Monthly Archives: March 2019

Antidepressants: The Hidden Contributor to Obesity

Years after weight gain was recognized as a side effect of antidepressant therapy, researchers have presented evidence of its contribution to the increase in obesity.  For those patients, who for years have described the devastating effect antidepressant have had on their weight, it is a ‘told you so’ moment. Last spring the British Medical Journal published a report by Rafael Gafoor, Helen Booth and Martin Gulliford, documenting the significant weight gain in Britain experienced by  patients on a variety of antidepressants, compared to the general population.  Using electronic medical records, they tracked weight status of the 53,000 British patients who had been prescribed antidepressants over ten years, and compared their weight to a similarly large group of untreated individuals.  Both groups gained weight, but a significantly larger number of those in the antidepressant-treated group increased their weight. Moreover, weight gain did not stop after the first year of treatment, but according to their findings continued, on average, for six more years.  The drug that caused the most weight gain was mirtazapine (Remeron).

Moreover, weight gain as a side effect of antidepressant treatment was not confined to those who were overweight or obese at the start of their therapy, but included patients who were of normal weight prior to treatment. The authors conclude that the impact of antidepressant drugs contributing to the increase in obesity in the UK has been overlooked, and should be considered a major risk factor. Their assessment of the impact of antidepressant therapy on generating obesity can be applied to the USA where, as in the UK, it has been almost entirely ignored as a risk factor.

That antidepressants and related drugs used for bipolar disorder and other mental  disorders cause weight gain is well known to patients and their mental health providers.  Several years ago, my associates and I were asked to develop a weight maintenance center at a Harvard associated psychiatric hospital to help patients lose the weight they gained (or were gaining) on psychotropic drugs.  What was so striking about our clients was that unlike those who have struggled with weight gain all their lives, they rarely had a problem with their weight prior to their treatment: eating a healthy diet and exercising characterized their lifestyle, and few had ever needed to be on a diet.

Because the data for the BMJ report was derived from electronic records, no information about alterations in food choice instigated by drug treatment was reported. However, several papers (as cited in the reviews below) have pointed to an increase in carbohydrate intake, and the absence of satiety associated with antidepressant use.

Those attending our clinic complained of an almost irresistible need to snack frequently on sweet or starchy foods and some (although usually those on mood stabilizers) would report eating a second meal an hour or so after the first, because they did not feel full. A professor of psychiatry at Boston area hospital shared the experience of a patient on Remeron who woke up every night to eat boxes of crackers and cookies.

The BMJ report did not offer information on whether weight was lost after withdrawal from antidepressants; presumably, after the psychotropic drug(s) is no longer in the body, appetite should return to normal. There have been reports of patients unable to lose weight despite dieting and exercising, sometimes for months and indeed years, after they have stopped their medication – but this information is largely anecdotal.

Recognizing the contribution of psychotropic drugs to the rising rate of obesity may lead to interventions to prevent or diminish weight gain. Ideally a patient should be advised on diet and exercise at the initiation of the drug therapy, but one wonders whether adhering to a regimen to prevent weight gain is practicable for a patient while still symptomatic. Moreover, often the dietary advice, although well intentioned, may be counterproductive if it includes restricting carbohydrates. Since the synthesis of serotonin depends on the consumption of carbohydrates, and since not only mood but satiety is dependent on serotonin activity, offering a low carbohydrate diet may only exacerbate the cravings and the absence of satiety.

Acknowledgment by practitioners of the real possibility of weight gain as a side effect of psychotropic drug treatment, and the availability of Individual and/or group weight loss support must be part of the treatment plan.  Obesity is not a benign side effect; it has well known health consequences, and may significantly affect the quality of life of the individual. Social isolation, employment discrimination, embarrassment at a body no longer recognizable are but a few of the consequences. Consideration of a patient’s weight status prior to treatment is also important;  a drug like Remeron known to cause uncontrolled eating may catapult an overweight individual into obesity.

Those who have gained weight as a consequence of their psychotopic medication have been invisible as a sub-group among the obesity community. One hopes that this report is the first step in making us notice and help them.

Chronic Lack of Sleep May Have Serious Consequences

Insomnia is a lonely and often neglected problem. This disorder may be found in 10-30 percent of the population, and perhaps higher among the elderly, females, and people with medical and mental disorders, according to the review by Bhaskar, Hemavathy and Prasad. But chronic insomnia may be neglected by family practitioners or treated inadequately. The insomniac cannot call their medical care provider at 2 or 3 a.m. after (once more) lying awake for hours and ask for the doctor for help the way one would if experiencing a medical problem during the day. Nor is waking someone up to relieve the 3 a.m. loneliness a good idea; it’s likely that the person awakened would not be good company. Moreover, since almost everyone has faced sleepiness at some point due to muscle pain, jet lag, a barking dog, or worry, we who suffer from insomnia sporadically may not realize how debilitating this condition can be when it is chronic.

