Donna Tweedell
Family Nursing Consultants
32 Chedoke Avenue
Hamilton, Ontario L8P 4N9
CANADA
Email: tweedell@mcmaster.ca
Acknowledgments:
This project was supported financially by St. Joseph’s Healthcare Hamilton, Centre for Mountain Health Services, Hamilton, Ontario, Canada.
Keywords
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 involved.
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.
Method
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 female.
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.
Findings
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 interruption.
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 nutrients.
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
own recovery.
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 push-ups.”
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.
References
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, 100, 3-16.
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, 101, 416-432.
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