A first-of-its-kind study from St Patrick’s Mental Health Services (SPMHS) and University College Cork (UCC) explores the preferences and needs of people with lived experiences of weight gain from anti-psychotic medication.
The qualitative study from researchers within the Pharmacy Department here in SPMHS and the School of Pharmacy in UCC has revealed the urgent need for tailored guidelines in managing antipsychotic-induced weight gain (AIWG).
The study, Informing the development of antipsychotic-induced weight gain management guidance: patient experiences and preferences - a qualitative descriptive study, has recently been published in the journal BJPsych Open. It explores how patients with lived experiences of AIWG perceive and manage this challenging side-effect.
Findings highlight the gaps between current guidelines and practices and the needs of people taking antipsychotics.
Current context
Prescribing of antipsychotic medication extends to many mental health difficulties beyond psychosis. Managing weight gain effectively in patients with mental health difficulties who are taking antipsychotic medications is crucial to ensuring their physical health is maintained.
Clinically significant weight gain is seen as a greater than 7% increase in body weight when compared to baseline weight. Clinically significant weight gain has been linked to almost all antipsychotic medications and is usually seen within weeks of starting treatment. It appears not to be related to the dose of the medication, and it is difficult to predict whether a person will be affected by AIWG: even among people prescribed the same antipsychotic, weight changes range from minimal to extreme changes.
However, while limited international guidance exists, management recommendations for clinicians largely replicates, or follows, recommendations for population level weight management practices: often, self-led ‘lifestyle changes’ are given focus, and using additional medications to reduce appetite increases caused by antipsychotic medication is considered only when other options have proven ineffective. The development of current management recommendations has largely been informed by the expert opinion of guideline development groups, with no or minimal representation of the voice of lived experience.
Overview of the study
This study was the first of its kind to explore the preferences of patients with experience of managing weight gain from antipsychotics and to compare this with current management algorithms informing clinicians’ practice. A management algorithm is a set of steps, or protocols, for treating and managing an area of physical or mental health, where the steps are informed by responses to the interventions and treatments provided.
A diverse range of people (sample size of 17) with experiences of mild to severe AIWG and mental health difficulties, including schizophrenia, bipolar affective disorder and major depressive disorder, were interviewed about:
- Their experiences of managing AIWG
- The acceptability, feasibility, and transferability of current management algorithms and the interventions they contain (both pharmacological and non-pharmacological)
- How patient-centred management practices can be achieved within Irish healthcare settings.
Study findings
Speaking about the study, Lead Researcher and Senior Pharmacist here at SPMHS, Ita Fitzgerald said: “Findings have shown that the lack of available management guidance for AIWG remains a challenge for clinicians, with currently endorsed approaches neither being fit-for-purpose or aligned with the experiences and needs of those prescribed antipsychotics and who experience unwanted weight gain."
"This study provides guidance and recommendations for ways in which a proactive, individualised, holistic, and collaborative approach to AIWG management can be practically realised both within guidelines and services."
"It is hoped that the publication of this study will mark a significant step towards empowering and supporting clinicians to manage the complex side effect of antipsychotic-induced weight gain in a way that is most responsive to the needs of the individual patient.”
Highlights of the key findings are shown below, while you can see the full research findings here.
Patient preferences differ significantly from management guidelines.
Patients with AIWG describe current management guidelines as overly simplistic and lacking the flexibility needed for weight management to be tailored towards their needs.
The standard approach is a stepwise approach, or one which follows a number of steps. This approach focuses on using lifestyle changes as first-line management, or the first method a clinician chooses for treatment. This is then followed by considering a change in antipsychotics and/or use of additional medications to manage weight gain, only if the earlier options are ineffective.
This standard approach is universally recommended, but does not reflect the realities of managing overweight or obesity caused by antipsychotics.
One study participant said “It’s a hunger you just can’t do anything about, you know; food doesn’t, food doesn’t satisfy it. I couldn’t find way really, any other way really other than be hungry. I could eat twice the amount of dinner and you’re still as hungry as when you started”.
Behavioural changes are often insufficient.
Many participants reported that lifestyle changes alone were insufficient, or not enough, to manage AIWG. Continued recommendations from clinicians to make lifestyle changes could worsen the person’s feelings of isolation and internalised stigma, while also reducing their likelihood of seeking help in future due to fear of stigma.
For one study participant, “it leaves me feeling kind of isolated as well because how it looks is that I am not making an effort to improve my position and then I don’t want to see people and be judged for it…being overweight and having mental health issues, I just don't want to be perceived as lazy”.
Individualised approaches are key.
Participants emphasised that AIWG is a unique cause of weight gain and, as such, requires an equally distinctive approach to management. Recommendations for managing AIWG must recognise the diversity among people and allow for interventions to be tailored towards risk of living with overweight or obesity, individual physical and mental health capabilities, and patients’ treatment preferences.
There is a need for early use of pharmacological interventions.
Study participants advocated for the earlier use of pharmacological interventions, such as metformin, especially for people who are severely ill at the onset of antipsychotic treatment, who have a personal or family history of living with obesity, or who have severe appetite increases following starting an antipsychotic medicine.
One study participant explained “If you were dealing with psychosis, if somebody has been very ill, they may not be able to make diet and lifestyle changes. In their case the tailoring may involve more preventative use of metformin because they just may not be in that position to make those decisions for themselves that really require being very proactive at a time when you are recovering”.
Study recommendations
Based on the experiences of participants, the study recommends that current guidelines are expanded to include preventive measures and early interventions tailored to individual patient needs and risks. The study recommendations also put forward ways in which the four tenets of patient-centred management (proactive, individualised, holistic and collaborative approaches) can be enacted both within guidelines and psychiatric services.
Professor Laura Sahm, co-author of the study and Head of Clinical Pharmacy Practice at UCC, said: “This study represents a crucial step in recognising the importance of a patient-centred and patient-informed approach to combat AIWG. By working collaboratively, patients and prescribers can adopt a strategy that aligns best with their shared and agreed goals of therapy.”
