Antipsychotic medication and weight gain

Introductio­­n

This article, written primarily for people with mental health problems and their carers, is about weight gain with antipsychotic medication. Antipsychotics are a group of drugs that are mainly used to treat schizophrenia and manic episodes in bipolar disorder. In both conditions, they are effective in treating symptoms and reducing the risk of a person becoming unwell again (i.e. having a relapse). Some antipsychotics are helpful in other mental health disorders. Unfortunately, antipsychotics can cause side effects. One of the most common and serious is weight gain. People with schizophrenia are twice as likely to be obese than people in the general population.[1] Antipsychotic medication contributes to this. Other causes of overweight include physical inactivity, an unhealthy diet, other medications and the effect of some symptoms of mental illness. For example, depressed mood and lack of drive can make a person less active and contribute to weight gain. Overweight increases the risk of having a heart attack and stroke and developing many physical illnesses including high blood pressure, type 2 diabetes, sleep apnoea, osteoarthritis and some cancers. In general, the more overweight a person is, the greater their risk of developing these problems. Overweight is associated with reduced self-esteem, reduced quality of life and stigma. People taking antipsychotics regard weight gain as one of the most distressing side effects caused by their medication.

Risk of weight gain with different antipsychotics

The fastest weight gain occurs in the first 6 months after starting an antipsychotic. Weight gain can continue after this but more slowly.  There is no clear relationship between weight gain and antipsychotic dose, at least within the ranges usually used to treat mental health problems.² Antipsychotics differ in their risk of causing weight gain, and other side effects, but do not differ in their effectiveness in treating symptoms of schizophrenia or mania. The one exception is clozapine which is more effective than other antipsychotics in treatment resistant schizophrenia. This is a form of schizophrenia in which psychotic symptoms (e.g. hearing voices) have not responded to treatment with at least two different antipsychotics.

The table shows the risk of weight gain with different antipsychotics. However, weight change can differ greatly from person to person. With any antipsychotic, some people may gain a lot of weight, some a moderate amount and some may not gain any weight or actually lose some weight. Greater weight gain during the first month of antipsychotic treatment tends to predict greater weight gain in the longer term. Antipsychotics can increase glucose (sugar) and lipid (fat) levels in the blood. The drugs that do this the most tend to be the same ones that cause the most weight gain.

Starting antipsychotics for the first time

A person starting antipsychotic medication for the first time is likely to gain more weight than someone starting the same medication who has previously taken other antipsychotics. This is because weight will often have been put on with earlier antipsychotic treatment. In a study of people early in the course of schizophrenia, who received treatment for up to one year, approximately eight out of ten people prescribed olanzapine developed significant weight gain (defined as an increase of 7% or more of their starting weight).[3] This compared to about five or six out of ten people who gained significant weight when treated with quetiapine or risperidone. In a different study of people who had previously received long-term antipsychotics, and were followed for 18 months, significant weight gain (more than 7% of starting weight) occurred in one third of people who started olanzapine with rates about half of this for those starting quetiapine or risperidone.[4] Comparing the two studies shows that weight gain is more likely in people earlier on in their illness. This corresponds to people being treated by early intervention teams in the UK.

How antipsychotics cause weight gain

Weight gain is the result of taking in more energy (calories) from food and drink than are used up through the body’s resting metabolism plus activity and exercise. The extra energy or calories are stored as body fat. Many factors can affect this energy balance and lead to weight gain. The main way that antipsychotics cause weight gain is by stimulating appetite so that people feel hungry, eat more food and take in more calories.  Some people taking antipsychotics report craving sweet or fatty food.

The regulation of appetite and food intake is extremely complex and is controlled by part of the brain called the hypothalamus. The hypothalamus integrates information it receives from other part of the brain and from hormones released from outside of the brain including fat (adipose) tissue and the gut. These hormones include leptin and ghrelin but there are many others. Exactly how this complex system works and how antipsychotics disrupt it are not fully understood. Neurotransmitter receptors in the brain seem to play a part, with evidence implicating the serotonin 5-HT2C and 5-HT1A receptors, histamine h2 receptor and dopamine D2 receptor among others. Antipsychotics differ in their ability to block these receptors and this partly explains their different liability to cause weight gain. Both olanzapine and clozapine, drugs with a high risk of weight gain, bind strongly to the histamine h2 and serotonin 5-HT2C receptors.

The pharmacology of antipsychotics is not the only factor that determines their effect on weight. As already mentioned, if a group of people take the same antipsychotic there will be differences between them in their subsequent weight change. This reflects differences between people in their diet, level of activity and genetic makeup. Variations (polymorphisms) in a large number of genes, including the gene that codes for the 5-HT2C receptor, have been linked to susceptibility to gain weight with antipsychotics. It is the combined effect of these genes, rather that variation in a single gene, that is relevant to weight gain. Currently doctors and patients choose drugs partly based on their ‘average’ effects seen in clinical trials, for example the risk of weight gain as summarised in the table. In the future, it may be possible to conduct a simple blood test (i.e. a genetic screen) to identify a person’s likelihood to gain weight, and to develop other side effects, when treated with different drugs, so called personalised medicine. This could help people choose the best drug for their treatment. However, such a test is not currently available.

