Family Nursing Consultants
32 Chedoke Avenue
Hamilton, Ontario L8P 4N9
This project was supported financially by St. Joseph’s
Healthcare Hamilton, Centre for Mountain Health Services, Hamilton,
listening to patients’ stories, recovery, motivation
Mental health consumer involvement in planning, delivery and evaluation
of mental health services continues to be more a vision than a
reality. Consumers expressed an interest in sharing with
clinicians their experiences of taking second generation neuroleptic
medications. During three discussion groups, twelve consumers
discussed their concerns about weight gain, and their struggles to
reduce its impact and to gain control over their lives. The
opportunity to share with clinicians and each other their experiences
and suggestions for managing weight gain was a valuable one for all
Weight gain is an adverse effect of many psychotropic medications,
occurring in 50% of patients using these medications over the long-term
(Baptista, 1999). Second generation neuroleptics offer advantages
over traditional antipsychotics, but their potential to produce
considerable weight gain is a serious concern (Taylor & McAskill,
2000; Kawachi, 1999). Development of obesity and its related
co-morbidities, non-adherence to medication and the return of psychosis
are potential outcomes. Stigma and reduced quality of life are
also reported anecdotally.
To gain an understanding of the problem locally, a chart audit was
conducted on 20 inpatients of a tertiary care psychiatric
hospital. Identifying data included: current medication
dosages, length of time on medications, initial weight and BMI, current
weight and BMI, diet prescribed and level of activity. Weight
gain was evident in 87% of this inpatient population. Length of
time on second generation neuroleptics ranged from 4 – 24 weeks.
All but one ate a regular diet and 56% were described as having
excellent to good participation in the recreation program offered.
Based on the apparent extent of the weight gain issue, a series of
discussion groups was held with individuals taking a second generation
antipsychotic medication. This initiative was supported
financially by the hospital administration, whose mission includes
involving clients in evaluating care.
We sought to determine the impact that weight gain had had on their
lives and, in turn, the impact that they had had on the weight
gain. Our ultimate purpose was to understand: what weight
gain had meant to them, what they had tried to do themselves, and what
might be helpful and efficacious in managing weight gain in the early
stages of taking second generation neuroleptics.
Discussion groups are well suited for use in psychiatric settings due
to their informality and potential for perceived support of peers who
have many similar concerns. Neuroleptic medication users are the
experts on their own experience. The group setting invites
participants to explore each other’s experiences.
Three discussion groups were held in three different settings in a city
in southwestern Ontario in the spring of 2000. In total, 12
individuals participated. All had a diagnosis of serious mental
illness. All participants were taking second generation
neuroleptic medications and had been stable on these medications for a
minimum of one year and were living in the community.
Participants ranged in age from 23 to 48 years, and one third was
Participants were solicited by a telephone call to three sites asking
health care providers if they knew individuals who might be interested
in participating in a group to talk about weight gain and/or weight
loss and lifestyle changes. Each individual who agreed was sent
an invitation to attend a group. At the completion of the
discussion group each participant received $10.00 for their time and
travel, an assortment of low calorie/low fat snack food and an
insulated mug. Facilitators took notes during the group
discussions, and the discussions were audio taped and transcribed.
No group members identified exactly how much weight they had gained or
lost. They were pleased with the second generation neuroleptic
they were currently taking, feeling "more motivated”, “energetic”,
“enthusiastic, stable and enjoying life more". In spite of this
experience three people admitted they had considered stopping the
medication due to weight gain. They ascribed a strong therapeutic
alliance with their case manager as preventing this potential treatment
Group participants eagerly shared their experiences and ideas with the
facilitators. Four dimensions of weight gain emerged:
• Almost 50% of the participants revealed a serious
lack of knowledge about nutrition and how the body uses
This was of concern as more
than half lived on their own in the community, and were
responsible for grocery shopping and meal preparation.
• People with severe mental illness want to look and
feel well, no matter how long they have been ill and are not willing to
compromise on either aspect.
• All participants had useful ideas about developing
a fitness program and were eager to discuss this with others.
