Treatment of morbid obesity in a chronic schizophrenia patient
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《中华医药杂志》英文版
Treatment of morbid obesity in a chronic schizophrenia patient
[Abstract] Morbid obesity is a major public health problem associated with excess mortality and poses a major risk factor for cardiovascular, metabolic, and neoplastic conditions. Schizophrenia patients are at increased risk for obesity and obesity-related disorders. Weight reduction is a complex task, especially for schizophrenia patients with morbid obesity. We present the case of a schizophrenia patient with extreme obesity who, following a switch in atypical antipsychotic treatment, successfully significantly reduced his body weight while receiving cognitive behavior therapy, and nutritional supervision.
[Key words] morbid obesity; schizophrenia; body mass index; atypical antipsychotic agents; nutrition
INTRODUCTION
Morbid obesity is a major public health problem associated with excess mortality. It is called “morbid” obesity because it is associated with life-threatening diseases such as hypertension, coronary heart disease, type II diabetes mellitus, sleep apnea, osteoarthritis and some types of cancer[1,2]. Body mass index (BMI) is the most common measure used to gauge body fat. It takes into account a person’s weight and height. Morbid obesity is diagnosed when the patients BMI is > 40. Schizophrenia patients have an increased mortality rate as they have an elevated risk for obesity, obesity related disorders[3], and physical co-morbidity[4].
Weight reduction programs for schizophrenia patients have been assessed. Five of eight pharmacological intervention studies reported small reductions in weight (25%)[5].Vreeland,et al.[6],showed that a weight control program incorporating nutrition, exercise and behavioral interventions was effective. Additional positive results were achieved with cognitive behavior therapy. Patients who received group based behavior therapy had greater weight loss than patients who received usual care[7].
We present the case of a schizophrenia inpatient who suffered from morbid obesity. After his antipsychotic treatment was switched, he received weight reduction intervention that included behavioral therapy, nutritional education and physical exercise. All identifying information has been removed.
CASE REPORT
A., a 32 year-old single Israeli man with a 23 year psychiatric history. Due to severe behavioral problems and restlessness at age nine, following unsuccessful attempts with psychological interventions, A. was admitted to a children’s psychiatric ward. During that year-long hospitalization he was diagnosed with ADHD, and eating disorders characterized mainly by uncontrolled overeating and gradual weight gain. A. was never discharged from psychiatric hospitalizations, and rehabilitation attempts failed. About 12 years ago, in addition to his bulimia and behavioral problems, A. developed psychotic symptoms accompanied by suicidal and aggressive behavior. He was admitted to a closed ward at our mental health center, and was later diagnosed with schizophrenia and transferred to a long-term
1 Lev Hasharon Mental Health Center, Netanya, Israel
2 Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
Correspondence to Dr. Yuval Melamed, Deputy Director, Lev Hasharon Mental Health Center, P.O.Box 90000, Netanya 42100, Israel
Tel:972-9-8981245,Fax:972-9-8945054
E-mail:ymelamed@post.tau.ac.il
hospitalization ward. His psychotic symptoms were resistant to adequate trials of anti-psychotic agents and various psychotherapeutic approaches. A. remained withdrawn, delusional, hallucinatory and nonfunctioning. Traditional neuroleptics were replaced by risperidone in the late 1990’s, at which time his weight exceeded 170 kg. His extreme obesity slowed him down considerably and made it almost impossible for him to participate in any productive activities. Trials with topiramte did not lead to weight reduction.
When his weight reached 174 kg (BMI=50.8) his pharmacotherapy was switched from risperidone 6 mg/day to ziprasidone 160 mg/day. Although no immediate improvement was observed in terms of positive and negative schizophrenia symptoms, A.started to lose weight. Three months later, A.weighed 160 kg, (BMI=46.7), and three months after that, he was down to 150 kg, (BMI= 43.8). At that time an emphasis was placed on behavioral therapy, positive reinforcement, nutritional education with professional dietary supervision, and physical exercise. The staff dietician involved the family in A/s weight reduction program and encouraged them to bring no calorie drinks and health food snacks rather than sweets. Staff nurses weighed him weekly, and encouraged him to adhere to his weight control regimen. For the first time in his life A.cooperated with a dietary program, and began exercising and walking daily. A.’s weight continues to drop. Ten months later he weighed 117 kg (BMI=34.7), total weight loss 57 kg.