Managing weight gain with antipsychotics

Decisions on choosing medication and managing weight, as with other areas of treatment, should be made jointly by a patient and their doctor. The main approaches to managing weight with antipsychotics are:

1. Ensure that the risk of weight gain, and other side effects, are considered when choosing an antipsychotic. Wherever possible use drugs with a lower risk of weight gain.
2. Monitor weight and Body Mass Index (BMI) during antipsychotic treatment. More regular measurements are needed in the first few months of treatment as this is when the risk of weight gain is highest.
3. Use lifestyle approaches to manage weight gain. These include increased physical activity, exercise and changes to diet and eating behaviours, for example eating regular meals, having smaller portions and cutting down on foods and drinks rich in sugar and fat.
4. If weight gain with an antipsychotic is problematic, consider switching to an antipsychotic with a lower risk of weight gain. Depending on the drugs involved, this can lead to weight loss. The risks of switching include the new medication causing side effects and being less effective for that person, leading to a relapse of their psychiatric disorder.

Other approaches can sometimes help manage weight gain including adding certain medications to antipsychotics. These approaches are reviewed in a recent BAP Guideline that also considers the broader issue of reducing the risk of cardiovascular disease (i.e. heart disease and stroke) in people with psychosis.²

Some people may consider stopping antipsychotic treatment due to weight gain. The issue of how long to continue antipsychotic treatment is complex. Space only allows some basic comments to be made here. Excess weight caused by an antipsychotic will usually be lost gradually after medication is stopped. Weight put on for other reasons is likely to remain. The downside of stopping antipsychotics is an increased risk of becoming unwell, especially for people with schizophrenia and bipolar disorder. Sometimes relapse occurs suddenly with serious repercussions. A person should never stop their antipsychotic, or alter the dose, without discussing this first with their psychiatrist. Together, the patient and doctor should carefully consider the advantages and disadvantages of continuing medication, stopping medication and other options for managing mental health, weight gain and other side effects. These will differ from person to person and reflect their medical history and current circumstances. The discussion should lead to a jointly agreed management plan that is tailored to the individual. For some people stopping medication is a realistic option but for others it is inappropriate. If a decision is made to stop antipsychotic treatment, then the dose should be reduced gradually. Medication should not be stopped suddenly. A healthcare professional should monitor the person for signs and symptoms of relapse while the dose is reduced and after it is stopped. For people with schizophrenia or psychosis, monitoring is recommended for at least two years after antipsychotics are stopped.[5]

Recent and ongoing research

A great deal of research is trying to improve outcomes for people with mental health problems. This includes developing more effective medications with a lower risk of weight gain and other side effects. Lifestyle modification programmes have a modest benefit in reducing weight gain in people starting antipsychotics and helping those established on antipsychotics to lose weight.[6] An additional advantage is that these programmes can reduce lipid (fat) and glucose (sugar) levels in the blood. These interventions can be given to individuals or to groups or both approaches can be combined. A recent example of a group intervention is the STRIDE study in the United States.[7] In STRIDE, people who were overweight, had a serious psychiatric illness and were taking an antipsychotic were randomised to weekly two-hour group meetings for six months or to normal care alone i.e. a control group. Participants were encouraged to eat a healthier diet and spend at least 25 minutes per day doing moderate activity. At six months, 40% of participants (compared with 17% of controls) had lost at least 5% of their initial body weight and 18% of participants (compared to 5% of controls) had lost at least 10% of their initial weight. It is generally accepted that for people who are overweight, losing 5% to 10% of total weight has health benefits[8], though greater weight loss is more beneficial. The intervention in STRIDE was also effective in reducing weight and lowering blood sugar levels at 1 year i. e. after an additional 6-month follow-up period. The STEPWISE study is currently assessing the effectiveness of a group programme to reduce weight in people with psychosis taking antipsychotics across ten mental health NHS trusts in England.[9]

If psychosis, at least in some people, could be treated by giving antipsychotics for shorter periods than is current practice then it would reduce weight gain and other medication side effects. The RADAR trial is an ongoing randomised trial in the UK that compares a gradual and supported programme of antipsychotic reduction to maintenance antipsychotic treatment (i.e. staying on the current antipsychotic dose).[10] Within the dose reduction group, it is envisaged that some people will eventually stop medication whereas others will stabilize on a lower dose. The main outcomes in the RADAR trial are social functioning and relapse.

There is strong evidence that adding cognitive behaviour treatment (CBT), a ‘talking treatment’, to antipsychotic medication reduces symptoms of schizophrenia further and decreases the likelihood of rehospitalisation. ⁵ Researchers have started investigating CBT as an alternative to antipsychotic medication to treat psychosis. This approach has the advantage of avoiding antipsychotic side effects altogether. This work is at an early stage and at the time of writing its effectiveness is not known, though initial results are promising.[11] CBT without antipsychotic medication, if proven to be effective, would not be suitable for everyone with psychosis. Nevertheless, it would widen treatment choice for some people and represent a major step forward in treating psychosis.

