Organized Chaos - Volume 3
On Medication
by Eda Gorbis, Ph.D., MFCC
1. Is the weight gain an unavoidable side effect of the medications used to treat OCD? Why?
[Other than CBT], OCD is treated with SSRIs. In complicated cases a combination of medication is used. Often SSRIs are used in combination with antipsychotic medications. One of the undesirable side effects of SSRIs is weight gain. Some SSRIs are likely to cause more weight gain than others.
Medications usually have sedative effects that lead to increased sleep and decreased amount of activity. Therefore, fewer calories are burned, which leads to weight gain.
2. Which medications used to treat OCD cause weight gain?
SSRIs are more likely to cause weight gain than other antidepressants. One study compared the effects of Prozac, Paxil, and Zoloft. Results showed that Paxil caused more weight gain than Prozac and Zoloft. Paxil causes up to 25% more weight gain. Other studies show minimal or no weight gain with Celexa. More complicated OCD cases will not improve with SSRIs. So other drugs need to be added to augment the response. Drugs that are sometimes added include: olanzapine (Zyprexa), risperidone (Resperdal), Quitiapine (Seroquel), and ziprasidone (Geodon).
3. What other drugs besides the anti-obsessionals (SSRIs) that are used to treat OCD can cause weight gain?
Antipsychotic medication, such as, Zyprexa, Risperdal and Seroquel, are the most common non anti-obsessional medications used to treat OCD. All three can cause weight gain as well. Researchers have looked specifically at adolescents and found that Zyprexa and Risperdal caused significant weight gain. Average weight gain was significantly higher for the Risperdal group than for the Zyprexa group. Patients on Haldol didn't change. Other data suggest that Geodon does not cause weight gain in most individuals. Authors noted that adolescents are more likely to gain weight on medications than adults.
4. What effects do these medications cause on the body that contributes to weight gain?
Medications create sedation. This requires more sleep and rest, which in turn causes a decreased amount of activity. SSRIs were noted to create a craving for carbohydrates. Patients treated with SSRIs increase carbohydrate intake after beginning treatment. Very often patients do not report that they are eating more than before. It is tempting to hypothesize that there is a drug-induced decrease in metabolism. However, there is no substantial data that gives evidence to this hypothesis. There is only one paper that proves such change in metabolism. Authors of this paper state that weight fluctuations reflect changes between caloric intake and caloric expenditure. Weight gain is due to increased amount of calories consumed. Resting metabolic rate reflects the number of calories utilized by the individual. A resting state represents at least 70% of the daily calories burned by individuals. So, a reduction in metabolic rate occurs, an individual gains weight without increasing calories because they are resting more.
5. Is weight gain unavoidable when using these drugs?
"Yes" and "no." Weight gain is due to the sedative effects of the medication and the decrease in metabolic rate. If a therapist anticipates weight, they will usually initiate an anticipatory precognitive intervention prior to weight gain. The therapist will start preparing patients for the possible weight gain They teach them ways of managing weight. The strategies include keeping a daily food diary, exercising more, and decreasing caloric intake, especially carbohydrates.
6. Do these drugs lower one's metabolism?
The results suggest that weight gain is at least partially due to decrease in metabolic rate. SSRIs affect the brain chemical called serotonin, which in turn affects appetite and food intake.
7. Do these medications affect men and women differently? How about adolescents vs. adults?
There is no empirical evidence to substantiate the answer that there is a difference in weight gain in men and women. Adolescents are more likely to have a greater weight increase. Because everybody's metabolism/body is different, it will respond differently to different doses of medication.
8. Do some medications have more of a propensity to cause weight gain than others?
Yes. Risperdal causes more weight gain than Zyprexa. Paxil causes up to 25% more weight gain than Prozac and Zoloft. Some studies also indicate that with Celexa weight gain is minimal or nonexistent. Those findings are tentative.
