The Role of Mental Health in Obesity Management
Key messages for healthcare policy makers
- Be aware of the links between mental illness and obesity, and ensure you manage the weight gain side effects of medications used in the treatment of mental illness.
- Be aware that mental illness can impact obesity management efforts, and screen patients for potential mental illnesses that need to be addressed.
- Physicians should be aware of the weight gain and cardiometabolic risks associated with off-label antipsychotics use (absence of approval by regulatory bodies), even when these medications are prescribed at lower doses.
- When initiating anti-psychotic treatment for the first time, medications with higher metabolic risk, such as olanzapine, should be avoided. Individuals in their first episode usually respond well to therapeutic doses, regardless of which medication is prescribed (and are at greatest risk for weight gain).
- Consider switching strategies to a lower metabolic liability anti-psychotic in individuals with mental illness who gain weight on an anti-psychotic treatment, if clinically appropriate.
- Behavioural therapy, ideally as part of a multidisciplinary treatment approach, can be effective in helping to manage obesity in individuals with cooccurring mental illness. The type and intensity of the behavioural intervention will need to be personalised to the needs of individuals with more severe psychopathology in the context of obesity.
- Given the prevalence of mental health issues in individuals with obesity, screening for mental illness is recommended, as undetected mental health difficulties may have a negative impact on obesity management.
- For patients with severe mental illness who gain weight on anti-psychotic treatments, the option of trialling weight management medications in conjunction with behavioural obesity management interventions should be explored. Glucagon-like peptide 1 (GLP-1) agonists are licenced in Ireland for weight management and have the greatest supporting evidence of both safety and efficacy in chronic obesity management of all licensed preparations.
- However, off-label use of metformin is also an effective and more commonly used intervention that has been studied extensively in patients with mental illness and anti-psychotic-induced weight gain. Metformin is likely to be more effective when initiated at earlier stages of antipsychotic treatment and should be considered as a first-line management option prior to GLP-1 agonists. Cost may be a barrier for individuals trying to access GLP-1 agonists. See Table 1 for prescribing information for these medications.
- For individuals regaining weight after bariatric surgery, biopsychosocial/psychosocial interventions should be used to address comorbid psychiatric symptoms interfering with obesity management, such as depression and eating psychopathology, and to support behavioural change long term.
- For individuals with binge eating disorder (BED) and obesity or overweight, lisdexamfetamine is indicated to reduce eating pathology. Off-label use of topiramate has also been shown to help.
- Given the prevalence of mental health issues in individuals with obesity, screening for mental illness is recommended, given the potential negative impact that undetected mental health difficulties may have of management and recovery for obesity. Screening for conditions such as depression, anxiety, BED, attention deficit hyperactivity disorder (ADHD) and trauma should be considered in patients seeking obesity treatment.
- The current approved obesity medications can be helpful in patients with a mental illness and should be used based on clinical appropriateness and cost considerations. GLP-1 agonists have the greatest supporting evidence of efficacy in chronic obesity management and indirect evidence demonstrates their superior efficacy compared to alternative options. These options include orlistat and the combination tablet naltrexone/bupropion. The latter is contraindicated amongst those with a history of bipolar disorder due to risk of mania induction. See Chapter 11 Pharmacotherapy in Obesity Management for further information.
- For people with overweight or obesity and BED, evidence highlights that the following medications, lisdexamfetamine, topiramate and second-generation anti-depressants, including serotonin reuptake inhibitors, duloxetine, and bupropion, can be effective in reducing eating pathology. However, all are offlabel pharmacological interventions in Ireland. While these medications are effective in reducing eating pathology, their effect on weight loss is less certain.
- Referral for more intense (i.e., longer term) psychological and behavioural interventions, such as cognitive behavioural therapy, interpersonal therapy and acceptance and commitment therapy should be considered for individuals with significant binge eating and depressive symptoms in the context of obesity, in an effort to address comorbid mental health issues that may contribute significantly to their obesity management and outcomes.
- If a patient is actively attending a mental health service, such as their local community mental health team, clear communication and liaison with their treating team should take place during the weightmanagement interventions to optimise positive outcomes.
- Patients seeking bariatric surgery should be screened for mental health comorbidities. The presence of an active psychiatric disorder does not exclude patients from bariatric surgery but warrants further assessment of the potential impact on long-term weight loss and consideration of the impact that surgical intervention may have on mental health stability.
- A stepped care model should be utilised to organise provision of mental health services. The level of care is “stepped up” to more intensive or specialist services as required and, depending on the level of patient distress, senior liaison psychiatry input should form part of the multidisciplinary team.
- Individuals undergoing bariatric surgery should undergo a pre-surgical mental health screen by a specialist mental health clinician to identify early risk factors for poor outcomes or mental health deterioration.
- Assessment and monitoring of an individual’s mental health should continue following surgery and can include the use of either clinician-administered or patient self-report measures, where appropriate.
Individuals with mental health difficulties should receive ongoing monitoring by a healthcare professional for mental health symptomatology, including eating psychopathology, substance misuse and risk behaviours, such as suicidal ideation or selfharm, after bariatric surgery.
