A cognitive/behavioral group intervention for weight loss in patients treated with atypical antipsychotics

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Abstract

Obesity and diabetes have caused problems for individuals with schizophrenia long before atypical antipsychotic agents. The prevalence of obesity, insulin resistance, impaired glucose tolerance, type 2 diabetes mellitus, dyslipidemia, and the Metabolic Syndrome has increased in people with schizophrenia as compared to the general population. Risk reduction studies for persons with obesity, diabetes, and cardiovascular disease indicate that cognitive/behavioral interventions that promote motivation and provide strategies to overcome the barriers in adherence to diet and activity modification are effective interventions for weight management and risk reduction. In the landmark multi-center randomized-controlled trial study, the Diabetes Prevention Project (DPP), a cognitive/behavioral intervention, was more successful in producing weight loss and preventing diabetes than the drugs metformin, troglitazone or placebo. This pilot study examined the effectiveness of a cognitive/behavioral group intervention, modified after the DPP program, in individuals with schizophrenia or schizoaffective disorder taking atypical antipsychotics in a large urban public mental health system. Outcome measures included body weight, body mass index, waist–hip ratios, and fasting glucose levels. Both groups demonstrated elevated fasting glucose levels and were obese with a mean BMI of 33. The group that received the cognitive/behavioral group intervention lost more weight than the treatment as usual group. The CB group participants lost an average of 5.4 lb or 2.9% of body weight, and those in the control group lost 1.3 lb or 0.6% body weight. The range of weight loss for the treatment group was from 1 to 20 lb. This pilot study has demonstrated that weight loss is possible with cognitive/behavioral interventions in a population with a psychotic disorder.

Introduction

Weight gain is a serious health concern for individuals with schizophrenia. It increases their morbidity and serves as an additional reason for non-adherence with pharmacologic treatment (Green et al., 2000, Perkins, 2002, Weiden et al., 1996). It is estimated that 40% to 60% of persons with schizophrenia are obese as compared to 20% prevalence in the general US adult population (Green et al., 2000). Thus, it is not surprising that the prevalence of insulin resistance, impaired glucose tolerance, type 2 diabetes mellitus, and the MS has increased in people with schizophrenia as compared to the general population (Henderson et al., 2000). The recent introduction of new pharmacologic therapies for the treatment of schizophrenia, which are commonly referred to as the ‘atypical antipsychotics’ has been correlated with a further increase in the prevalence of excess body weight and type 2 diabetes in this population (Allison and Casey, 2001, Allison et al., 1999). In one of the few descriptive studies examining the health of those with schizophrenia, Brown and colleagues reported in 1999 that on average, individuals with schizophrenia eat a diet high in fat, smoke heavily, and get very little exercise. In addition to obesity, individuals with schizophrenia appear to have increased visceral fat, regardless of drug treatment, which is highly correlated with insulin resistance and risk of diabetes (Thakore et al., 2002).

In a recent epidemiological study, as little as a 5% increase in body weight is correlated with a 200% greater risk of developing this metabolic or insulin resistance syndrome by middle age (Everson et al., 1998). Thus, individuals with schizophrenia, already overweight, significantly increase their chances of significant co-morbidity with as little as a 5% weight gain. Data to support prevention of weight gain and appropriate choices of antipsychotic medications has become a public health priority. Risk reduction studies for persons with obesity, diabetes, and cardiovascular disease indicate that cognitive/behavioral interventions that promote motivation and provide strategies to overcome the barriers in adherence to diet and activity modification are effective interventions for weight management and risk reduction (Nawaz and Katz, 2001, Williamson and Perrin, 1996).

In the landmark multi-center Diabetes Prevention Project (DPP), a cognitive/behavioral lifestyle intervention was more successful in producing weight loss and preventing diabetes than the drug metformin (Knowler et al., 2002). The group that received troglitazone actually had the lowest diabetes incidence in the first year but they only received the drug for the first 9 months and this benefit was not sustained over the three years of the trial (Knowler et al., 2005). The intensive lifestyle intervention in the DPP was found to decrease the incidence of diabetes by 58% in high-risk populations. Further, the investigators found that the randomized clinical data collected from 27 clinical sites throughout the country, showed that intensive cognitive/behavioral therapies that focused on modifying diet and increasing activity were just as effective for both men and women, in all age groups, and in all ethnic groups.

Weight reduction studies in the population with schizophrenia have been cited in the literature but results are mixed and none have used a randomized-control model. This pilot study examined the effectiveness of a randomized-control group design cognitive/behavioral group intervention based on the DPP lifestyle intervention in those individuals who were taking atypical antipsychotics for schizophrenia or schizoaffective disorder in a large urban public mental health clinic system. It was hypothesized that those individuals completing the 16-week program would demonstrate significantly different weight, body mass index (BMI), waist–hip ratio (WHR), and fasting glucose levels than those in the treatment as usual (TAU) group.

Section snippets

Sample

A randomized, placebo-controlled design was chosen for this pilot study to test the efficacy of this group intervention. The sample was recruited over approximately one month from over 900 patients per month attending a large urban public mental health clinic in Dallas. The PI used flyers in the clinic as well as working with the case managers and medical providers to recruit over 30 potential subjects. The first seventeen subjects who qualified and were interested in participating were

Results

Demographic and clinical characteristics of the two groups prior to intervention are summarized in Table 1. Both groups tended to be obese with the mean BMI of subjects in each treatment arm measuring 33. Five subjects in each group were taking olanzapine with the remaining subjects taking risperidone, ziprasidone, and quetiapine. None of the subjects were taking clozapine. There were no differences in weight, BMI, or blood sugar between the subjects based on drug, although both groups showed

Discussion

No rigorous randomized-controlled trials of CB interventions to combat weight gain in public mental health settings have been reported. This study is the first randomized trial that was conducted in the larger community of patients with schizophrenia who are experiencing significant weight gain problems with atypical antipsychotics. Behavioral treatment of obesity in patients with schizophrenia was reported as early as 1963 with single case reports (Ayllon, 1963, Bernard, 1968). Since that

References (27)

  • J. Bernard

    Rapid treatment of gross obesity by operant techniques

    Psychological Reports

    (1968)
  • S. Everson et al.

    Weight gain and the risk of developing insulin resistance syndromes

    Diabetes Care

    (1998)
  • E. Ford et al.

    Prevalence of the metabolic syndrome among US adults: findings from the third National Health and Nutrition Examination Survey

    Journal of the American Medical Association

    (2002)
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