DISCUSSION
Second generation antipsychotic agents, that brought new hope to patients are also associated with metabolic side effects, including weight gain, which may contribute to the deterioration of the patient’s physical condition. In a meta-analysis, Allison,et al.[8],found that ziprasidone, unlike the other atypical antipsychotic agents, is considered “weight neutral” producing little if any weight gain after 10 weeks of administration. In a retrospective cohort chart review of[9] randomly selected patients who were being treated with ziprasidone or olanzapine in an integrated health care system, Brown and Etoup[9] found that ziprasidone-treated patients exhibited weight loss. Though it is not yet clear how ziprasidone differs from antipsychotic drugs that produce weight gain, Casey and Zorn[10] have put forth several suggestions, considering ziprasidone’s different pharmacological profile (e.g. potent agonism at 5-HT 1A receptors and general activation of 5-HT and adrenoceptors like that of sibutramine, an approved antiobesity drug, via combined 5-HT and NE uptake inhibition).
Maintaining a healthy life style including proper nutrition and physical exercise is challenging even for the general population, nevertheless success in behavioral management of obesity in the chronically mentally ill has been documented[6], and outcomes show evidence that schizophrenia patients can acquire skills related to eating behavior in the same manner that other psychosocial skills are taught through training programs. The essential aspects of any behavioral intervention for obesity include frequent monitoring, nutritional and lifestyle counseling and skills training focusing on exercise, nutrition, health education and behavioral techniques.
A., a 32-year-old male inpatient suffering from chronic schizophrenia, began to lose weight following a switch in antipsychotic treatment from risperidone 6 mg/day to ziprasidone 160 mg/day, and received intensive behavior therapy for weight control. In addition, his family was supportive and cooperated by encouraging A. to follow the strict nutritional guidelines suggested by our staff. A.’s baseline weight was 174 kg, BMI 50.8. Ten months later his weight was reduced to117 kg, BMI 34.7.
Following treatment, in addition to significant weight loss (32.7%), improvement in A.’s clinical state, well being, and self-esteem was noted. At first it was difficult to imagine A. participating in physical activities, because he had been sedentary for so long due to his weight, but he began daily exercises which soon became an integral part of his daily routine. Pharmacotherapy was continued throughout the intervention and contributed to the general improvement in A.’s condition.
A.’s case is unusual in that he suffers from chronic schizophrenia, has been hospitalized for many years. The staff diligently persisted in searching for new treatment alternatives that would facilitate rehabilitation and weight reduction, and once the process was initiated, A with the support of his family and devoted staff, he achieved significant weight reduction and improvement in his clinical state.
This case demonstrates that comorbid schizophrenia and morbid obesity is amenable to combined behavioral and pharmacological treatment, and that proper awareness on the part of the medical community, caregivers and patients can help offset the detrimental consequences often associated with antipsychotic treatment.
REFERENCES
1. Aronne LJ. Epidemiology, morbidity, and treatment of overweight and obesity. J Clin Psychiatry, 2001,62 Suppl 23:13-22.
2. Kawachi I. Physical and Psychological Consequences of Weight Gain. J Clin Psychiatry,1999, 60 Suppl 21: 5-9.
3. Consensus Development Conference on Antipsychotic Drugs and Obesity and Diabetes. Diabetes Care, 2004, 27: 596-601.
4. McIntyre RS, Mancini DA, Basile VS. Mechanisms of antipsychotic-induced weight gain. J Clin Psychiatry,2001, 62 Suppl 23:23-29.
5. Faulkner G, Soundy AA, Lloyd K. Schizophrenia and Weight Gain Management: A Systematic Review of Interventions to Control Weight. Acta Psychiatr Scand, 2003, 108: 324-332.
6. Vreeland B, Minsky S, Menza M, Rigassio Radler D, Roemheld-Hamm B, Stern R. A program for managing weight gain associated with atypical antipsychotics. Psychiatr Serv,2003, 54:1155-1157.
7. Brar JS, Ganguli R, Pandina G, Turkoz I, Berry S, Mahmoud R. Effects of behavioral therapy on weight loss in overweight and obese patients with schizophrenia or schizoaffective disorder. J Clin Psychiatry, 2005,66:205-212.
8. Allison DB, Mentore JL, Heo M, et al. Anti-Psychotic Induced Weight Gain: A Comprehensive Research Sythesis. Am J Psychiatry, 1999,156: 1686-1696.
9. Brown RR, Estoup MW. Comparison of the metabolic effects observed in patients treated with ziprasidone versus olanzapine. Int Clin Psychopharmacol, 2005,20:105-112.
