Weight Considerations in Psychotropic Drug Prescribing and Switching

Abstract

Our review describes potential weight-altering effects of psychotropic medications (antipsychotics, antidepressants, anti-anxiety medications, mood stabilizers, sedative-hypnotics, medications for attention-deficit/hyperactivity disorder, and other psychotropic medications) and offers guidance on switching a medication if its weight-altering effect becomes problematic. For second-generation antipsychotics, the risk of weight gain is high with clozapine and olanzapine, low with amisulpride, aripiprazole, and ziprasidone, and medium with other second-generation antipsychotics. Switching from a high-risk antipsychotic to a low-risk antipsychotic usually mitigates or reverses weight gain. For second-generation antidepressants, there may be modest weight loss with bupropion and modest weight gain with mirtazapine and paroxetine. Other second-generation antidepressants are weight neutral but individual variations can occur. If significant change in weight occurs, switching to or adding a low-risk second-generation antidepressant should be considered. Mood stabilizers include lithium, valproate, carbamazepine, lamotrigine, oxcarbazepine, and most second-generation antipsychotics. Risk of weight gain is high with lithium and valproate and low with carbamazepine, lamotrigine, and oxcarbazepine. Given the complexity of bipolar disorder and its management, a switch of a mood stabilizer would be best done by a psychiatrist. Benzodiazepines, non-benzodiazepine and melatonergic hypnotics, doxepin, and trazodone are weight neutral. Diphenhydramine may cause weight-gain and can be switched to a weight-neutral hypnotic if needed. Stimulants can cause varying degrees of weight loss and switching to atomoxetine or bupropion may reverse this problem. If that fails, switching to clonidine or guanfacine can be tried. Switching must be evidence-based and take into account status of the condition being treated, efficacy, side effect profile, potential drug-drug interactions, required laboratory monitoring and cost of the drug(s) being considered, and patient's pregnancy status or plan. Non-pharmacological interventions both for mental disorders and overweight/obesity must be fully availed.

Depressive and anxiety disorders: Associated with losing or gaining weight over 2 years?

“…However in our study we found evidence for an association between mental disorders and weight gain independent of smoking, alcohol consumption, physical activity and social activity, which was in line with recent prospective studies that adjusted for lifestyle (Brumpton et al, 2013;Singh et al, 2014;Lasserre et al, 2014). The use of psychotropic medication has been suggested as a confounding factor in the association between psychopathology and weight change since medication use has shown to interact with mechanisms regulating food intake and appetite (Virk et al, 2004;Demyttenaere and Jaspers, 2008;Papakostas, 2008;Vieweg et al, 2008;Hasnain and Vieweg, 2013). Initially we found in a subsample of our study with persons having a current depressive and anxiety disorders that SSRI users as well as benzodiazepine users compared to non-users were more likely to gain weight.…”

“…However, the found effects for SSRI use seemed to be mainly driven by the severity of the depressive symptoms. Surprisingly, the effect of benzodiazepine use on weight gain remained borderline significant after full adjustment, which is conflicting with previous research which found that benzodiazepine use was weight neutral (Vieweg et al, 2008;Hasnain and Vieweg, 2013). Other explaining mechanisms for the association between mental disorders and subsequent weight increase are physiological abnormalities found in depressed persons such as increased inflammation, and longterm disturbances of the HPA-axis.…”

“…Some recent cross-sectional and longitudinal studies suggest that depressive and anxiety symptoms are associated with weight independently from lifestyle factors (physical activity, smoking and alcohol consumption) suggesting that there is no or a limited influence of lifestyle factors (Zhao et al, 2009). Furthermore the use of psychotropic medications, often prescribed for depressive and anxiety disorders, might be an additional explanatory risk factor for weight change (Virk et al, 2004;Demyttenaere and Jaspers, 2008;Vieweg et al, 2008;Hasnain and Vieweg, 2013). Underlying shared biological abnormalities such as inflammation, leptin or HPA-axis dysregulations could further play a linking role between mental health and weight change (Bjorntorp, 2001;Bornstein et al, 2006;Pasco et al, 2008;Vreeburg et al, 2009;Milaneschi et al, 2012).…”

Use of Propranolol for Hypersexual Behavior in an Adolescent With Autism

“…In addition, there were concerns about further weight gain on mirtazapine in an already obese adolescent. 26 Increasing risperidone, considering its effect on hypersexual behaviors as mentioned above, was one of the options in our patient; however, this was dismissed after discussion of possibility of worsening metabolic side effects and weight gain. Sexual dysfunction is a known side effect of β-blockers, including propranolol.…”

Genetics of second-generation antipsychotic and mood stabilizer-induced weight gain in bipolar disorder

“…We investigated the percentage body weight change during treatment with an antipsychotic and/or a MS that has been associated with a high-medium risk of weight gain [48]. Patients treated for at least five consecutive visits with a SGAP (olanzapine, clozapine, quetiapine or risperidone) or a MS (lithium or valproate) were selected.…”