Summary

Antipsychotics are effective in treating schizophrenia and mania but can cause a range of side effects. Weight gain is a common and serious side effect, especially due to its impact on physical health. Various interventions can help and a psychiatrist will be able to offer advice on these. Many people taking antipsychotics can lose some weight with simple changes to their diet and lifestyle. Losing even a small amount of weight can have important health benefits. Ongoing research is attempting to find ways to better manage or ideally avoid this problem.

Further information

Body Mass Index: The best way to determine whether weight is ‘normal’, or should be regarded as overweight and unhealthy, is to calculate the Body Mass Index (BMI) using a person’s height and weight. An NHS online BMI calculator is available at: www.nhs.uk/Tools/Pages/Healthyweightcalculator.aspx

The BAP Guidelines on the management of weight gain, metabolic disturbances and cardiovascular risk associated with psychosis and antipsychotic drug treatment are available at: www.bap.org.uk/pdfs/BAP_Guidelines-Metabolic.pdf

An article reviewing these Guidelines is available at: www.bap.org.uk/articles/bap-guidelines-metabolic/

References

[1] De Hert M et al (2009). Cardiovascular disease and diabetes in people with severe mental illness position statement from the European Psychiatric Association (EPA), supported by the European Association for the Study of Diabetes (EASD) and the European Society of Cardiology (ESC). Eur Psychiatry 24(6):412-24.

[2] Cooper SJ et al (2016). BAP guidelines on the management of weight gain, metabolic disturbances and cardiovascular risk associated with psychosis and antipsychotic drug treatment.  J Psychopharmacol 30(8):717-48.

[3] McEvoy JP et al (2007). Efficacy and tolerability of olanzapine, quetiapine, and risperidone in the treatment of early psychosis: a randomized, double-blind 52-week comparison. Am J Psychiatry 164(7):1050-60.

[4] Lieberman JA et al (2005). Effectiveness of Antipsychotic Drugs in Patients with Chronic Schizophrenia. N Engl J Med 353:1209-1223

[5] National Institute of Health and Care Excellence (NICE) (2014). Clinical guideline [CG178] Psychosis and schizophrenia in adults: Treatment and management [CG178]. Last updated: March 2014.

[6] Bruins J et al (2014). The Effects of Lifestyle Interventions on (Long-Term) Weight Management, Cardiometabolic Risk and Depressive Symptoms in People with Psychotic Disorders: A Meta-Analysis. PLoS One 9(12): e112276.

[7] Green CA et al (2015). The STRIDE weight loss and lifestyle intervention for individuals taking antipsychotic medications: a randomized trial. Am J Psychiatry 172(1):71-81.

[8] Wing RR et al (2011). Benefits of Modest Weight Loss in Improving Cardiovascular Risk Factors in Overweight and Obese Individuals with Type 2 Diabetes. Diabetes Care 34(7): 1481–1486.

[9] Gossage-Worrall R et al (2016). STEPWISE – STructured lifestyle Education for People WIth SchizophrEnia: a study protocol for a randomised controlled trial. Trials 17:475

[10] Registration information for the RADAR trial is available here

[11] Morrison AP et al (2014). Cognitive therapy for people with schizophrenia spectrum disorders not taking antipsychotic drugs: a single-blind randomised controlled trial. The Lancet 383(9926), 1395-1403.

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Why and How Does It Happen?

Seroquel (Quetiapine) is an antipsychotic drug for the treatment of various mental health disorders, like schizophrenia, bipolar disorder, and depression. Unfortunately, the antipsychotic is known for a broad range of side effects. Among the adverse effects is that it can lead to weight gain. Seroquel weight gain is an issue patients are commonly facing. Discover what causes quetiapine weight gain, how much can be gained, and if losing weight on Seroquel is possible.

Does Seroquel Cause Weight Gain?

Quetiapine is an antipsychotic drug used mainly to treat schizophrenia. Some doctors recommend Seroquel for bipolar disorder as well. Currently, there are more than 600,000 patients who have been successfully treated by Quetiapine around the world.

But does Seroquel cause weight gain? Along with the effects of Seroquel on the conditions mentioned above, the medication poses a risk of body mass gain. According to the Neuropsychiatric Disease and Treatment Journal, quetiapine is believed to have a medium risk of weight gain. This information, however, should not be generalized as different patients have different experiences due to factors other than the medicine’s reactions. Some may experience a more significant body mass increase than others, while some patients may not gain weight at all. On average, it was mentioned that patients gain up to 5 lbs during short-term treatment and up to 8 lbs on the treatment course that is longer than 52 weeks.

It is essential to always consult a doctor before using Quetiapine or other antipsychotic medications to prescribe the most suitable type for existing health conditions.

How Seroquel Causes Weight Gain

Generally, antipsychotics tend to increase sugar and fat (lipid) levels in the blood. The imbalance of calorie intake and calorie consumption can cause it. While on antipsychotics, the brain stimulates appetite, especially for calorie-intensive foods such as donuts and fast food. Besides, it is common for psychotic patients to suffer from depression. Depression usually results in physical inactivity, which accelerates quetiapine weight gain.

The different ways people can gain weight as a result of quetiapine medication are given as follows:

Cravings

It is often noted that people who use antipsychotics like Seroquel crave foods that are high in sugars and fats.

