1. Improving Weight and Related Side-Effects of Antipsychotic Medication Alexander S. Young, MD, MSHS Amy N. Cohen, PhD VISN-22 Mental Illness Research, Education, and Clinical Center (MIRECC) UCLA Department of Psychiatry

2. Overview Antipsychotic medications & weight gain Management of weight gain Quality of usual care EQUIP: options for improving care

3. CATIE Results: Weight Gain Per Month of Treatment olanzapinerisperidoneperphenizinequetiapineziprasidone Weight gain (lb) per month

4. Risk of Death Increases with BMI

5. Waist Circumference and BMI Increase the Risk of Diabetes, Hypertension, and Cardiovascular Disease BMIWaist men ≤ 40 inches women ≤ 35 inches Waist > 40 inches > 35 inches Underweight< 18.5-- Normal18.5 – 24.9-- Overweight25.0 – 29.9IncreasedHigh Obese30.0 – 34.9 35.0 – 39.9 High Very High Extremely Obese≥ 40Extremely High

6. Weight Management Programs Are Effective Group and individual psychoeducation improves weight in people with psychotic disorders – these are specialized programs – numerous controlled research trials Weight loss is modest: average 5 lbs Modest weight loss is associated with health benefits

7. EQUIP Weight Management Program Located in specialty mental health – led by mental health clinician – tailored for learning disabilities 16 sessions – each focused on one nutrition or exercise topic Handouts for every session – large font – room for patients’ notes Food models Fast food guide

8. Weight Management Session Content 1. Poor diet and health problems 2. Food pyramid and portion sizes 3. Food pyramid and portion sizes (continued) 4. Increasing fiber intake 5. Increasing water intake 6. Importance of exercise 7. Decreasing fat and cholesterol 8. Starting to exercise

9. Weight Management Session Content (cont’d) 9.Limiting sugar intake 10.Walking as exercise 11.Controlling hunger 12.Limiting salt; fast food 13.Expected lifestyle changes 14.Avoiding alcohol 15.Making exercise a daily routine 16.Review and summary

10. Changing Antipsychotic Medication Can Cause Weight Loss CATIE study Among patients who gained more than 7% of weight in Phase 1 When switched to the following, how many lost more than 7% – olanzapine: 0% – quetiapine: 7% – risperidone: 20% – ziprasidone: 42%

11. Changing from Olanzapine to Aripiprazole Causes Weight Loss Newcomer et al 2008 Overweight patients on olanzapine Switch to aripiprazole vs. remain on olanzapine – randomized controlled trial, n=173, 16 weeks Results – weight change (pounds): -4.0 vs. +3.1 – lost more than 7%: 11.1% vs. 2.6% – lipids improved – CGI-Improvement: no change - minimal improvement

12. How Are We Doing? Most research on quality of care for schizophrenia was performed in 1990s – 1st generation antipsychotic medications Newer 2nd generation antipsychotics – fewer neurologic side-effects – more weight gain (varies by agent) Change in – frequency of clinical problems? – appropriateness of treatment?

13. Methods Random sample of patients with schizophrenia – 3 VA mental health clinics (n=398) Patient interviews – symptoms: psychosis, depression – side-effects: parkinsonism, akathisia, tardive dyskinesia, weight gain Prescription data Use explicit criteria to evaluate appropriateness – derived from national guidelines

14. Results Clinical problems – few patients had depression without psychosis (3%), parkinsonism (2%), or akathisia (1%) – 44% had severe psychosis – 11% had tardive dyskinesia – 46% were substantially overweight Appropriate medication changes – 27% of patients with psychosis – 2% of patients with elevated weight

15. Conclusions Problems in care were equally common at all 3 clinics Compared with the 1990s – patients more likely to have severe psychosis quality of care for psychosis is unchanged – weight is now the most important side-effect treatment rarely changed in response to weight

17. Improving Care: Options Routine monitoring of weight Clinician education Patient education Make services available

18. Enhancing QUality of care In Psychosis (EQUIP) 3-year clinic-level controlled trial – funded by VA HSR&D QUERI – 4 VISNs: 3, 16, 17, 22 – 320 providers, 900 patients intervention: evidence-based quality improvement, improved patient information, care reorganization – weight – employment

19. EQUIP Leadership Team VISN 16 Anna Teague, MD (PI: Houston) Dean Robinson, MD (PI: Shreveport) Kathy Henderson, MD Avila Steele, PhD VISN 3 Eran Chemerinski, MD (PI: Bronx) Charlene Thomesen, MD (PI: Northport) Deborah Kayman, PhD VISN 22 Christopher Reist, MD (PI: Long Beach) Larry Albers, MD David Franklin, PsyD, MPH VISN 17 Max Shubert, MD (PI: Central Texas) Wendell Jones, MD Staley Justice, MSW Alexander S. Young, MD, MSHS (PI) Jennifer Pope, BS Patricia Parkerton, PhD Paul Jung Youlim Choi Amy N. Cohen, PhD (co-PI) Alison Hamilton, PhD Katy Oksas, MFT Stone Shih Paul Jung Los Angeles (Coordinating Site)

20. Routine Monitoring of Weight In specialty mental health Challenges – purchase scales – check weight at every visit

22. Patient Education

23. Make Services Available: Wellness Groups Challenges – services not currently provided – few clinicians believe weight is a high priority – patient motivation – patient transportation Facilitators – clinicians like providing the groups – audio (VANTS) or video – PRRC’s

24. Make Services Available: Medication Change Challenges – psychiatrists are not changing medications – few psychiatrists believe this is a high priority – “It’s too hard for patients to lose weight.” – “Symptom management is more important.” – medication changes require early follow-up Facilitators – start with ziprasidone and aripiprazole – next try risperidone or quetiapine – provide patient-specific feedback

25. Summary Individuals with psychotic disorders are at a high risk for weight gain and related medical problems Monitoring – weight: at every visit & at home Implementation – weight management groups – medication change