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Recently there has been a lot of attention to the problem of weight gain and possible risk of diabetes from psychiatric medication. This is a serious concern for many people, and I will try to answer some common questions that often come up when contending with this issue. Let's take a question and answer approach, and perhaps this can help you when thinking about your own situation.

Which psychiatric medications cause the most weight gain?

Many, but not all, of the psychiatric medications can cause weight gain. Among the antipsychotic medications, clozapine (Clozaril) and olanzapine (Zyprexa) cause the most weight gain, risperidone (Risperdal) and quetiapine (Seroquel) somewhere in the middle, and ziprasidone (Geodon) and aripiprazole (Abilify) are least likely to cause weight gain. Among the mood stabilizers, valproate (Depakote) and lithium often cause weight gain. Among the antidepressants, paroxetine (Paxil) and mitazepine (Remeron) seem to have more weight gain than other commonly used antidepressants.

Why do these medications cause weight gain?

The exact biologic mechanism for weight gain has not been worked out yet, but what is known is that weight gain comes from changes in appetite. People find that they are always hungry, and they don't stop eating because they just don't feel full after eating.

Could you be more specific about when weight gain from medication happens?

When medications cause weight gain, it happens right away! People gain weight within a few weeks of starting these medications. But, please remember that not everyone gains weight, even when taking one of the medications associated with weight gain listed above. If you don't gain weight right away, it'll be very unlikely that you'll have a weight gain problem from that medication later on.

Do higher doses cause more weight gain?

The dose of the medication is not a big factor in weight gain. Therefore, the dose should generally be adjusted to get maximum benefit from the medication. If the weight gain is not acceptable, then you will have to consider other ways to reverse the weight gain, such as diet, exercise, or switching to another psychiatric medication that has less weight gain.

What can I do to avoid weight gain before starting medication?

The good news is that there now are many effective medications that do not cause much weight gain. Before starting a new medication, you should ask your doctor how much of a problem weight gain is with that medication, and whether or not there are other alternatives. If you decide to start a medication that is likely to cause weight gain, it is important to record your weight before you start, and check your weight every week. Remember, not everyone gains weight and you may not have a problem. Or, if weight gain is a problem, it is better to catch it early and see whether it can be controlled, or perhaps whether the medication choice should be reconsidered.

What should I do if I've gained weight on my medication?

First, do not stop your medication on your own! Remember that you have many choices. Make sure that the weight problem really is from the medication-it may be that most of the weight problem was there before you started this medication. Let's assume that the weight gain is caused by the medication. What are the options? If the medication causing the weight problem is not working very well, there is a good chance that you should be thinking of changing medication anyway. If that is the case, then you should ask about changing to a medication that does not cause as much weight gain. If you are lucky and the next medication you try works well, you'll get benefits without making the weight problem worse.

It is a much tougher problem to know what to do when the medication that has caused you to put on pounds is also doing a good job for your symptoms. The first step is to try diet and exercise. If that works and gets your weight off, you do not need to do anything else. If you have tried diet and exercise, and weight is still a problem, then you and the doctor need discuss the possible treatment options. There usually are three options:

1) Don't make any changes because the medication is very helpful and you can live with the weight gain;

2) Try adding some other medication to help you lose some of the weight you have gained;

3) Change to another psychiatric medication that has less weight gain.

Often there is no clear right or wrong answer here. The first option of keeping things "as is" is the safest from the point of view of your emotional condition, but may cause health problems later on. The second option, adding something to the medication, is frequently done. Some medications that have been tried include sibutramine (Meridia), amantadine (Symmetrel) or topirimate (Topomax). I personally do not recommend this approach. The problem is that these medications have their own side effects, and the amount of weight loss from using these medications is not so great. The third option is to switch medications. There is good news and bad news here. The good news is that switching to a medication with a better weight profile will probably reverse your weight gain from the medication you are on. The bad news is that, for people who have responded well to their current medication, there is no guarantee that the next medication will work as well. The fact that different people have different responses to psychiatric medications makes it impossible to predict how well you may respond to a new medication before you try it. Even though it may not always be clear what you should do, there is something I really want you not to do. Whatever else you do, please, please, do not use over-the-counter weight loss pills such as Ephedra-doing that is very dangerous and can lead to sudden death.

I've heard about something called BMI. What is that?

Most of us look at our weight in pounds, or sometimes kilograms (a kilogram = 2.2 pounds). Doctors evaluate weight in relation to the person's height. You can imagine that a short person who weighs 200 pounds has a bigger weight problem than a tall person. To correct for this, doctors also will ask you for your height. Using your height and weight they will calculate your Body Mass Index, which is also called BMI. The BMI is a better way to tell if someone is overweight or has a serious weight problem.