9. How can a person prevent or minimize weight gain?
Weight gain can be minimized or prevented with a specially tailored program. A doctor and patient have a partnership agreement in which patients agree to adhere to certain rules. The rules include behavioral interventions, such as, keeping a food intake diary and faxing it to the doctor on daily basis. This is done so that doctor can monitor the food intake and make necessary adjustments when needed.
10. Will diet and exercise affect weight gains caused by medication?
Yes. It is helpful if one has some kind of sport activity as a hobby. There are the two psychological motivators: avoidance of pain and desire of pleasure. People are more likely to do things that they enjoy. During exercise, endorphins are released that cause certain level of pleasure. This in turn increases the amount of activity. In my practice, I always use a slogan, "Mind over matter."
11. How do you deal with medication-induced weight gain in your practice? Do you introduce the topic when the patient begins taking the medication or do you wait until he has experienced a weight gain?
If I anticipate a weight gain in the patient, I introduce behavioral intervention prior to starting medication. It is important to prepare patients for the possible side effects, such as, weight gain. Also to teach them how to manage these effects. I start with educating patients about their diet and exercise. I explain what adjustments they may need to make to control their weight while on medication. I make a contract with a patient that they will keep a daily food diary and fax it to me.
12. Can weigh gain be prevented completely? How?
Weight gain is related to one's mind-body relationship. Adjustments usually need to be made to the diet. The amount of exercise done on a regular basis to control any weight gain that might accompany the taking of an SSRI is adjusted. Certain things, such as, heredity, can affect the results as well. It is always an interaction of biology and environment. A healthy diet and adequate exercise help manage the weight gain. It is important to note that effects of medications are very individual. What one body will do, another will not. Medication effects need to be discussed individually. In the same way that medication and its dosage need to be tailored to each individual.
13. Is there a way to eat to avoid gaining weight?What kind of diet do you prescribe?
I tell my patients to drink a lot of water (up to 10 glasses a day). Decrease the carbohydrate intake, and increase their consumption of protein. Eat whole grain foods. There are several other techniques that might be helpful.. For example, a patient needs to dedicate time to eating. This means no eating on the go. Furthermore, before sitting down for a meal, it is advisable to drink two glasses of water. Drinking water prior to eating curbs one's appetite. Drinking diet coke or coffee will decrease the appetite (caffeine tends to decrease appetite).
14. Does someone on SSRIs have to stop eating certain types and kinds of food?
Someone taking SSRIs should decrease his/her consumption of carbohydrates and eat more proteins as well as fruits and vegetables.
15. Will exercise help curb weight gain?
Exercise burns calories and, therefore, helps curb weight gain.
16. What types and how much exercise should someone do to control the weight gain?
I recommend 30 minutes of exercise about 4-5 times a week The type of exercise is not the most important thing. People are more likely to do something that they enjoy doing, like playing sports, going rollerblading or running. An exercise plan should be build around the sports activities one enjoys.
17. Does the weight gain ever level off or stop?
It doesn't stop. Some people are more genetically prone to gaining weight. So, they are more likely to gain more weight.
18. What suggestions do you give your patients for stabilizing their weight once they've lost the amount they wanted to lose?
Continue the program they used. It is about lifestyle changes. Once you've lost the weight, it does not mean you will stay this way forever. Once you go back to the old habits, you gain the weight back.
19. Are there any medications that someone can take to offset the weight gaining effects of SSRIs? Would you recommend using them? What are their side effects short term and long term?
If the weight gain is uncontrollable despite the behavioral intervention, talk to your psyhcopharmacologist. There are several medications that can help: Ritalin, Topamax, and Cytomel.
Eda Gorbis, Ph.D., MFCC
Assistant Clinical Professor, UCLA School of Medicine
Westwood Institute For Anxiety Disorders, Inc.
921 Westwood Blvd., Suite 223
Los Angeles, CA 90024
(323) 651-1199
Web Site: http://hope4ocd.com
