Arya M. Sharma, MD

To round up my posts on the obesity articles of the January issue of the Canadian Journal of Psychiatry, I would like to briefly highlight some of my comments published in an editorial I wrote for this issue.

Reader will by now be familiar of the many links between obesity and mental health problems. With regard to this relationship, I write:

“Thus, while it is not complicated to appreciate the fact that mental health is an important determinant of body weight, it is also important to recognize that this relationship is complex.

While the links between mental illness and weight gain can be as simple as the induction of ‘hedonic hyperphagia’ with the use of ‘atypical’ antipsychotics, they can be as complex as the link between early childhood trauma and binge eating disorder or the recurrence of addictions following bariatric surgery.”

I conclude with what I have said often enough:

“It is therefore of considerable importance that mental health practitioners familiarize themselves with the complexity of obesity and its management whilst, by the same notion, anyone attempting to manage obesity requires at least basic competencies in the art and science of assessing mental health.

Indeed, nowhere are mental and physical health closer related to one another than in the context of the mental health and obesity epidemics – close enough perhaps to consider them close cousins, if not siblings. While reducing the burden of mental health on Canadians may well go a long way in improving their physical health, reducing the burden of obesity on Canadians without also addressing their often underlying mental health problems will prove virtually impossible.”

I do hope that this issue of the Canadian Journal of Psychiatry, will draw more attention to this relationship and will hopefully receive feedback on this from my readers and colleagues.

AMS
Edmonton, Alberta

p.s. Readers in Edmonton may be interested in attending a CIHR Café Scientifique: Is Canada ignoring obesity in men? Wednesday, February 15, 2012, 5:00 p.m. to 7:00 p.m. Edmonton City Hall (Hosted by the CIHR Institute of Gender and Health and the Canadian Obesity Network).

Continuing my posts on the recent articles on obesity and mental health published in the January issue of the Canadian Journal of Psychiatry, I now turn my attention to a paper by Valerie Taylor and colleagues on the many links between mental health issues and obesity.

Whilst in the previous post I have focussed on the relationship between psychiatric medications and weight gain, a problem that is common knowledge to the mental health community, this article highlights many of the lesser known links between mental health problems and excess weight. These include interesting neurobiological, psychological, and sociological factors, that are now increasingly understood.

For e.g.

“‘Atypical’ depression, a type of major depressive disorder characterized by an increase in the need for sleep and food, may actually characterize the most ‘typical’ presentation of major depression For the majority of people with depression, therefore, a diagnosis of major depression is synonymous with a phenotype that increases vulnerability towards weight problems.”

In fact,

“The neurobiology of depression [also] confers increased risk of obesity. The most common biological perturbation associated with depression is an increase in cortisol. This increase, and the hypothalamic pituitary adrenal axis abnormalities that accompany it, is similar to changes seen in Cushing syndrome, an endocrinological illness caused by an increase in cortisol that is characterized phenotypically by excessive visceral weight gain. While levels of cortisol found in major depression disorders are much lower than that of Cushings, the biological impact of excess cortisol is similar; a predisposition towards increased deposition of centrally located adipose tissue.”

In addition mood disorders often affect sleeping behaviour, which in turn affects important regulators of appetite and metabolism like ghrelin, leptin, adiponectin, and other hormones. Moreover, chronic inflammation may play a role in both major depression and obesity.

In the case of schizophrenia, primary negative symptoms like amotivation, which can be observed even in the earliest stages of the illness, may lead to reduced physical capacity and altered self-perception. Hypodopaminergic activity may in part explain increased propensity for substance use, especially cannabis, which can promote hyperphagia.

There is an increasingly recognized association between obesity and attention deficit disorder, and it may well be that impulsivity may play an important role in overeating.

