treated for many years, and is obviously quite overweight already by the time she volunteers for this study. I think clinically you might have switched your attention off of this lady because she was having difficulty in the beginning and actually lost very little weight to start off with. Then, it picked up a little bit. This is the 2-year follow-up now, and you can see how, even with just the booster sessions every 2 weeks, she continues to lose weight. So, despite this relatively modest initial weight loss, her trajectory of weight loss is really quite good. Also, she has figured out what works for her and what does not. She has gained control of certain things, her eating primarily. She has worked rather diligently at this whole business of wasting energy, and this is one of the things we do encourage our patients to do. Walk down the stairs. Maybe it is too difficult to walk up the stairs. That is fine. Walk down the stairs. Walk down the hill. So, this patient walks down the hill to us.
Dr. Ganguli: Given how difficult it is to lose weight and all the problems that one has once one has gained weight, we turned our attention to the possibility at least of prevention, involving patients with schizophrenia or schizoaffective disorder, starting on a novel antipsychotic—risperidone, olanzapine, quetiapine, ziprasidone or clozapine. Aripiprazole was not readily available at that time. We did take patients with a BMI that was in the obese range but not in the extremely obese range. The reason is that patients who are already obese are quite capable of gaining even more weight when challenged with a weight-gain inducing antipsychotic. We randomized the subjects to the intervention or to usual care, and we followed them up for 16 weeks. Again, this was a relatively short-term intervention, but if you look at the trajectory of weight gain induced by antipsychotics, the patients who are at risk for weight gain will manifest this tendency fairly early on, within the first 6 to 8 weeks.
Dr. Ganguli: Given that this is a preventive intervention, we only wanted to deliver it at the intensity that is required. We broke it down into 4 steps, so if patients went along and were monitored and did not gain weight, then there was nothing further done. However, if patients did gain weight they received the next intervention.
Dr. Ganguli: 1 kilogram is the threshold for the intervention to get stepped up. Here is where we could have gotten into a whole discussion of how many BMI points or what percentage of the initial weight should be the threshold, which would have been extremely difficult for clinicians to implement. So, we said “If you have 1 kilogram of weight gain, you get the next intervention”—very simplistic but easy to implement. Clinicians can easily keep track of things like that. In the example here, Patient 1 gains 1 kilogram at the 9th week, so then he gets to the next level of intervention. He gained another kilogram at the 14th week, so he received 1 more step of the intervention. Patient 2 actually uses up all the steps of the intervention without succeeding in arresting his weight gain.
Dr. Ganguli: This was the average change in weight between the treatment and the control group. The treatment group, as you can see, on average neither gained nor lost weight. This is obviously an extremely insignificant amount of weight loss, a little less than a kilogram. The mean for the control group was to gain about 2 and 3/4 kilograms, which was obviously a statistically significant difference. However, the means are the mean for the whole group: some people gained weight, some people lost weight, and some people did not change in weight.
Dr. Ganguli: This is the proportion of who gained or did not gain weight. This is again reassuring. Obviously we do not help everybody, but with the intervention delivered in a somewhat cost-effective manner, only being triggered by actual weight gain, we are succeeding in preventing some people from gaining weight, it would appear.
Dr. Ganguli: The last piece of data from that study was a little bit more mixed. You cannot treat this in any way statistically for 2 reasons: the numbers are small and, more importantly, people are not randomly assigned to these medications. You can look at the difference in the proportion of patients who gained or who did not gain depending on whether they were in the intervention or the control group. If you look at risperidone and quetiapine, you can see that the intervention groups actually do not gain weight for the most part, whereas the control groups do. If you look at olanzapine and clozapine, you find that there is much less effect of treatment. Are you more successful in your intervention with certain medications than you are with others? This would suggest that that is indeed the case.