Fast food is the quickest and cheapest option to satisfy these cravings and therefore contributes to Seroquel weight gain the most. In addition to this, sweet treats are also sought after but should be avoided to maintain weight.

Hormonal changes

The drug is believed to tamper with the hormone levels in the body. The alteration of hormones in the body directly impacts the weight that can be gained as a result of taking quetiapine. Seroquel has been found to interfere with the production of the thyroid-stimulating hormone, lowering the levels of (T4) thyroxine and (T3) triiodothyronine in the bloodstream.

Motivational Deficits

Seroquel MOA can lower dopamine levels and therefore result in demotivation, sleepiness, and laziness. This lack of motivation and grogginess can reduce the user’s physical activity resulting in low metabolism and calorie imbalance.

Fat Storage

Seroquel and weight gain connection is sometimes thought to be the result of the body changing the way it stores fat. The user may notice packing on fat in areas of the body that were previously slim. This may be caused by Quetiapine as well.

Slow Metabolism

One of the drug’s impacts on health is slowing a person’s metabolism, which means that even if a healthy diet and an exercise routine are maintained, it is still possible to gain body mass. The degree of severity of this Seroquel side effect varies from person to person. However, it is one of the common reasons people start gaining weight after taking Quetiapine and other similar drugs.

It is important that everyone will have a different experience when taking Seroquel depending on their tolerance levels and health and how these factors come together in their own experience.

Personal Factors That Influence Quetiapine Weight Gain

There are other factors that determine the amount of weight that can be gained as a result of Seroquel’s treatment. These are differently applicable to every individual and can, therefore, not be generalized. Since they are different for everyone, it may explain why some users gain more than others.

Individual Factors

Genetic makeup is one of the most important factors to consider and also the most personalized one. Quetiapine affects different gene types in different ways, which means that some users may face an immense increase in body mass while others may not find it changing at all.

Other Personal Factors Include:

• BMI (body mass index)
• Diet quality
• Sleep quality
• Physical activity
• Stress level

If sleep and diet qualities are well, and there are normal amounts of physical activity, a user will probably gain less than someone with high stress levels and poor sleep and diet quality.

Duration Of Administration

There seems to be a positive relationship between the duration of taking Seroquel and weight gain. The amount of weight a person gains in the first 12 months is the highest, after which the rate of body mass increase significantly slows down. This is because the body gets used to the treatment. However, when the treatment is carried on for an extended period, it is more likely that the user will notice a significant body mass increase over time.

Polytherapy

If patients use Seroquel with other drugs, it is possible that they may interact and exaggerate Seroquel weight gain. Some antidepressants, for example, have the side effect of body mass gain at similar rates to Quetiapine. It is advisable to consult a doctor regarding all the medications that one takes to ensure that this does not happen unless necessary. The doctor can then prescribe the correct antipsychotic drug that suits the patient considering their other medical intake.

Dosage

Most medications have a dose-weight relationship, which implies that increasing the dosage will increase the amount of pounds the user gains. Theoretically, this makes sense because antipsychotics gain control of the brain and nervous system. Increasing the dose should technically increase the control of the medication gains, so if the patient gains pounds on a low dosage, a higher dosage should make the gain even more significant.

However, it is not true for Seroquel. Patients taking quetiapine are lucky because increasing the dosage has no apparent relationship with an increase in BMI. That being said, it is still true that everyone has a different genetic makeup and is subject to different external conditions, which is why patients taking Quetiapine should still be cautious, consult a doctor and take the prescribed dosage.

Losing Weight on Seroquel: Is It Possible?

Some patients may experience Seroquel weight loss after stopping the medication. Other studies and clinical trials show that Seroquel has a neutral effect on body mass and that the increase in mass is not linked with dosage.

One such study analyzed 134 patients treated with quetiapine as monotherapy with controlled and open-label extension trials. In the beginning, their weight was assessed using the BMI and then again after 18 months. This test showed that no matter what the dose, Seroquel does not cause users to gain a lot. On the contrary, some patients with obesity were noted to have been losing weight on Seroquel during the 18-month trial. It may be because antipsychotic patients are advised to refrain from excessive eating and introduce some physical activity in their routines.

Managing Weight Gained From Quetiapine

The precise reason why antipsychotics lead to body mass gain has not yet been found, which is why there is also no sure shot way of protecting oneself from it. That being said, Seroquel weight gain is usually the result of a calorie imbalance where a person consumes more calories than they burn.

To manage Seroquel and weight gain, the user should maintain regular exercise, preferably more than their normal routine, as antipsychotics slow the body’s metabolism. Also, patients should find cheap and healthy alternatives for fast food. Fast food is the quickest and most affordable way to satisfy calorie cravings. If healthier options are just as readily available, they should be chosen instead. It may be done by making a meal plan.

The best way to tackle this problem of increase in body mass is a complete shift in lifestyles.

Healthy Eating

Ex-patients of Quetiapine who have gained pounds usually try to find a substitute with the help of a doctor. Unfortunately, this is not of much use as the body mass has already been changed.

Instead, one should try their best to live a healthy lifestyle by eating healthy. Antipsychotics increase sugar levels in the blood. This is dangerous for the heart and is also why Seroquel and diabetes are often linked. After completing the treatment, users should choose foods that are low in fats, sugars, and cholesterol. It is beneficial for heart and body health.

