UNMASKING HIDDEN DANGERS IN PSYCHIATRIC TREATMENT:
Obesity, Changes in Metabolism, and Premature Death

by Loren Crabtree, M.D.

In the United States, adults with serious and persistent mental illness (SPMI) have a life expectancy that is 20 percent shorter than that of the general population. This discrepancy is chiefly accounted for by coronary heart disease, hypertension, and other outcomes of arteriosclerosis and diabetes. Lifestyle factors include sedentary living, a diet rich in fat and with high carbohydrate and caloric content, and chronic stress.

In order to refine the prediction of life threatening illnesses, experts in the fields of heart disease and diabetes have identified five early warning signs of what they call the Metabolic Syndrome. The coexistence of three or more of the following component abnormalities establishes the presence of this syndrome:

Abdominal obesity: waist circumference greater than 35 in. for women and 40 in. for men; High triglyceride level: above 150 mg/dL; Low high-density lipoprotein (“good” cholesterol): below 50 for women and 40 for men; Hyperglycemia: fasting blood sugar above 110 mg/dL; High blood pressure: above 130/85.

Project Transition’s ongoing monitoring of the Metabolic Syndrome seeks to determine its frequency and component abnormalities in our resident members, a group of adults with SPMI. These findings have led to our ongoing investigations of corrective interventions, including medication changes, the use of pharmaceutical aids, and strategies that help individuals develop and maintain healthier lifestyles.

Method. Over a two-year period, we compiled laboratory and physical findings and conducted structured interviews for 105 adults with SPMI. Analyses included the frequency of the Metabolic Syndrome and its component abnormalities, and comparisons between the study sample and that of a national health survey (NHANES III).

Results. The frequency of the Metabolic Syndrome for the total patient sample was 40 percent. For patients 20-59 years of age, the frequency was 46.3 percent, compared to 20 percent for the same age cohort in the national sample. While the syndrome’s presence increased with age in both samples, its frequency for patients with SPMI in their 30’s and 40’s was similar to that of adults age 60 and older in the national sample.

Conclusions. Adults with SPMI were twice as likely to experience the Metabolic Syndrome than adults in the general U.S. population. The presence of each abnormal component was higher in the study sample as compared to the national sample. Three of these components (low HDL, elevated triglycerides, and abdominal obesity) were approximately twice the levels of those in the national sample. This implies that persons with SPMI are at a significant risk of developing type II diabetes, arteriosclerotic illnesses, related medical co-morbidities, and premature death.

Multiple Causes and Interventions. Relevant implications emerging from these findings include the importance of early detection, as well as the presence of multiple cause factors. Together, these aspects help define a comprehensive approach to treatment and prevention.

Trends in Psychiatry. Understanding this crisis invites us to consider important changes in the field of psychiatry. The treatment of psychosis, agitation, chaotic moods, and depression frequently includes the newest generation of psychotropic medications. Polypharmacy (the use of medication combinations) has become the standard for treatment practice in most fields of medicine. Once roundly criticized and avoided, it has essentially replaced monotherapy (the use of a single medication) in treating people with SPMI. Further, there is also a tendency to use medications indefinitely as compared to short-term use for the acute phases of an illness. This is done with the hope of preventing relapse and hospitalization. But some of them further the vulnerability toward major weight gain and obesity, as well as abnormalities of lipid and glucose metabolism.

Although there is growing knowledge about the effect of single psychotropic medications on weight gain, obesity, and type II diabetes, there are few studies that explore the effects of medication combinations. Some combinations can either intensify or lessen weight gain and the development of lipid and glucose abnormalities, but other combinations appear to have less of an effect.

A preliminary review of data from a related Project Transition study (in progress) shows that weight gain is associated with a number of medications: Clozapine, Olanzapine, short-acting Depakote, Neurontin, Lithium, Paxil, Remeron, and others. Weight gain varies among people and is sometimes accompanied by the other abnormalities associated with the Metabolic Syndrome. This suggests that an additive effect may be present in at least some medication combinations. In addition, individuals who receive medication combinations often fail to lose weight in spite of sustained efforts consisting of diet, exercise, and stress reduction techniques, suggesting induced metabolic changes. For some members, eliminating or lowering the dose of a medication can reverse the progression of abnormalities.

A Need for Action. With some of the root causes of the Metabolic Syndrome within this population known, further and aggressive investigation of the epidemic must increase. All credible findings related to the shortened average life span of this group must be publicized and responsibly acted upon. Mental health professionals, consumers, and their family members should advocate for the changes and investments necessary to offset this compounding tragedy.

In our efforts to help members improve their overall health, the major problems that we have encountered relate to motivation. Lifestyle changes are difficult for anyone to sustain, and mental illness multiplies these challenges. We were impressed, however, that a number of our clients showed sustained interest in our lifestyle modification program and demonstrated positive results in each of the intervention strategies that were offered. Timing, readiness, and personal fit are very important. In our setting, a supportive element of effective interventions has been Project Transition’s therapeutic approach. In addition, we now educate our clients and their families about the Metabolic Syndrome’s role as a prelude to type II diabetes and illnesses related to arteriosclerosis. This helps our physicians, staff, clients, and their families accept the presence of a condition.

The best news for everyone is that the Metabolic Syndrome can often be effectively managed and nullified through the careful choreography of medication combinations, lifestyle changes in nutrition, physical activity, stress management, wellness practices, and the use of pharmaceuticals that support positive results.

Dr. Loren Crabtree is the co-founder and medical director of Project Transition. He has been practicing psychiatry for 45 years. To learn more about Project Transition, call 215.997.9959 or visit their website.