• Even in the early days of their illness,
individuals were thinking about and looking for opportunities to become
more active and involved in their
Weight gain concerns fell into three domains:
• Physical concerns such as “feeling sluggish,
bloated and being out of breath” with little exertion,
• Self-image and resultant social isolation concerns,
such as “feeling unsure of myself and abilities” and “I stopped going
out as much”,
• Unsuccessful coping experiences described as
“weight loss-gain cycles” and “having an eating disorder”.
All participants, except one individual who did not gain weight,
identified that they decided to "take on" their weight problem.
This decision was a result of self-determination or, in two cases, due
to negative comments made by concerned friends who also offered to lend
a hand. Several were motivated by possible health risks that
could threaten their new found freedom. Others envisioned
themselves at an earlier, more active, physically healthy time, and
were determined to reclaim it. “I was thinking about how I was
before, I was more active and outgoing, stronger, and I looked at my
strengths like I had before and I gradually did certain things like
In each of the three groups, members were eager to share successful and
unsuccessful strategies they had tried. They had suggestions for
the health care team regarding resources and supports that would be
helpful to them while in the hospital: "exercise bikes that work
and [are] kept in good repair" and "carpets on the floor near the TV
where you could do sit ups and push ups while watching a
program". One participant commented that "nurses exercising along
with you to a video tape was helpful and fun". In addition,
"evening snacks that include fruit, veggies and dip rather than bread
and peanut butter or donuts" were highly endorsed. Access to
healthy, inexpensive snack food in the hospital, as an alternative to
high fat and high carbohydrate snacks like potato chips and chocolate
bars, was also suggested.
Their recommendations were consistent with suggestions found in the
literature (Baptista, 1999; McIntyre, McCann, & Kennedy, 2001;
Aquila & Emanuel, 2000; Masand, 1999; Ganguli, 1999) proposing that
nutritional counseling and exercise be introduced early in treatment of
novel neuroleptics to deal with the problem of weight gain.
Participants strongly encouraged professionals to address weight gain
early with an approach emphasizing regularity, repetition, and support.
When asked what advice they would give to a friend who was thinking
about starting a medication that had the side effect of increased
weight gain, participants responded: "most importantly, do not
lose hope", "[try] a medication that is less likely to make you weight
gain, before taking the medication most frequently associated with
weight gain", “accept help from staff", and “prepare yourself for the
likelihood of weight gain and feel proud of yourself when you achieve
one of your goals for the day".
Discussion and Conclusion
Clinicians, working in institutions, have an important role to play in
encouraging, educating and actively instilling hope for successful
outcomes for clients early in their treatment. Efforts directed
at increasing activity levels, making healthy lifestyle choices and
managing weight gain are highly valued by clients and they identify
these efforts as important in their recovery. Consumers of mental
health services are as interested in recovering their physical health
as their mental health. Where services are not directly available,
working with community partners in an advocacy role is necessary.
Aquila, R. & Emanuel, M. (2000). Interventions for weight gain in
adults treated with novel antipsychotics. Primary Care Companion
Journal of Clinical Psychiatry, 2, 20-23.
Baptista, T. (1999). Body weight gain induced by antipsychotic
drugs: Mechanisms and management. Acta Psychiatrica Scandinavica,
Ganguli, R. (1999). Weight gain associated with antipsychotic drugs.
Journal of Clinical Psychiatry, 60(Suppl 21), 20-24.
Kawachi, I. (1999). Physical and psychological consequences of weight
gain. Journal of Clinical Psychiatry, 60(Suppl 21), 5-9.
Masand, P. S. (1999). Weight gain with psychotropics: Size does matter.
Journal of Clinical Psychiatry, 60(Suppl 21), 3-4.
McIntyre, R. S., McCann, S. M., & Kennedy, S. H. (2001).
Antipsychotic metabolic effects: Weight gain, diabetes mellitus,
and lipid abnormalities. Canadian Journal of Psychiatry, 46, 273-281.
Taylor, D. M. & McAskill, R. (2000). Atypical antipsychotics and
weight gain: A systematic review. Acta Psychiatrica Scandinavica,