I have included a chart with BMI and other medical tests that you can use to compare with your own results to see if you have a weight problem, or are at risk for diabetes, high blood pressure, or high lipids and cholesterol.

Table: Some important health test numbers

Lab Test OK Warning Danger
BMI 19 to 24 25 to 29 30 and above
Glucose(fasting) Less than 110 110 to 125 More than 126
Blood Pressure Less than 130/85 130 to 139/85 to 89 140 or higher/90 or higher
Total Cholesterol Less than 200 200 to 239 240 or higher
Triglycerides Less than 150 150 to 199 200 and higher

What about antipsychotic medications and the risk of diabetes?

Let's first discuss diabetes. Diabetes is a serious medical condition that is becoming much more common in the United States these days. Experts are saying we are in the middle of a diabetes epidemic. They think that the reason why more people get diabetes now than ever before is because more people are obese (fat) and sedentary (don't exercise) now than ever before. Both obesity and lack of exercise are risk factors for diabetes. Persons with schizophrenia are more likely to have diabetes than the general population, probably because they are more likely to be overweight, and less likely to exercise.

Let's now consider the relationship between weight gain and diabetes risk. Studies have shown that weight gain for any reason increases diabetes risk. There is no reason to think that patients with psychiatric conditions are any different. Thus, weight gain from medication does increase a person's risk of getting diabetes. Now, keep in mind that some people get diabetes even if they are not overweight, and other people can be very obese and never get diabetes. Therefore, people who are already overweight will be put at higher risk from weight gain from medication (assuming they cannot lose this weight on their own). If you are already overweight, an additional weight gain of 20 pounds from medication (or any other reason, for that matter) might double the risk of eventually getting diabetes. Please keep in mind that it may take years between when the weight gain happens until the time that diabetes is diagnosed. This long delay makes it much harder to figure out the relationship between psychiatric medication and diabetes risk. Please keep in mind that if you have not gained weight on any medication you have been taking for awhile, then this discussion does not apply to you!

I've read that sometimes diabetes happens right away. What is that about?

There are case reports in the medical literature that describe new cases of diabetes that are diagnosed in the first few weeks of starting some of the newer antipsychotic medications. There is some controversy among researchers whether this may be a signal of some additional risk for diabetes that is unrelated to the weight gain we've discussed above. In any case, this problem only happens in the first few weeks of medication and this is not an issue when people stay on medications beyond that time. Please discuss this with your doctor before you start. Your doctor may want to do a blood test to see if you have a tendency towards diabetes. That test would include a fasting blood sugar and perhaps something called "Hemoglobin A1C," which basically measures how much sugar has been floating around in your blood over the last month (please see the table). Some signs of diabetes include being very sleepy, feeling nauseous, getting very thirsty and urinating constantly, and losing weight all of a sudden for no reason. In my opinion, the major risk for diabetes is related to weight gain. If you gain a lot of weight on medication, you'll be at higher risk of getting diabetes down the road, if you don't gain weight, you won't be at higher risk because of the medication.

This article makes me nervous! I've got enough problems. What should I do?

First of all, I sympathize. It is upsetting to discuss health risks, and it is complicated and confusing to discuss how helpful psychiatric medications can sometimes make health problems worse. You probably have enough challenges and problems in life without having to deal with weight and diabetes on top of all of that. Keep in mind that this is not just an issue for people with psychiatric conditions. In fact, weight gain, obesity, and diabetes are terrible health problems for all of us. It winds up that people with mental illness have more than their share of risk factors for medical illnesses.

What is the good news?

The good news is that many of these risk factors-smoking, weight gain, lack of exercise-are modifiable (modifiable means that you can do something about it!). As a psychiatrist who has worked with people with serious psychiatric conditions, I can say that I did not address these problems nearly as much as I should have. Nowadays, I am much more active in helping my patients deal with risk factors such as smoking or obesity. Also, nowadays, because of the newer medications, my patients tend to have their symptoms under much more control. This makes it easier for us to address some of these problems.

Don't ignore the health risks, but don't overstress about it either.

On the one hand, these issues can be overwhelming and you should not jeopardize your emotional health by getting too stressed out about these issues. If your psychiatric symptoms are not adequately controlled, usually that has to be the priority before you can tackle problems like weight gain or smoking.

But, many people, including me, tend to ignore these kinds of risk factors until a problem happens. My advice to you, which I wish I had taken myself, is not to ignore these health issues. Deal with them-one at a time-before a medical problem happens. If you ignore your weight, smoking, blood pressure, or cholesterol, you may find that the years you have put into mental health recovery will be threatened by new medical problems. Talk about unfair! What I would suggest is to take a middle ground. Discuss your physical health as well as your mental health with your prescribing psychiatrist. Take one step at a time. Keep in mind that there are more choices among psychiatric medications these days, and it is a lot easier to find medications that can control your emotional symptoms without adding to medical risks.