Regular Exercise

Secondly, daily exercise should be a part of the routine for patients who are tapering off Seroquel. This will help burn extra calories. Daily workouts eventually lead to weight loss, confidence, boost energy, strength, and motivation. All these benefits improve the mental and physical condition of the patient.

In addition, most doctors advise taking Quetiapine before bedtime, as the patient can sleep through the hunger pangs and cravings. This way, one can avoid unnecessary calorie intake. Finally, patients should keep in touch with their healthcare providers and monitor their health condition regularly. Regular medical assessment can prevent not only body mass increase but Seroquel misuse and abuse cases as well.

In the case of quetiapine abuse physician’s advice is to schedule an appointment with an addiction treatment expert. They will consult a patient about suitable rehabilitation options in the area and select the best facility together.

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Page Sources

1. Maguire, G. A. (2000). Impact of antipsychotics on geriatric patients: efficacy, dosing, and compliance. Primary care companion to the Journal of clinical psychiatry, 2(5), 165. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC181134/
2. Findling, R. L., Pathak, S., Earley, W. R., Liu, S., & DelBello, M. (2013). Safety, tolerability, and efficacy of quetiapine in youth with schizophrenia or bipolar I disorder: a 26-week, open-label, continuation study. Journal of child and adolescent psychopharmacology, 23(7), 490-501. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3778946/
3. Brecher, M., Leong, R. W., Stening, G., Osterling-Koskinen, L., & Jones, A. M. (2007). Quetiapine and long-term weight change: a comprehensive data review of patients with schizophrenia. Journal of clinical psychiatry, 68(4), 597-603. https://pubmed.ncbi.nlm.nih.gov/17474816/
4. Dayabandara, M., Hanwella, R., Ratnatunga, S., Seneviratne, S., Suraweera, C., & de Silva, V. A. (2017). Antipsychotic-associated weight gain: management strategies and impact on treatment adherence. Neuropsychiatric disease and treatment. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5574691/
5. Werneke, U., Taylor, D., & Sanders, T. A. (2013). Behavioral interventions for antipsychotic induced appetite changes. Current psychiatry reports, 15(3), 347. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3586399/
6. Zhang, Z. J., Yao, Z. J., Liu, W. E. N., Fang, Q. U. N., & Reynolds, G. P. (2004). Effects of antipsychotics on fat deposition and changes in leptin and insulin levels: magnetic resonance imaging study of previously untreated people with schizophrenia. The British journal of psychiatry, 184(1), 58-62. https://pubmed.ncbi.nlm.nih.gov/14702228/
7. Fava, M. (2000). Weight gain and antidepressants. Journal of Clinical Psychiatry, 61(11), 37-41. https://pubmed.ncbi.nlm.nih.gov/10926053/

Published on: February 19th, 2020

Updated on: April 23rd, 2021

About Author

Dr. Ahmed Zayed

Dr. Ahmed Zayed has degrees in Medicine and Surgery and is a graduate of The University of Alexandria. Dr. Ahmed Zayed has a passion for writing medical and healthcare articles and focuses on providing engaging and trustworthy information to readers.

Medically Reviewed by

Michael Espelin APRN

8 years of nursing experience in wide variety of behavioral and addition settings that include adult inpatient and outpatient mental health services with substance use disorders, and geriatric long-term care and hospice care.  He has a particular interest in psychopharmacology, nutritional psychiatry, and alternative treatment options involving particular vitamins, dietary supplements, and administering auricular acupuncture.

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Checking myths

11/14/22

Daniil Davydov

medical journalist

Author profile

In 2017, 3. 4% of the world’s population suffered from depression, i.e. 264 million people.

At the same time, the cures for this disease are surrounded by many myths. Antidepressants are accused of ineffectiveness and severe side effects, but often the problem is not with the drugs themselves, but with their misuse.

We collected 8 myths about antidepressants and found out how close they are to the truth.

Go see a doctor

Our articles are written with love for evidence-based medicine. We refer to authoritative sources and go to doctors with a good reputation for comments. But remember: the responsibility for your health lies with you and your doctor. We don’t write prescriptions, we give recommendations. Relying on our point of view or not is up to you.

Myth 1

Antidepressants almost never help

Most likely, this myth arose due to the fact that antidepressants do not work in all patients – so even some doctors and scientists doubt their effectiveness. However, antidepressants cannot be called ineffective, there are just important nuances in the use of these drugs.

Antidepressants are a class of drugs that normalize the level of neurotransmitters, that is, chemicals that help nerve cells in the brain exchange information.

What are Antidepressants – International Drug Database RxLis

What Medications Help with Clinical Depression in Adults – International Primer for Physicians UpToDate

How Antidepressants Help Pain – Mayo Clinic Bulletin

All antidepressants used to treat depression in adults , work – The Lancet

Who Antidepressants Help and Who Don’t – Clinical Guidelines for British PhysiciansPDF, 141 KB

These medicines help people whose problems are due to a deficiency or excess of neurotransmitters. Antidepressants reduce symptoms of depression, obsessive-compulsive disorder, generalized anxiety disorder, post-traumatic stress disorder, and bipolar affective disorder.