Some occupations are vulnerable to sleep deprivation, either because their jobs don’t give them enough time to sleep, or because they have trouble falling asleep. Shift workers are prone to insomnia, and it may worsen when their sleep-wake cycle changes on their days off or when moving into a new work cycle. One consequence is a significantly greater occurrence of depression among shift workers compared to other groups, according to an analysis published a few years ago.

Despite the many symptoms associated with insomnia, the consensus seems to be that it is a disorder which is under-recognized and under-treated. This may be because sleep habits are not queried by the health provider, and complaints are not offered by the patient unless linked to an obvious cause for sleeplessness, such as pain, hot flushes, reflux, sleep apnea, or medication. Health providers may have neither the time nor the expertise to treat the disorder, assuming it is not related to an obvious cause . . . such as sleep apnea. Or, they may rely on pharmacological interventions to induce sleep, even though these drugs have side effects and/or limited efficacy. Sleep clinics may detect the underlying cause(s) of the sleep disturbances, but usually do not offer long-term therapeutic help.

Support groups for insomniacs exist and may provide information and help if this is not available from health providers. A.W.A.K.E., which stands for “alert well and keeping energetic,” is a national organization started years ago by the American Sleep Apnea Association to provide support for people using a new device, the PAP (positive airways pressure) machine, for sleep apnea. Currently the A.W.A.K.E program has expanded its outreach to anyone in the community with sleep problems. Other support groups helping those with specific problems that interfere with sleep, such as restless legs, are also listed on Internet sites and found throughout the country. But these groups are only as good as the information offered. Someone with serious psychological side effects from lack of sleep probably won’t find anyone in these support groups with the expertise to deal with their problems. However, one benefit may be no longer feeling isolated and lonely when sleep is elusive. Perhaps these groups, at the very least, give the insomniac the name of someone to talk to at 3 a.m.

Medical residents are another group that has been identified as vulnerable to impairments in mood and performance because of sleep deprivation. Their sleep needs are not met, because their work schedules require being “on-call” all night, after working all day. The numerous television hospital dramas with their interpersonal catastrophes fail to mention that the hospital staff may be suffering from depression, impairment of performance, and difficulties with interpersonal relationships because of inadequate sleep. The cognitive deficits associated with restricted sleep are not emphasized in these programs either, but are also a well-researched side effect.

However, emotional, cognitive, and physical impairments potentiated by sleep deprivation are not restricted to these two groups. In an article describing the results of a multi-site study testing an intervention to improve sleep, Freeman and his co-workers link a lack of sleep to clinical depression and suggest that many insomniacs experience general mental distress at their continuing failure to achieve restful sleep. Their study targeted university students whose insomnia caused paranoia and hallucinations, side effects that are probably not well known as a consequence of insomnia. The authors used an online cognitive-behavioral intervention over several weeks and compared the effects to conventional treatments for insomnia, such as medication, and suggestions about avoiding caffeine, regular bedtimes, and relaxation techniques. Despite the fact that no therapist was present in the experimental intervention, the online treatment was effective. Their intervention significantly reduced insomnia, paranoia, and hallucinations after 10 weeks, decreased depression and anxiety, and improved general well-being. What is striking about their results is that the improvements in mental and cognitive function were accomplished without drugs, and the therapy and the educational and cognitive interventions were carried out online.

References

“Prevalence of chronic insomnia in adult patients and its correlation with medical comorbidities,” Bhaskar, S, Hemavathy D and Prasad S, J Family Med Prim Care, 2016 Oct-Dec; 5(4): 780–784.

“Night Shift Work and Risk of Depression: Meta-analysis of Observational Studies,”  Lee A, Myung S-K Cho J, et al, J Korean Med Sci, 2017 32(7): 1091-1096.

“Sleep Deprivation and Depression,”  Al-Abri M, Sultan Qaboos Univ Med J, 2015; 4: 4-6.

The Unhappy Consequence of Not Being Able to Exercise

I knew she was going to become depressed. The email she sent said that her doctor said no tennis, swimming, golf, or rapid walking until the wound on her leg healed. She had fallen off her bike, the wound became infected, and a short healing time turned into weeks.