Patients should be monitored for alcohol- and substance-use changes, after bariatric surgery and informed about the possibility of altered alcohol metabolism following surgery.
For individuals regaining weight after bariatric surgery, biopsychosocial interventions should be used to address comorbid psychiatric symptoms complicating obesity management.
Patients should undergo pre-bariatric surgery psychosocial and mental health assessments by an experienced mental health clinician. Assessment should continue following surgery and can include the use of either clinician-administered or patient self-report measures.
We recommend psychiatric medication monitoring following bariatric surgery due to potential changes in drug absorption and thus therapeutic effect, especially with malabsorptive surgical procedures. Furthermore, for individuals with existing mental illness, continuing psychiatric medications after surgery, and monitoring of therapeutic effect, is critical to maintaining mental health stability in the post-surgical period and longer term.
Post-bariatric surgery behavioural and psychological interventions to support maintenance of weight loss and to prevent significant weight regain may be useful.
Multi-disciplinary bariatric surgery teams should focus on evidence-based strategies to improve patient engagement during the post-surgery follow-up period, specifically for high-risk patient groups, to optimise patient recovery and good outcomes. Such strategies should include close communication with other specialities, such as mental health and primary care.
Recommendations
- Regular monitoring of weight, fasting glucose and lipid profile in people with a mental health diagnosis who are taking medications associated with weight gain is recommended (Level 3, Grade C)2,3.
- Healthcare professionals (HCPs) can consider both efficacy and effects on body weight when choosing psychotropic medications (Level 2a, Grade B)4-16.
- Pharmacological treatment, such as metformin, and psychological treatment, such as cognitive behavioural therapy, should be considered for prevention of weight gain in people with severe mental illness who are treated with anti-psychotic medications associated with weight gain (Level 1a, Grade A)17,18.
- HCPs should be aware that both lisdexamfetamine and topiramate have been shown to reduce eating pathology and weight in people with overweight or obesity and in binge eating disorders (Level 1a, Grade A)19-21. However, neither medication is licensed in Ireland for this indication currently, and specialist opinion should be sought before considering such treatment options in conjunction with psychological interventions (Level 4, Grade D, consensus).
Key messages for people living with obesity
- There are clear links between mental illness and weight. Healthcare professionals should be aware of all treatments that patients are taking for their mental health.
- Individuals with co-occurring mental illness should be offered biopsychosocial interventions, including behavioural therapy to help manage obesity.
- Individuals with co-occurring mental illness should receive psychoeducation about the potential impact of bariatric surgery on their mental state and the potential effects on the efficacy of their psychotropic medications.
- Early emergence of psychiatric symptoms and eating difficulties after bariatric surgery could negatively influence post-surgical weight loss. Individuals should undergo mental health screening before bariatric surgery and have a specialised multi-disciplinary team to identify and manage psychiatric symptoms and eating difficulties arising after surgery.
- Given the potential risk for relapse of psychiatric symptoms, individuals undergoing bariatric surgery should be made aware of the potential changes in the absorption and metabolism of their psychotropic medications post-bariatric surgery and should be advised to discuss this with their treating team.
- Given the potential increased risk of substance-use problems (such as alcohol), individuals undergoing bariatric surgery should be made aware of the potential changes in absorption and metabolism of these substances following bariatric surgery, and they should be advised to seek help as needed.
- The importance of monitoring mental health in the post-operative period should be emphasised, to ensure that individuals access appropriate supports.
- Anti-psychotic medications should not routinely be prescribed (especially on a long-term basis) for issues like sleep and anxiety. Psychological interventions, such as cognitive behavioural therapy, should be recommended in the first instance, where appropriate.
- If a patient has started an anti-psychotic recently and has gained weight, or there is concern about future weight gain, and behavioural interventions have not or are unlikely to be sufficient in addressing this concern, metformin can be used to prevent further weight gain. Metformin may also help to reduce some weight already gained. However, it’s main benefit is in preventing future weight gain from anti-psychotics.
- Where anti-psychotics have caused a significant amount of weight gain, metformin treatment may not be sufficient to reverse this. Early studies suggest that, amongst medications approved for long-term weight management in Ireland and overseas, glucagon-like peptide 1 (GLP-1) receptor agonists have the most evidence to support their use in reversing weight gained from antipsychotics.
- No medication is licensed in Ireland for preventing or treating weight gain caused by anti-psychotics. GLP- 1 receptor agonists also currently come at significant cost to patients. Individuals should discuss with their doctor or pharmacist what options might be suitable and affordable for them.
- If an individual has gained weight from an antipsychotic medication, they should be advised to ask their doctor or pharmacist if there might be another anti-psychotic with a lower weight-gain risk. This should be a collaborative decision, taking into careful consideration other potential side effects/tolerability and risk of deterioration in mental health.
- For patients with binge eating disorder, two medications (lisdexamfetamine and topiramate) can be helpful to reduce both binge episodes and weight. These medications are currently not licenced in Ireland for these indications but have shown benefits for some patients.
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