There is evidence that antidepressants are effective for chronic pain. Antidepressants increase the amount of neurotransmitters in the spinal cord, which reduces pain signals.

Most specialists have no doubts that antidepressants work. For example, according to the British Royal College of Psychiatry, 50-65% of people with depression who take antidepressants feel better – compared with 25-30% of those who take a placebo.

However, there are situations where the benefit of antidepressants is questionable. For example, antidepressants are good for treating moderate to severe depression, but do not work well for people with mild depression – psychotherapy is more suitable for them.

And there are situations when these medicines were prescribed by mistake. Then antidepressants really won’t help.

When antidepressants don’t help

Sergey Divisenko

psychotherapist

There are three cases when antidepressants most often cause problems.

The antidepressant didn’t work because the doctor prescribed the wrong dose. The minimum doses of these drugs do not help in half of the cases. Then competent doctors increase the doses to those recommended in clinical guidelines, while illiterate ones refuse them.

Sometimes, in order for antidepressants to work, they need to be augmented—i.e., enhanced—with other classes of drugs. For example, second-generation antipsychotics, or normothymics, that is, drugs that stabilize mood. If this is not done, the person taking antidepressants will not feel relief.

The antidepressant didn’t work because the doctor misdiagnosed and was trying to treat a condition that these drugs don’t work for. To help a person, one had to either use other drugs or use non-drug methods of treatment: for example, psychotherapy, transcranial stimulation, or electroconvulsive therapy.

For example, in bipolar disorder, symptoms can be very similar to depression or anxiety. But with bipolar disorder, antidepressants help only if they are used together with other drugs – mood stabilizers. By themselves, they will either work for a short time, or they will not work, or they can cause a phase inversion – that is, a person will switch from a depressive phase to a manic one.

The patient was not helped by a particular antidepressant, but another might. Antidepressants differ in the principle of action – on this basis they are divided into classes. It happens that one antidepressant does not work, but another from the same or another class helps. If the treatment does not work, you should not stop drug therapy, but continue to look for a drug that will help this particular patient.

Myth 2

Antidepressants only relieve symptoms, but do not eliminate the cause of the disorder

In most cases, this is not a myth. However, in some situations, antidepressants act on the cause of the disorder.

Depression is a heterogeneous disease. Experts identify a different number of subtypes of depression – from 4 to 12. But for our purposes, depression can be divided into two large subtypes.

American Criteria for Depressive Disorders – A Handbook for Psychiatrists DSM-5PDF, 32 MB

Understanding Depression – An International Primer for Physicians UpToDate

illness, not associated with depression. Disorders that can be attributed to this group are more common.

If these causes affect a person long enough and he does not understand how to deal with them, depression may develop. In this situation, antidepressants act as drugs that alleviate the symptoms of the disease. To influence the cause of the problem, psychotherapy is needed.

Depression provoked by internal causes. Approximately 7% of people with depression have the correct way of thinking, there are no internal conflicts and injuries, and there are no serious illnesses. In this situation, the cause of depression is the lack of neurotransmitters: serotonin, norepinephrine and dopamine in the synapses of brain nerve cells. In such people, the antidepressant acts precisely on the cause of the disease, that is, it corrects the production of serotonin in neuronal synapses.

Myth 3

As soon as it gets better, you can stop taking the antidepressant

This is also not entirely a myth – it would be more correct to call it a belief that is true only for some, but not for all patients with depression.

It is generally advised to continue taking antidepressants for at least six months after remission. If the duration of the disease is short, that is, the person was ill for about two weeks, then for the onset of remission, one or two months usually need to take medication. If the duration of the disease is long, from several months or years, then more time is required for the onset of remission. It’s impossible to say exactly how much: different people with depression have different recovery times.

Some people have recurrent depression. In this case, the period during which you need to take the medicine depends on how many bouts of depression have already been during your life. If more than three, it is recommended to take antidepressants for several years or for life.

Myth 4

Antidepressants cause addiction

Perhaps the roots of this myth are that some people need to take depression medication for life. And at the beginning of treatment, some patients have to increase the dose. But in fact, antidepressants do not cause either true physical or drug dependence.

True physical dependence on a drug is a situation where a person becomes so addicted to a drug that when it is withdrawn, the symptoms of the disease sharply increase. People who are dependent on the drug have to increase the dosage, otherwise the drug stops helping.

What is True Drug Addiction—Bulletin of the National Institute for the Study of Drug AbusePDF, 7 MB

What is Drug Addiction—Bulletin of the American Psychiatric Association

Drug dependence may include physical dependence on a drug. But this addiction has a unique feature. Dependence can also develop in a healthy person who used the drug not to recover, but to enjoy it. But when he tries to quit the drug, he still experiences physical suffering, which is called the withdrawal syndrome. As a result, a person is forced to look for a new dose of a drug.

Although a person who takes antidepressants to treat depression gets better, the drugs themselves are neither pleasurable nor addictive. Taking them as drugs is useless.

Of all the drugs that are used in psychiatry, true physical dependence can only be caused by psychostimulants that activate mental activity and anti-anxiety, that is, benzodiazepine tranquilizers. Antidepressants are not included in this list, because there is no need to increase the dosage of correctly selected drugs from this group.