“I don’t know what to do with myself,” she  wrote.  “I am irritable, worried, depressed and anxious.  This is the longest I have gone without any physical activity.”

She exercised all her life, and has a master’s degree in exercise physiology. Her outside activity used to change with the seasons, but now that she had traded life in a cold European country for the warmth of Florida, she had been able to engage in outside physical activity year-round. But, for the time being, she could only prop up her leg and hope the healing would occur quickly .

My friend’s mood changes are well known among  committed exercisers who must stop exercising.  Magazines devoted to particular sports, such as running, devote columns to alternate types of exercise while recovering from an injury sustained during a race, for example. And the Internet is replete with articles, blogs and anecdotes written by those who find themselves unable to pursue their sport because some part of their body has been injured.   Moreover, many research studies have been carried out quantify, to some extent, the degree of mood changes brought on by experimentally-induced cessation of exercise.

In an experiment designed to see whether runners really do experience mood changes when they stop running, forty male runners who ran regularly were divided into two groups. One group was allowed to run during the six weeks of the study, and the other group was not allowed to run for two weeks in the middle of the study. Depression and other mood states were rated weekly and confirmed what my friend and others have experienced.  Depression, anxiety, insomnia and general stress were elevated during the non-running weeks among the runners. When they were allowed to go back to running during the last two weeks of the study, their moods were the same as the group that never stopped running.

Similar findings were reported among 40 women who engaged in aerobic exercise regularly and were told to stop their aerobic activity. Their moods were compared to a placebo group that had continued to exercise.  Those who abstained from exercise exhibited depressed mood and increased fatigue compared with those who did not stop their physical activity…And these below-listed studies are a small example of many that have been published.

And yet, exercise withdrawal due to injury, or other factors such as caring for a sick parent or child, overwhelming work obligations, prolonged adverse weather conditions, and numerous other life events, may be overlooked as a cause of significant changes in mood. Mental health professionals recognize exercise addiction and the mood changes that occur when the exercise is stopped, either due to injury or because the amount of exercise is pathological. But my friend exemplifies an individual who is not addicted to physical activity but does it, like brushing her teeth, as part of her daily routine. Indeed, soon after we spoke, another friend who had a surgical procedure on her leg called to tell me that she was “going crazy” because she was not allowed to swim until the surgical wound was healed.

“What am I going to do?” she almost wailed to me on the phone. “How can I survive without swimming?”

How many primary care physicians inquire about change in exercise patterns when investigating depressed or anxious mood, or increased fatigue in a patient?  Would it even occur to many (unless they also exercised regularly) to ask about changes in activity? Or when a physician tells a patient that he or she can’t run, or go to a gym, or play tennis, or walk quickly for several weeks, is there any thought given to the impact of such prohibition on the mood of the patient?

Conversations about exercise focus heavily on the benefit of physical activity on mood, weight loss, sleep, cognition, and on and on to convince those who would rather sit than walk on a treadmill to start to move for their health. But has enough attention been paid to helping patients deal with the mood and energy changes that occur when it must cease for a period of time?

One problem is understanding why stopping consistent exercise should have such a negative effect on general well-being.  Many who have experienced the inability to exercise for a period of time often cite an increase in stress and worry that no longer can be dampened by vigorous activity. Exercise allowed them to cope; without it, they must seek out alternatives and often don’t find them.  But what is it about running or biking or swimming or working out in a gym that allows our brains to increase their coping skills? Moreover, even when we find out the answer beyond such things as endorphins—which not everyone experiences, and certainly not all the time—the problem remains: what to do until exercise can begin again?

Magazine articles, Internet chatter and blogs offer some suggestions, but what about professional help? Shouldn’t a patient who is told, “No exercise for X weeks!” be referred to a physical therapist to learn what physical activity can be done? My non-swimming friend did learn from a physical therapist that she could do Yoga and Pilates; my other friend decided to do upper body strength training. When I last checked, both were considerably less grumpy.

 

 

 

“Effects of temporary withdrawal from regular running,” Morris, M, Steinberg, E , Syeks A et al,  J of Psychosomatic Res. 1990; 34: 493-500.

“Depressive mood symptoms and fatigue after exercise withdrawal: the potential role of decreased fitness,”  Berlin A,1, Kop W,, Deuster P,. Psychosom Med. 2006 Mar-Apr;68(2):224-30.

“Mental health consequences of exercise withdrawal: A systematic review,” Weinstein A, Koehmstedt C and Kop W,. General Hospital Psychiatry 2017; 49:11-18.