Also,

“Poor planning and an inability to delay reward, processes largely mediated by the pre-frontal cortex, may lead individuals with ADHD to over-consume highly palatable, fattening foods. A related hypothesis is that individuals with low intrinsic dopamine activity in brain areas mediating reward may attempt to compensate by using various reinforcing behaviors including increased food consumption. This has been termed the “reward deficiency syndrome” and has been described separately in ADHD and in obesity suggesting that ADHD and obesity may thus reflect different manifestations of a single biological change related to low dopamine activity in prefrontal attentional areas and brain reward pathways.”

The paper also discussed findings showing that ADHD is associated with more media consumption, less participation in physical activity and organized sports.

Finally, the paper examines the literature on the relationship between obesity and childhood adverse events like sexual, mental, physical abuse and emotional neglect, which can have important impacts on the hypothalamic-pituitary-adrenal axis as well as on sex hormones that may promote fat accumulation.

“The use of food as a coping strategy or a “self-soothing behavior” is seen in both trauma patients and in those with mood disorders, and it may be related to the use of food to modulate neurotransmitters involved in affect control. Most work in this area has focused on serotonin and dopamine, both of which play a critical role in both eating behavior and mood regulation. It may be that the ability of certain foods to temporarily boost mood can create a behavioral cycle where food is consumed to control feelings of sadness.”

As readers of these posts may be well aware,

“The relationship between trauma and weight is especially evident during weight loss treatment programs and in bariatric surgery programs, a past history of trauma can be a harbinger of post-operative problems. Food and weight gain in response to abuse may be related to a desire to become “bigger” to be able to defend against an abuser, it may have been a way to change appearance when an individual inaccurately felt they were somehow provoking the abuse or it may have become a surrogate comfort mechanism when appropriate supports failed.”

Thus, clinicians (and patients) must be aware of the complex relationship between obesity and mental health issues that go well beyond just the issue of weight gain with psychiatric medications (which of course further compound these issues).

All the more reason, why all health professionals called upon to manage obesity should be well versed in recognizing and helping patients address mental health problems.

AMS
Edmonton, Alberta

Following yesterday’s post on the issue of weight gain and metabolic syndrome seen in kids treated with second-generation antipsychotics (SGAs), today, I look at another paper by Silvia Alessi-Severini and colleagues from the University of Manitoba published in the same issue of the Canadian Journal of Psychiatry.

This paper examines the use of antipsychotics in children and adolescents (aged 18 years or younger) based on data collected from the administrative health databases of Manitoba Health and the Statistics Canada census between the fiscal years of 1999 and 2008.

Over these 10 years, prevalence of antipsychotic use increased with the introduction of the SGAs from 1.9 per 1000 in 1999 to 7.4 per 1000 in 2008.

The male-to-female antipsychotic usage ratio increased from 1.9 to 2.7 as the male youth population represented the fastest-growing subgroup of antipsychotic users in the entire population of Manitoba.

Notably, the paper finds that total number of prescriptions also increased significantly despite the lack of approved indications in this population.

More than 70% of antipsychotic prescriptions to children and adolescents were written by general practitioners with the most common diagnoses being attention-deficit hyperactivity disorder and conduct disorders. In fact, the use of antipsychotics in combination with methylphenidate (ritalin) increased from 13% to 43%.

Thus, it appears that there is extensive off-label use of SGAs in kids and youth in Manitoba (and likely in other provinces), a finding that is of concern not least because of the significant (30-fold increased) risk of weight gain and metabolic syndrome associated with the use of these compounds.

So, while there is no doubt that these drugs may provide important clinical benefits in kids who do need them, it is hard to imagine that this degree of off-lable prescription is indeed warranted.

Again, I would love to hear from my readers regarding experience with these medications in children and youth.

AMS
Ottawa, Ontario

In the first post on several articles on obesity and mental illness published in the January issue of the Canadian Journal of Psychiatry, I would like discuss the paper by Constadina Panagiotopoulos and colleagues form the University of British Columbia, that looks at the prevalence of metabolic syndrome (MetS) and its components in children and youth treated with second-generation antipsychotics (SGA).