However, some people who stop taking antidepressants early sometimes experience withdrawal symptoms such as nausea, hand tremors, and some feel “shocks” in the head, similar to the sensations of an electric shock. Depressive symptoms return to patients who need to take the medicine for a very long time.

Antidepressants are sometimes abused, but they cannot cause addiction – Journal of Modern Psychiatry

To avoid unpleasant consequences, stop taking antidepressants only if the attending physician says that they are no longer needed. But even in this situation, it is necessary to cancel antidepressants slowly, that is, gradually reducing the dose. This will help avoid unpleasant side effects.

Myth 5

A person on antidepressants becomes lethargic and loses interest in life

This popular myth is based on real but outdated data.

These mental changes are seen in patients taking first-generation tricyclic antidepressants such as amitriptyline. It has a sedative, that is, a sedative effect. A person who takes high doses of amitriptyline can indeed become sleepy and indifferent to the outside world.

Amitriptyline – Sedative – Drugs.com International Drug Database

SSRIs do not sedate – Drugs.com International Drug Database

Current second-generation antidepressants that are recommended to start treatment with, such as selective serotonin reuptake inhibitors, or SSRIs almost never cause drowsiness and apathy.

On the contrary, in most people with depression they return interest in life.

Sometimes SSRIs do cause drowsiness, but this has not yet been proven

Sergey Divisenko

psychotherapist

It is believed that in rare cases, modern antidepressants can provoke SSRI-induced apathy. But this condition is extremely rare.

And even then psychiatrists still doubt that the cause is precisely in the drugs, and not in the patient’s condition. After all, some people during the time of taking antidepressants may develop other adverse mental states in which apathy occurs: for example, schizotypal disorder, which was not noticed before.

Myth 6

Antidepressants have many side effects

This is partly true: both SSRIs and antidepressants from other groups have side effects. But it is quite possible to deal with them.

At the beginning of treatment, when people first start taking antidepressants, many complain of increased anxiety, dry mouth, nausea, and trouble sleeping. But after a few days or weeks after the start of the course of treatment, these symptoms usually disappear. If the side effects do not stop, it makes sense to consult a doctor – he will replace the antidepressant.

Dealing with antidepressant side effects – tips from the Mayo Clinic staff

Here’s what to do before the side effects go away:

1. Take antidepressants with meals, unless the instructions say otherwise, so the antidepressant will be less annoying stomach;
2. put a bottle of clean water on the work table – if your mouth is dry, you can take a sip. Unsweetened lollipops and chewing gum also help with dry mouth;
3. take a walk for at least half an hour before going to bed to make it easier to fall asleep. If you can’t sleep at all, you can ask your doctor to pick up sleeping pills.

The second most common side effect is an increase in anxiety at the start of antidepressant use. To avoid this problem, psychiatrists resort to two effective methods:

1. titrate the dose – that is, start with the minimum dose of the antidepressant and then gradually increase it;
2. at the beginning of the reception, sedatives – tranquilizers are prescribed together with the antidepressant.

The third common side effect of SSRIs, especially sertraline, known as Zoloft, and escitalopram, better known as Cipralex, is decreased libido. Approximately 20-30% of people taking antidepressants from this group experience a decrease in sexual desire to one degree or another. At the same time, it is difficult to say how much the drugs are to blame, because approximately 35-50% of people with depression have already experienced sexual dysfunction.

Many people with depression experience sexual dysfunction before starting antidepressants – Harvard Medical School Bulletin

Switching to another antidepressant usually helps, but many people prefer to wait until the medication can be stopped. In some cases, psychiatrists prescribe antidepressants from other groups in addition to the libido-lowering antidepressant. Sometimes it helps to regain interest in sex.

Myth 7

Weight gain due to antidepressants

This is not a myth, but a half-truth. There are both antidepressants that contribute to weight gain, and those that do not have a similar effect.

The most common complaint about weight gain during treatment is people taking the tetracyclic antidepressant mirtazapine, which actually increases appetite. Another weight gaining antidepressant is paroxetine, better known by the trade name Paxil. But “Zoloft” and “Cipralex” do not contribute to weight gain.

If a patient feels that an antidepressant is causing them to overeat, it is wise to consult a doctor and discuss a change of drug.

Myth 8

Antidepressants are expensive

True, but not for all patients. Most people can cure depression and not go broke.

Antidepressants from different groups vary greatly in price. There are both very expensive drugs and relatively low-cost drugs among them. At the same time, both of them work equally well. However, there are situations when a cheap antidepressant cannot be dispensed with.

On the left – inexpensive “Zoloft” for 327 R, a drug based on sertraline, on the right – the most expensive antidepressant “Ixel” based on milnacipran for 2453 R

For example, there is a good antidepressant venlafaxine. The maximum dose of venlafaxine can reach up to 375 mg per day. If these are inexpensive tablets of a domestic manufacturer, then a course of treatment for a month costs about 2000 R. But sometimes inexpensive tablets are not very well tolerated: they cause headache, nausea, sweating, tachycardia, that is, rapid heartbeat. In such cases, you need to switch to a prolonged form of venlafaxine – “Venlafaxine Retard”, or “Velaxin XR”. But this drug is more expensive: a course of treatment will cost about 5000 R per month.

