This episode deals with the question of weight gain from antipsychotic medication:

I'm on 20 milligrams of olanzapine. It's helping me and I don't want to change it. The only thing is that I've gained a lot of weight that makes me feel very unattractive. I’ve spoken to my psychiatrist about it, but I haven't gotten any guidance on the matter. Are there any solutions to weight gain from this kind of medicine?

Modern antipsychotic medications can be very helpful for some people. And they are less likely to cause neurological side effects, compared to their first-generation predecessors. However, many of these newer medicines can cause someone to gain significant amounts of weight.

This is a serious problem that the psychiatric profession (in my view) has been very slow to address.

In this episode, Dr. Erik Messamore describes several strategies that can reduce the risk of medication-related weight gain or that can reverse weight gain once it has started.

 

Strategy 1. Choose antipsychotic medications with low weight gain risk

Different antipsychotic medications come with different degrees of weight gain risk.

Table 1 in this open-access medical journal article lists medications with higher or lower risk of weight gain. The graph in this article also illustrates the differences in weight gain risk among the various antipsychotic medications.

 

Strategy 2. Switch to an antipsychotic medication with lower weight gain risk

People who have gained weight from higher-risk medications – like quetiapine (Seroquel) or olanzapine (Zyprexa), for example – may lose weight after switching to a lower-risk medication.

On the other hand, some people (like the person who sent in today’s question) might mostly like their current medication, or may not want to take the risks involved in medication switching (e.g., the switched-to medication might not work as well, or might have other side effects). In situations like these, there are several weight loss options worth considering.

 

Strategy 3. Diet and exercise to reduce weight from antipsychotic medication

Many studies show that antipsychotic-induced weight gain does respond to standard diet or exercise interventions. A relatively small reduction of 150 calories per day can lead to about 16 pounds of weight loss over a year. For many people, that can be achieved by sticking to natural, whole foods and avoiding processed foods with a lot of carbohydrates or added sugars.

Exercise and physical activity can enhance weight loss. And numerous studies show that exercise can improve mood, reduce anxiety, increase cognitive performance, and reduce symptoms of psychosis.

Very low carbohydrate diets like the ketogenic diet are popular these days. These diets are designed to reduce insulin levels, which can make it easier to lose weight (because insulin is a fat-storage signal). Many people who undertake these diets can maintain calorie deficits without feeling hungry. Several case reports and a small clinical study suggest that the low-carb/ketogenic diet might help some people with schizophrenia, psychosis, or bipolar disorder to experience fewer symptoms.

 

Strategy 4. Metformin to reduce weight from antipsychotic medication

Metformin is a widely-used treatment for type-2 diabetes. It improves the body’s insulin signals and reduces spikes in blood sugar. Metformin can also help people without diabetes to lose weight. And there are many studies showing the metformin can reduce weight in people who have gained weight from antipsychotic medications.

 

Strategy 5. GLP-1 Agonists to reduce weight from antipsychotic medication

GLP-1 is an abbreviation for glucagon-like peptide 1. The GLP-1 agonist drugs mimic the action of natural GLP-1. They optimize the body’s insulin responses and reduce appetite. Some of these medications – liraglutide (Victoza, Saxenda); semaglutide (Ozempic, Rybelsus, Wegovy) – even have FDA approval for treating obesity.

Lirgalutide has been studied in weight gain from antipsychotic medication and appears to produce more weight loss than metformin.

 

Strategy 6. Melatonin might reduce weight gain from antipsychotic medications

This episode mentions that some studies show that melatonin might reduce the amount of weight gained from antipsychotic medication, while at the same time helping to further reduce symptoms of psychosis.

The studies referred to are:

• Romo-Nava F et al. (2014) Melatonin attenuates antipsychotic metabolic effects: an eight-week randomized, double-blind, parallel-group, placebo-controlled clinical trial
• Modabbernia A et al. (2014) Melatonin for prevention of metabolic side-effects of olanzapine in patients with first-episode schizophrenia: randomized double-blind placebo-controlled study.
• Mostafavi A et al. (2014) Melatonin decreases olanzapine induced metabolic side-effects in adolescents with bipolar disorder: a randomized double-blind placebo-controlled trial.

 

Summary and suggestions

Although the psychiatric profession has been slow to respond to the problem of antipsychotic-related weight gain, there are several options that can reduce the risk of weight gain or that can help someone lose weight.

Many psychiatrists are aware of these options and are willing to help.

But in cases where the psychiatrist does not know about these options or does not have experience with prescribing medications to assist with weight loss, it’s likely that a general practice doctor or an endocrinologist does.

The goal of treatment is always to maximize improvement and to avoid side effects whenever possible. And in cases where side effects are unavoidable, the goal should be to minimize them as much as possible.

If you’re concerned about weight gain, there are options and solutions. Your health care provider should be able to address them, or refer you to someone who can.

 

Topics

0:44 This episode’s question is about weight gain from antipsychotic medication

1:20 – How common is the weight gain problem?

5:49 – Which medications are more likely (or less likely) to cause weight gain?

12:38 – How to these medications lead to weight gain?

15:27 – What are some strategies to prevent or reduce weight gain from antipsychotic medications?

20:56 – How effective is diet and exercise for antipsychotic-related weight gain?

26:28 – Suggestions for someone who is concerned about weight gain from antipsychotic medications.

 

About the Podcast:

Dr. Erik Messamore is a board-certified psychiatric physician and PhD-level pharmacologist. He’s a consultant psychiatrist, researcher, lecturer, teacher, and solution-focused scholar currently affiliated with the Northeast Ohio Medical University in Rootstown, Ohio. He is joined on this podcast by Melissa Xenophontos, a journalist, radio producer and longtime mental health advocate.

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Useful Links

Dr. Erik’s website and blog

Podcast website

Ask A Psychiatrist YouTube Channel