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February 2009

Combination Approach to Childhood Anxiety
In a study of children with anxiety disorders, the combination of cognitive behavioral therapy and an antidepressant was superior to either treatment alone.

Antipsychotic-Induced Weight Gain: Management Without Meds
Several behavioral interventions effectively promote weight loss in patients taking antipsychotics.

Allopurinol: Novel Treatment for Mania?
Allopurinol (Lopurin and others) as an adjunct to lithium may help improve manic symptoms in patients with bipolar disorder.

In Brief
Behavioral Risk Factors Mediate Hospitalization and Mortality; International Internet Day of Action Results in Drug Seizures

Adjunctive Estrogen for Schizophrenia?
Exogenously administered estradiol added to antipsychotic therapy might benefit women with schizophrenia.

Injection Site Reactions with Naltrexone
Injections of extended-release naltrexone (Vivitrol) can cause serious skin reactions.

Antipsychotic-Induced Weight Gain: Management Without Meds

February 2009

To prevent or reverse the weight gain often associated with antipsychotic drugs (BTP 2007;30:45-46, 2006;29:53), doctors have turned to adjunctive medications or behavioral approaches. Álvarez-Jiménez and coauthors conducted a systematic review and meta-analysis of randomized controlled trials that examined nonpharmacologic strategies.1

Ten trials met inclusion criteria for the meta-analysis. Six involved cognitive behavioral treatment (CBT); three, nutritional counseling; and one, a combination of nutritional counseling and exercise. Half of the trials tested group interventions, while the other half studied individual therapy. In all, 482 patients were assigned to one of these interventions versus treatment as usual for 8 weeks to 6 months.

On average, patients assigned to experimental treatment lost 2.56 kg (5.69 lb) more than those who received usual care (P < .001). The treatment effects were comparable whether the intervention was used to prevent or to reverse antipsychotic-related weight gain. There were neither statistically significant nor clinically relevant differences between therapeutic approaches—whether individual versus group or CBT versus nutritional counseling. Three studies reported follow-up data. In these, the statistically significant advantages of nonpharmacological interventions were maintained at 2 to 3 months following treatment discontinuation.

Adherence to any of the weight management programs was strongly associated with weight loss. This suggests that whichever approach engages an individual patient in treatment is the one most likely to be effective for that person. The authors cite evidence that adventure- and recreation-based interventions are often favored by people with chronic schizophrenia, and that young patients with recent-onset psychosis often like multi-component and flexible approaches that include exercise, diet, and behavioral programs.

A practical approach for patients of varying ages is a structured walking program. Diaries can be used to measure calories consumed and expended. The number of steps walked can be quantified with a pedometer. With modern technology, it is becoming cost-effective to monitor and graph progress electronically—for doctor, patient, and caregivers.

The patient who has benefited from an antipsychotic but gained weight presents a common clinical dilemma. The clinician, patient, and family members want to attenuate or reverse the weight gain because of the adverse health consequences. Lowering the dose or switching antipsychotic medications may be helpful, but at the possible cost of lost efficacy against the underlying psychosis. Other medications may be added to antipsychotic therapy to prevent or reverse weight gain, but no drug has yet proven clearly safe and effective for this purpose. By contrast, several behavioral interventions are efficacious and probably should be tried first. A treatment that engages a patient is the one most likely to work.

1Álvarez-Jiménez M, Hetrick SE, González-Blanch C, Gleeson JF, McGorry PD: Non-pharmacological management of antipsychotic-induced weight gain: Systematic review and meta-analysis of randomised controlled trials. Br J Psychiatry 2008;193:101-107.