The cost of a course of treatment with another good drug, Ixel, based on milnacipran, which is tolerated with minimal side effects, can reach up to 12,500 R. But, unfortunately, there is nothing to replace it, because this medicine does not yet have generics.

For comparison, on the left is a venlafaxine-based immediate-release drug for 443 R, on the right – with a sustained release in the same dosage for 1756 R. The price varies very much

Five unexpected factors affecting your weight

• Kirsty Brewer
• BBC

April 28, 2018

Sign up for our Context Newsletter to keep you up-to-date. Image caption,

Jackie (left) and Gillian are twins but have very different body mass indexes. Here are five unexpected factors that may be affecting your weight.

1. Gut microbiome

Gillian and Jackie are twins, but one weighs 41 kg more than the other.

Professor Tim Spector has been following their development for 25 years as part of the UK’s nationwide twin program. He believes that the difference in their weight is due to tiny microorganisms – microbes that live in our intestines.

“Every time you eat something, you feed hundreds of trillions of microbes. You never eat alone,” he explains.

Stool samples taken from each of the sisters revealed that the thinner Gillian had a very diverse gut flora, while Jackie had very few gut microbes.

• Kefir improves intestinal microflora. Scientific evidence
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• Scientists: obesity contributes to the development of 11 types of cancer

could be,” says Professor Spector, who bases his findings on a study of five thousand people.

Image copyright, Science Photo Library

Image caption,

Human gut bacteria

Diversifying your microbiome requires eating a healthy and varied diet rich in various types of fiber.

As the professor points out, most Britons consume only half the required amount of fiber.

Healthy fiber sources:

• bran cereal
• fruits, including berries and pears
• vegetables, such as broccoli and carrots
• beans
• pulses
• nuts

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Why do some people follow a strict diet, exercise regularly, but never lose weight, while others do almost nothing but stay in good shape?

Cambridge University scientists believe that about 40-70% of our weight depends on the set of genes that we inherited from our parents.

“It’s a lottery,” admits Prof. Sadaf Farooqi. “It’s pretty clear now that genes affect our weight, and if you have a defect in certain genes, that might be enough to make you fat.”

These specific genes can influence appetite, portion size, and even what kind of food a person prefers. Genes also determine how we burn calories and whether our body is able to distribute fat efficiently.

There are at least 100 weight-related genes, including the MC4R gene, which controls hunger and appetite.

Experts believe that one person in every thousand has a defective variant of the MC4R gene, which means that its owners tend to be hungrier and crave more fatty foods.

“You can’t do anything about your genes, but some people will benefit from knowing that their genes increase their chances of getting fat. Knowing this, they can change their diet and exercise,” says Professor Farooqi.

3.

Is dinner for the enemy?

There is some truth in the old saying, “Eat breakfast yourself, share lunch with a friend, and give dinner to an enemy”, but not in the way you might think.

Obesity expert Dr. James Brown says that the later we eat, the more likely we are to gain weight. And not because we are less active at night, as many people think, but because of our internal clock.

“Our bodies are wired to handle calories most efficiently during the day when it’s light, not at night when it’s dark,” he explains.

It is for this reason that people who work shifts or work different hours may find it harder not to gain weight.

At night, our body hardly digests fats and sugars, so it is better to eat something high-calorie before seven in the evening if you want to lose weight or not gain weight.

Image copyright Getty Images

Image caption

Eggs for breakfast are good!

Over the past ten years, the national average for dinner in Britain has moved from 5:00 pm to around 8:00 pm, and this has also contributed to the fact that more people are overweight, says Dr. Brown.

But even with today’s pace of life, and no matter what hours you work, there are things you can control to be in good shape.

According to Dr. Brown’s rules, you can’t skip breakfast or eat just one slice of toasted bread in the morning.

For breakfast, eat something that contains protein, some fat and carbohydrates, such as eggs and a piece of wholemeal bread. This way you will feel full longer.

This should be followed by a substantial, nutritious lunch and a lighter supper.

4. How to fool your brain

Image copyright, Getty Images calories.

Behavioral scientist Hugo Harper offers several ways to subconsciously change your eating habits so you don’t count calories all the time.

For example, it will be more effective not to rely on your own willpower, but simply to remove something from your field of view that whets your appetite.

Therefore, do not lay out unhealthy snacks in plain sight, rather put a bowl of fruit or something healthy there.

Do not sit in front of the TV with a pack of cookies – put as many cookies on the saucer as you are going to eat (maximum – two), and with this amount go to the living room.

Dr. Harper also advises to replace rather than cancel something completely, especially if you love it – just choose a low-calorie option.

For example, drink low-calorie carbonated drinks. Or reduce your serving size. This will be more effective than trying, for example, to completely get rid of the habit of drinking tea with chocolate chip cookies.

Image copyright, Getty Images

Image caption,

Be patient, Bobik, and the donut will be yours!

“People tend not to notice the difference if their portion is reduced by 5-10%,” says Harper.

In addition, people often eat mechanically without even thinking about what they are eating, so choosing a smaller plate or following the recipe on the package will prevent mindless calorie intake.