The study sample consisted of 117 SGA-treated and 217 SGA-naive children prospectively recruited from the Psychiatry Emergency Unit at British Columbia Children’s Hospital.

MetS was present in 19% of SGA-treated kids (including 2 cases of newly discovered type 2 diabetes) compared to less than 1% of SGA-naive kids showing an almost 30-fold increased risk of MetS in the former.

Among all of the various predictors studies, being treated with SGA and being male were the two major predictors.

Furthermore, the authors note that measurement of waist circumference as a measure of abdominal adiposity was more sensitive (92.9%) than BMI (68.8%) in detecting MetS, while fasting glucose of 5.6 mmol/L or more and HDL-C of 1.03mmol/L or less were most specific (94.1%).

It is perhaps also of interest that overall prevalence of overweight and obesity, although higher in the SGA treated kids, was almost twice as high in the general paediatric populations reported in British Columbia. This suggests that having a mental health condition alone already puts these kids at increased risk for obesity, a risk that is further drastically compounded by the use of SGA.

The authors conclude that standardized metabolic testing may be indicated in children treated with SGA and efforts to mitigate this risk should be started early in treatment.

While these ’side-effects’ are concerning and it may well be that increased risk of MetS may put these kids at long-term risk for cardiovascular problems, there are often poor alternatives for these children, who require such medications.

On the other hand, as I will discuss in tomorrow’s post, there is considerable ‘off-label’ use of antipsychotic and other psychiatric medications in kids, a practice that may require careful scrutiny given these findings.

AMS
Edmonton, Alberta

Before, I get into the promised review of the obesity papers in the January issue of the Canadian Journal of Psychiatry, I would like to set the stage by clarifying that I certainly do not consider obesity to be a mental illness.

Thus, I very much opposed the notion (proposed by some) to include obesity as a diagnosis in the the upcoming 5th edition of the Diagnostic and Statistical Manual of Mental Disorders and was very much relieved to see this proposal being rejected.

Although the brain is the ultimate regulator of energy balance and there is a significant and relevant relationship between mental health and the propensity for weight gain (as will be discussed in forthcoming posts), obesity itself is hardly a mental illness. In fact, the vast majority of overweight and obese individuals do not have any mental health problems that would be in any form or fashion differentiate them from the non-obese population.

This situation, however, is markedly different in the ‘weight-loss-seeking’ obese population, where an increased prevalence of mental health problems has been well documented. This is why clinicians dealing with obese patients, particularly those seeking obesity treatment need to be well versed in the diagnosis and basic principles of managing mental health problems.

What is also indisputable is the fact that for patients with mental health problems, weight management can prove particularly challenging.

When we consider how difficult implementing and maintaining the often complex regimens for weight management can be for most people, it should be no surprise that adding the additional burden of mental illness can make such efforts almost impossible.

Add to this the fact that many of the psychiatric medications can further promote weight gain, and we can easily see why obesity has become such an important challenge in light of the increasing use of such medications (whether indicated or not).

Remember, that in this discussion we are talking about significant and major mental health problems like depression, bipolar disorder, psychosis, anxiety, PTSD, or addictions. We are not talking about simple ‘overeating’ associated with stress, boredom, social pressures, or other factors that have little to do with severe mental health problems and should rather be considered completely normal and natural human behaviours.

Thus, it is important that in any discussion of the clinically important relationship between obesity and mental illness, we make sure that we do not add the stigmal of the latter to the already widespread stigma of the former.

In other words, while mental health problems can undeniably contribute to or complicate obesity, let us by no means assume that everyone with excess weight must somehow have a mental health problem - the vast majority of overweight and obese individuals do not.

Nonetheless, clinicians need to be well aware of this relationship, be able to identify it where it exists, and provide or refer individual obese patients, for whom this may well be a problem, to the appropriate services.

I would certainly love to hear from any readers who have experienced that addressing their mental health issues did indeed help them better manage their weight or from readers where their mental health problems are making contributing to their weight gain.

AMS
Saskatoon, Saskatchewan