CHICAGO – An innovative multidisciplinary lifestyle intervention in youth with first-episode psychosis can prevent the marked weight gain and other adverse cardiometabolic effects that typically arise during the first months of treatment with antipsychotic agents.
"Antipsychotic-induced weight gain can be halted through individualized lifestyle and life-skills interventions. Weight stability in the face of antipsychotic therapy is a realistic and attainable goal," Dr. Katherine Samaras said at the joint meeting of the International Congress of Endocrinology and the Endocrine Society.
Dr. Katherine Samaras
The multidisciplinary Australian effort, known as the Keeping the Body in Mind Program, is carried out by Dr. Samaras, an endocrinologist at St. Vincent’s Hospital in Sydney, Australia, together with a psychiatrist, a dietician, and an exercise physiologist. Their motivation in developing the program stems from studies documenting a 20-year life expectancy shortfall in patients with major mental illness, compared with the general population, which Dr. Sue Bailey, past president of the Royal College of Psychiatrists, has called "one of the biggest health scandals of our time."
In addition, as an endocrinologist Dr. Samaras was disturbed to see children and youth on antipsychotic agents in the diabetes clinic on virtually a daily basis. Her own clinical experience was underscored in a recent Tennessee Medicaid program study which found that 6- to 17-year-olds using antipsychotics were at more than threefold increased risk of type 2 diabetes. The risk was evident within the first year and grew with increasing cumulative dose (JAMA Psychiatry 2013;70:1067-75).
"As an endocrinologist, I expect youth with type 1 diabetes to have parity with respect to life expectancy, to maintain their current health, and to develop in education and life skills and have fulfilling life experiences. Imagine if we applied the diabetes care and prevention models we use every day in children with type 1 diabetes to youth with severe mental illness on antipsychotic medications," she mused.
The program is restricted to youth with first-episode psychosis who have been on antipsychotic medication for less than 4 weeks at enrollment. The program entailed weekly individualized counseling and monitoring by a dietician and an exercise physiologist, daily access to a gym converted from a staff conference room in the first-episode psychosis unit, and weekly group life-skills training classes in cooking, shopping, and budgeting.
"There may be very little family support for these people. They’re often living in shelters," Dr. Samaras explained.
She presented a 12-week pilot study involving 16 patients in the Keeping the Body in Mind Program and 12 sociodemographically similar controls in a more conventional Sydney first-episode psychosis program without lifestyle interventions. The subjects were 15-25 years old (mean age, 20 years). The most common psychiatric diagnosis was schizophreniform disorder, followed by bipolar disorder and major depression with psychotic features.
Over the course of 12 weeks, the lifestyle intervention group gained an average of 1.2 kg, compared with 7.3 kg in controls. Moreover, just 12% of the Keeping the Body in Mind Program participants experienced clinically significant weight gain, predefined by the investigators as a greater than 7% increase, compared with 75% of controls. Waist circumference, body mass index, lipids, blood pressure, and fasting blood glucose all remained essentially unchanged over time in the program participants. The group’s aerobic fitness as reflected in peak oxygen intake (VO2max) improved significantly. In contrast, all of these cardiometabolic parameters deteriorated significantly in the control group.
Dr. Samaras noted that most antipsychotic-induced weight gain occurs relatively early in the course of chronic treatment: In one representative study, the average gain was 12 kg during the first 24 months, another 4 kg in the following year, and an additional 3 kg at the 4-year mark.
However, when asked how long young patients with a first episode of major mental illness should remain involved in a lifestyle intervention program such as Keeping the Body in Mind, she was adamant: "I believe that as long as they’re on an antipsychotic agent they should receive dietetic and exercise physiologist support. The key is for us to walk along the path every step of the way for as long as these people need antipsychotics, and not to abandon them to the neglect that I think has characterized the physical health care of mental patients."
The study was supported by the Mental Health and Drug and Alcohol Office of the Ministry of Health for New South Wales. The presenter reported having no financial conflicts.