Dr. Ganguli: Final conclusions—we did prevent weight gain. The most powerful evidence is for self-monitoring. Instruction combined with self-monitoring actually got you a fairly big bang, and that was a relatively modest investment. The second thing was hints that the treatment might be less successful with some medications than with the others. The implication for the clinician is, with some medicines, you maybe need to switch. With other medicines, you may have behavioral tools that work better for you. Vreeland
Narrator: Ms. Vreeland, from University Behavioral HealthCare, the School of Nursing, and the Robert Wood Johnson Medical School, Departments of Psychiatry and Family Medicine, at the University of Medicine and Dentistry of New Jersey in Piscataway, will now present “A Multidisciplinary Approach to Managing Weight in the Mentally Ill.” She will talk about the need for teamwork among physical and mental health care providers in managing weight in mentally ill patients and will present an effective multidisciplinary weight management program.
Ms. Vreeland: I would like to start out saying that a lot of behavioral healthcare professionals really want to know, “Are health and wellness possible in people with major mental illnesses?” I think that our typical image is someone who is a couch potato, not interested in health and wellness, and I have some research that helps to dispel this myth.
Ms. Vreeland: There is growing evidence of the need to address physical and mental health together, and in the President's new Freedom Commission on Mental Health, they talk about how improving services for people with serious mental illnesses will require paying close attention to how mental health care and general medical care systems work together in order to bridge this gap.
Ms. Vreeland: If we are going to be able to bridge this gap, we need to look at the whole person. Behavioral healthcare providers are used to looking at people from the neck up, but we also need to look at people from the neck down. I think that nurses are ideally prepared to bridge this gap because of their holistic training. We operate out of a biopsychosocial spiritual approach to addressing the whole person, so, when we are looking at how we can improve some of these physical health outcomes, utilizing the nurse as an important part of the multi-disciplinary team can really help make a difference.
Ms. Vreeland: Additionally, we want to look at all of the members on our treatment team—behavioral healthcare professionals, social workers, psychologists, and all members of the treatment team.
Ms. Vreeland: There are many treatment team strategies that can help bridge this gap. It is important to increase communication with clinic staff, reminding patients by phone the day before the appointment and certainly reinforcing any patient education that comes up during clinic visits. I think that this is something that nurses can play an essential role in, reinforcing good clinical care. I have worked in a number of different settings where we see that nurses are making links with primary care centers and really helping people to get there and keep appointments and also getting the communication going back and forth.
Narrator: Choose the best answer. The correct answer is "D," all of the above.
Ms. Vreeland: The issue that I really want to focus on is lifestyle. Many of the major health problems—heart disease, cancer, stroke, respiratory diseases, diabetes—are all affected by lifestyle. Repeatedly we see that smoking, exercise, obesity, and diet are issues that we can be looking at in people with major mental illnesses.
Ms. Vreeland: Research from the Nurses' Health Study shows that there are some simple lifestyle rules that can reduce the risk of disease. Again we see that smoking, being physically active, eating a healthy diet, and maintaining a healthy weight are all lifestyle issues that can affect health.
Ms. Vreeland: It is very important to look at Prochaska and DiClemente's stages of change approach when we are looking at any type of lifestyle interventions. If we move someone from not having any interest in addressing the problem to thinking, "Well, you know what? I should quit, but it would be hard to," this is making progress.
Ms. Vreeland: Even more so than the average American, people who are living with major mental illnesses are more likely to have unhealthy lifestyle behaviors, such as smoking heavily, eating diets that are high in fat and sugars and low in fiber, and have addiction problems and other types of lifestyle behaviors that put them at higher risk of medical problems. There also is research that suggests that people with major mental illness can also adopt healthier lifestyles. We have research that shows that people can recover from addiction, stop smoking, and adopt a healthy diet. We can prevent and reverse psychotropic-associated weight gain, and I have some research that shows that, when we reverse the weight gain, it also improves physiologic measures just like in non-psychiatric populations.
Ms. Vreeland: There are national guidelines that have been established about how we identify, evaluate, and treat overweight and obesity. Treatment is recommended if anyone has a BMI of 30 or higher, or if they are in the overweight range or have a large waist circumference and have 2 or more risk factors.