10. Casey DE, Zorn SH. The pharmacology of weight gain with antipsychotics. J Clin Psychiatry,2001, 62 Suppl 7:4-10.
(Editor LEE)(Orit Stein-Reisner1,2, Yuval Melamed1,2,)
[Abstract] Morbid obesity is a major public health problem associated with excess mortality and poses a major risk factor for cardiovascular, metabolic, and neoplastic conditions. Schizophrenia patients are at increased risk for obesity and obesity-related disorders. Weight reduction is a complex task, especially for schizophrenia patients with morbid obesity. We present the case of a schizophrenia patient with extreme obesity who, following a switch in atypical antipsychotic treatment, successfully significantly reduced his body weight while receiving cognitive behavior therapy, and nutritional supervision.
[Key words] morbid obesity; schizophrenia; body mass index; atypical antipsychotic agents; nutrition
INTRODUCTION
Morbid obesity is a major public health problem associated with excess mortality. It is called “morbid” obesity because it is associated with life-threatening diseases such as hypertension, coronary heart disease, type II diabetes mellitus, sleep apnea, osteoarthritis and some types of cancer[1,2]. Body mass index (BMI) is the most common measure used to gauge body fat. It takes into account a person’s weight and height. Morbid obesity is diagnosed when the patients BMI is > 40. Schizophrenia patients have an increased mortality rate as they have an elevated risk for obesity, obesity related disorders[3], and physical co-morbidity[4].
Weight reduction programs for schizophrenia patients have been assessed. Five of eight pharmacological intervention studies reported small reductions in weight (25%)[5].Vreeland,et al.[6],showed that a weight control program incorporating nutrition, exercise and behavioral interventions was effective. Additional positive results were achieved with cognitive behavior therapy. Patients who received group based behavior therapy had greater weight loss than patients who received usual care[7].
We present the case of a schizophrenia inpatient who suffered from morbid obesity. After his antipsychotic treatment was switched, he received weight reduction intervention that included behavioral therapy, nutritional education and physical exercise. All identifying information has been removed.
CASE REPORT
A., a 32 year-old single Israeli man with a 23 year psychiatric history. Due to severe behavioral problems and restlessness at age nine, following unsuccessful attempts with psychological interventions, A. was admitted to a children’s psychiatric ward. During that year-long hospitalization he was diagnosed with ADHD, and eating disorders characterized mainly by uncontrolled overeating and gradual weight gain. A. was never discharged from psychiatric hospitalizations, and rehabilitation attempts failed. About 12 years ago, in addition to his bulimia and behavioral problems, A. developed psychotic symptoms accompanied by suicidal and aggressive behavior. He was admitted to a closed ward at our mental health center, and was later diagnosed with schizophrenia and transferred to a long-term
1 Lev Hasharon Mental Health Center, Netanya, Israel
2 Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
Correspondence to Dr. Yuval Melamed, Deputy Director, Lev Hasharon Mental Health Center, P.O.Box 90000, Netanya 42100, Israel
Tel:972-9-8981245,Fax:972-9-8945054
E-mail:ymelamed@post.tau.ac.il
hospitalization ward. His psychotic symptoms were resistant to adequate trials of anti-psychotic agents and various psychotherapeutic approaches. A. remained withdrawn, delusional, hallucinatory and nonfunctioning. Traditional neuroleptics were replaced by risperidone in the late 1990’s, at which time his weight exceeded 170 kg. His extreme obesity slowed him down considerably and made it almost impossible for him to participate in any productive activities. Trials with topiramte did not lead to weight reduction.
When his weight reached 174 kg (BMI=50.8) his pharmacotherapy was switched from risperidone 6 mg/day to ziprasidone 160 mg/day. Although no immediate improvement was observed in terms of positive and negative schizophrenia symptoms, A.started to lose weight. Three months later, A.weighed 160 kg, (BMI=46.7), and three months after that, he was down to 150 kg, (BMI= 43.8). At that time an emphasis was placed on behavioral therapy, positive reinforcement, nutritional education with professional dietary supervision, and physical exercise. The staff dietician involved the family in A/s weight reduction program and encouraged them to bring no calorie drinks and health food snacks rather than sweets. Staff nurses weighed him weekly, and encouraged him to adhere to his weight control regimen. For the first time in his life A.cooperated with a dietary program, and began exercising and walking daily. A.’s weight continues to drop. Ten months later he weighed 117 kg (BMI=34.7), total weight loss 57 kg.
