Improving Weight and Related Side-Effects of Antipsychotic Medication

1. Improving Weight and Related Side-Effects of Antipsychotic Medication Alexander S. Young, MD, MSHS Amy N. Cohen, PhD VISN-22 Mental Illness Research, Education, and Clinical Center (MIRECC) UCLA Department of Psychiatry

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

3. olanzapine quetiapine risperidone perphenizine ziprasidone CATIE Results: Weight Gain Per Month of Treatment Weight gain (lb) per month

4. Risk of Death Increases with BMI

5. Waist Circumference and BMI Increasethe Risk of Diabetes, Hypertension,and Cardiovascular Disease

6. Weight 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

7. EQUIP 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

8. Weight ManagementSession Content • Poor diet and health problems • Food pyramid and portion sizes • Food pyramid and portion sizes (continued) • Increasing fiber intake • Increasing water intake • Importance of exercise • Decreasing fat and cholesterol • Starting to exercise

9. Weight ManagementSession Content (cont’d) • Limiting sugar intake • Walking as exercise • Controlling hunger • Limiting salt; fast food • Expected lifestyle changes • Avoiding alcohol • Making exercise a daily routine • Review and summary

10. Changing Antipsychotic MedicationCan 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%

11. Changing from Olanzapine toAripiprazole 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

12. 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?

13. Methods • 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

14. Results • 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

15. Conclusions • 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

17. Improving Care: Options • Routine monitoring of weight • Clinician education • Patient education • Make services available

18. Enhancing QUality of care In Psychosis (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

19. Los Angeles (Coordinating Site) Amy N. Cohen, PhD (co-PI) Alison Hamilton, PhD Katy Oksas, MFT Stone Shih Paul Jung Alexander S. Young, MD, MSHS (PI)Jennifer Pope, BS Patricia Parkerton, PhD Paul Jung Youlim Choi EQUIP Leadership Team VISN 3Eran Chemerinski, MD (PI: Bronx) Charlene Thomesen, MD (PI: Northport) Deborah Kayman, PhD VISN 16 Anna Teague, MD (PI: Houston) Dean Robinson, MD (PI: Shreveport)Kathy Henderson, MDAvila Steele, PhD VISN 22Christopher Reist, MD (PI: Long Beach)Larry Albers, MD David Franklin, PsyD, MPH VISN 17Max Shubert, MD (PI: Central Texas)Wendell Jones, MDStaley Justice, MSW

20. Routine Monitoring of Weight • In specialty mental health • Challenges • purchase scales • check weight at every visit

22. Patient Education

23. Make Services Available: Wellness 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

24. Make Services Available: Medication 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

25. Summary • 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