Ms. Vreeland: Moderate weight loss has significant health benefits. Between 4% and 5% can lower or eliminate the need for antihypertensive treatment. 5% to 7% is associated with a 58% reduced risk for Type 2 diabetes. 6% to 7% can improve the metabolic syndrome. So, we see that a small amount of weight loss can really make a major difference in health.
Ms. Vreeland: If we look at a database of the National Weight Control Registry, over 5,000 individuals, what are the most successful strategies? Engaging in high levels of physical activity, between 60 to 90 minutes per day. Eating a diet low in calories and fat. Most of these people eat breakfast every day. They self-monitor weight regularly and maintain a consistent eating pattern. Also, they catch slips before they turn into large problems. I think this is also key: that these people initiate weight loss after a medical event, which can be defined as easily as a healthcare professional advising someone to lose weight.
Ms. Vreeland: Weight gain is not exclusive to people with serious and persistent mental illness, but we know it is associated with many psychotropics. It can affect forming all of these medical problems that we are seeing, but we also have research that shows that weight gain can be reversed, minimized, and prevented in this population.
Ms. Vreeland: My Healthy Living Study was looking at people with schizophrenia or schizoaffective disorder and losing weight. We have 31 subjects in 2 day-treatment programs. This was not a randomized trial. We incorporated nutrition, exercise, and behavioral interventions, and we followed the NHLBI obesity guidelines, the USDA Dietary Guidelines for Americans. We utilized a modularized approach solution for wellness. We did a walking video and weekly weights on the same scale. We did have a comparison group.
Ms. Vreeland: When compared to the major weight loss diets of Atkins, Zone, Weight Watchers, and Ornish, if we look at completers, at 12 months my Healthy Living Study subjects actually had the weights that compared with Weight Watchers and Zone.
Ms. Vreeland: We had about a 6.6-pound weight reduction in people who got Healthy Living and a 7-pound increase in treatment as usual.
Ms. Vreeland: We had a significant reduction in systolic and diastolic blood pressure.
Ms. Vreeland: We also had a significant reduction in hemoglobin A1C. Also, people between double and tripled their physical activity level by self-report, which was almost all walking.
Ms. Vreeland: We saw that very simple things were what really added up to make a big difference: teaching people to use the food label, look at portion size, eat more slowly, and reduce fast food intake. We actually had comparisons of different fast foods in restaurants. Probably some of the biggest changes were increasing physical activity by walking and minimizing soft drinks and sugar.
Narrator: Think about your answer.
Narrator: Mr. C, a 47-year-old man with schizophrenia, completed the 12-month Healthy Living Program and achieved dramatic improvements in health, including decreased weight, BMI, and blood pressure, and increased exercise.
Ms. Vreeland: In summary, people with mental illness have poor physical health. We know that the metabolic effects of our medications are making this worse and that we need to have improvement in health Screening, monitoring, and definitely in prevention. We also know the common causes of death and disability are influenced by behavior. People with major mental illness can really adopt healthier lifestyle behaviors just like someone without a psychiatric problem.
Ms. Vreeland: This integration between physical and mental healthcare is really critical, and there are so many things that we can do, small steps to improve access and utilization of primary care. Certainly think about utilizing nurses and others as part of the multi-disciplinary team to help to move this initiative forward. Preventive services are essential, and we need to really empower consumers to make healthier choices because with this knowledge they can change their lifestyle. Transforming the nation's mental health system is going to require organizational change, but we actually see that, as we are putting together many of these agencies across the nation using a multi-disciplinary approach, this can help to bridge the gap between physical and mental health. Thank you very much.
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Abbreviations
BID = twice a day
BMI = body weight index
FDA = Food and Drug Administration
LDL = low density lipoprotein
NHLBI = National Heart, Lung, and Blood Institute
USDA = United States Department of Agriculture