DISCUSSION
Second generation antipsychotic agents, that brought new hope to patients are also associated with metabolic side effects, including weight gain, which may contribute to the deterioration of the patient’s physical condition. In a meta-analysis, Allison,et al.[8],found that ziprasidone, unlike the other atypical antipsychotic agents, is considered “weight neutral” producing little if any weight gain after 10 weeks of administration. In a retrospective cohort chart review of[9] randomly selected patients who were being treated with ziprasidone or olanzapine in an integrated health care system, Brown and Etoup[9] found that ziprasidone-treated patients exhibited weight loss. Though it is not yet clear how ziprasidone differs from antipsychotic drugs that produce weight gain, Casey and Zorn[10] have put forth several suggestions, considering ziprasidone’s different pharmacological profile (e.g. potent agonism at 5-HT 1A receptors and general activation of 5-HT and adrenoceptors like that of sibutramine, an approved antiobesity drug, via combined 5-HT and NE uptake inhibition).
Maintaining a healthy life style including proper nutrition and physical exercise is challenging even for the general population, nevertheless success in behavioral management of obesity in the chronically mentally ill has been documented[6], and outcomes show evidence that schizophrenia patients can acquire skills related to eating behavior in the same manner that other psychosocial skills are taught through training programs. The essential aspects of any behavioral intervention for obesity include frequent monitoring, nutritional and lifestyle counseling and skills training focusing on exercise, nutrition, health education and behavioral techniques.
A., a 32-year-old male inpatient suffering from chronic schizophrenia, began to lose weight following a switch in antipsychotic treatment from risperidone 6 mg/day to ziprasidone 160 mg/day, and received intensive behavior therapy for weight control. In addition, his family was supportive and cooperated by encouraging A. to follow the strict nutritional guidelines suggested by our staff. A.’s baseline weight was 174 kg, BMI 50.8. Ten months later his weight was reduced to117 kg, BMI 34.7.
Following treatment, in addition to significant weight loss (32.7%), improvement in A.’s clinical state, well being, and self-esteem was noted. At first it was difficult to imagine A. participating in physical activities, because he had been sedentary for so long due to his weight, but he began daily exercises which soon became an integral part of his daily routine. Pharmacotherapy was continued throughout the intervention and contributed to the general improvement in A.’s condition.
A.’s case is unusual in that he suffers from chronic schizophrenia, has been hospitalized for many years. The staff diligently persisted in searching for new treatment alternatives that would facilitate rehabilitation and weight reduction, and once the process was initiated, A with the support of his family and devoted staff, he achieved significant weight reduction and improvement in his clinical state.
This case demonstrates that comorbid schizophrenia and morbid obesity is amenable to combined behavioral and pharmacological treatment, and that proper awareness on the part of the medical community, caregivers and patients can help offset the detrimental consequences often associated with antipsychotic treatment.
REFERENCES
1. Aronne LJ. Epidemiology, morbidity, and treatment of overweight and obesity. J Clin Psychiatry, 2001,62 Suppl 23:13-22.
2. Kawachi I. Physical and Psychological Consequences of Weight Gain. J Clin Psychiatry,1999, 60 Suppl 21: 5-9.
3. Consensus Development Conference on Antipsychotic Drugs and Obesity and Diabetes. Diabetes Care, 2004, 27: 596-601.
4. McIntyre RS, Mancini DA, Basile VS. Mechanisms of antipsychotic-induced weight gain. J Clin Psychiatry,2001, 62 Suppl 23:23-29.
5. Faulkner G, Soundy AA, Lloyd K. Schizophrenia and Weight Gain Management: A Systematic Review of Interventions to Control Weight. Acta Psychiatr Scand, 2003, 108: 324-332.
6. Vreeland B, Minsky S, Menza M, Rigassio Radler D, Roemheld-Hamm B, Stern R. A program for managing weight gain associated with atypical antipsychotics. Psychiatr Serv,2003, 54:1155-1157.
7. Brar JS, Ganguli R, Pandina G, Turkoz I, Berry S, Mahmoud R. Effects of behavioral therapy on weight loss in overweight and obese patients with schizophrenia or schizoaffective disorder. J Clin Psychiatry, 2005,66:205-212.
8. Allison DB, Mentore JL, Heo M, et al. Anti-Psychotic Induced Weight Gain: A Comprehensive Research Sythesis. Am J Psychiatry, 1999,156: 1686-1696.
9. Brown RR, Estoup MW. Comparison of the metabolic effects observed in patients treated with ziprasidone versus olanzapine. Int Clin Psychopharmacol, 2005,20:105-112.
10. Casey DE, Zorn SH. The pharmacology of weight gain with antipsychotics. J Clin Psychiatry,2001, 62 Suppl 7:4-10.
(Editor LEE)(Orit Stein-Reisner1,2, Yuval Melamed1,2,)