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mental health mondays :: big fat deal

well, the last few weeks have been kind of heavy in terms of all the information i've been throwing around on different mental disorders and the medications we can take to control them. so this week, i thought i'd focus a little more on one issue: psychiatric meds and weight gain.

as discussed in the last few posts, one of the things that worries people the most about taking medication for any mental disorder is the common understanding that these drugs will make you gain weight. in fact, a lot of patients stop taking their medications for exactly that reason- they simply can't handle the fact that dealing with depression, panic attacks or generalised anxiety involves the equally depressing spectacle of your body ballooning in size. ironically, weight gain as a side effect is likely to be mentioned in passing by a doctor if at all, when prescribing an anti-depressant. so if this is one of the most common reasons for discontinuing medications, why wouldn't it be part of the discussion on whether or not to take them to begin with? that has to do with prevailing attitudes about weight gain in general.

weight gain is not taken seriously as a side effect of medications, because, in this instance, it is largely seen as a question of vanity. and for many, that's exactly what it is. on the other hand, even if the concern is that one will be perceived as less attractive, or as becoming overweight, there are reasons to believe that others, whether they mean to or not, do judge people who are heavier more harshly than those who appear fit. there are also negative associations with sudden or ongoing weight gain- that one is lazy, indulgent, greedy, etc. the fact is that when most people see someone they know gaining weight, their first instinct is not to think that they may be on medications that are causing them to pack on pounds.

but weight gain is more than a problem of self-image and perception. everywhere, we are bombarded by messages that obesity is rampant, particularly in north america, but increasingly over europe as well. the dangers of being even moderately overweight are drilled into our heads in the same way that the dangers of nicotine were for decades. a billion-dollar industry thrives on our fears of weight gain, vaunting the benefits of "magic" foods to aid weight loss, low-calorie meals to control weight and restrictive diets of various sorts. and yet, when doctors are handing out medications, the topic of weight gain is treated as if it's frivolous. a bit of a mixed message to say the least.

as with all drugs, there is a benefit- liability analysis that should be done. if you're really depressed, medications may be your best option, but there are things that you should prepare yourself for, so that you can deal with them if they happen and weight gain is absolutely one of those. so here's a little primer on weight gain and mental meds. again, i'll specify that i'm not a doctor and, although i've made every attempt to draw my information from reputable sources, this shouldn't be taken as a medical opinion. consider it food for thought- that won't make you gain weight.

first off, there's the obvious question: will psychiatric meds make you gain weight?

yes- and no. many are known for their tendency to make you put on weight, but others show no significant evidence of weight gain compared to a placebo, while a few others actually tend to make you lose weight. whatever drug you've been prescribed, it's worth looking up the prescribing information sheet on line. these can get a bit dense in their language, but the information you need is in there- often with convenient charts to illustrate what the prevalence of side effects (including weight gain) were in clinical trials of the drug. this should at least tell you what you're up against.

which drugs are known to cause the most weight gain?

again, it varies from one med to another, but the worst offenders as a category are tricyclic anti-depressants and anti-psychotic drugs. modern anti-depressants, despite their reputation, are less prone to causing weight gain than tca's or other older anti-depressants like maoi's. even known offenders like paxil are less prone to causing spikes in weight than their older cousins. anti-psychotics and mood stabilisers, including anti-seizure meds used to control bipolar disorder, are very prone to causing weight gain, although the problems are often dosage-dependent (the more you take, the more you gain). there are no drugs that cause everyone to gain weight. it may happen, it may not. this is just a guide to which ones are most likely to cause this problem.

why do these drugs cause weight gain?

oh lots of reasons, some of which haven't been figured out yet. anti-depressants slow the body's metabolism, so that you're actually processing food less efficiently. in practice, that means that without changing a single thing about your eating and exercise habits, you'll be more likely to put on weight. studies indicate that tricyclics (which, again, have a worse profile than more modern drugs) can depress the metabolic rate by up to 10%. that means that your body will gain an extra pound every 7-10 days using exactly the same routines that have allowed you to maintain a consistent weight previous to starting anti-depressant medication. think about that and do the math. a pound every ten days spread over 365 days in a year.[note: the average weight gain on newer anti-depressants is far less.]

exacerbating this is the tendency of anti-depressants to make you lethargic, especially when first taking them. so not only are you more likely to gain weight from the food that you're eating, you're less likely to feel up to exercising at the same level you were. the lethargy tends to pass after a few weeks, but it can still cause problems over time.

the good news is that you can combat this with simple arithmetic. (your teachers told you it would be good for something.) weight maintenance is a ratio of calories consumed relative to calories burned. equalise the two and your weight will be consistent. anti-depressants are lowering your body's ability to burn calories, so in order to prevent weight gain, you need to proportionally lower your caloric intake. unfortunately, there's no magic way of telling how many calories your body is burning, so you might have to play around with it a little until you get it right. remember the 10% figure: this is really the maximum effect that any anti-depressant is going to have on your metabolism, so you shouldn't need to have more than a 10% reduction in calories in order to maintain your weight. not so intimidating when you look at it that way, is it?

powers your weight gain
as for anti-psychotics and mood stabilisers, the picture is a little trickier. the problem is that no one has quite figured out why these medications make you gain weight, even though it's widely accepted that almost all of them do. and for the ones that are weight neutral, no one can figure out why they don't make you gain weight, when they do basically the same thing as the drugs that do.

one obvious part of the tendency for these drugs to cause weight gain is that they are highly sedative. remember, these drugs are meant to curb mania, so they have a pretty strong calming effect that will generally make you a lot less likely to want to go for a jog. this is not simple lethargy. if these meds are working, you'll have less energy than you did before you started taking them. however, if you're manic enough to warrant being on an anti-psychotic, chances are the benefits of the drug well outweigh (no pun intended) the liabilities.

the problem is that even people who exercise and eat well can have problems with these sorts of drugs and no one seems to be able to figure it out. that's partly because the medications themselves are poorly understood. lithium has been around forever and doctors still aren't quite sure how or why it works- just that it does work. this is true of many psychiatric medications. the mechanism of action is known, but the reasons why this causes certain changes in mood and behaviour are basically just educated guesses. i'm sure that makes you feel much better.

with lithium, part of the "weight gain" can be fluid retention, since the drug is administered in its salt form. mineral salts have the exact same effect on your body as table salt- they make you thirsty and they make you retain the liquids you have or put in you. this will make you feel and, to some extent, look bloated, but it's not weight gain in the classic sense, since your body has not gained any mass.

serotonin, the neurotransmitter targeted by most anti-depressants, also has a link to appetite, so any drug that plays with the serotonin levels in your brain can also cause you to crave food more(or, in some cases, less). there's nothing you can do to change that, but it helps to be aware that when you think you want food, it's worth pausing to think about whether it's your stomach or your brain that's making the request. anti-depressants can't make your stomach empty- they can only make your brain think it is.

there are lots of theories on why these drugs make you gain weight, but hard facts are decidedly lacking. as a result, there aren't really any brilliant theories as to how you can avoid the weight gain. eat healthy, watch your sugar and fat intake (especially with beverages, since these drugs also tend to leave your mouth dry), get exercise (which helps depression anyway), get adequate amounts of sleep... you've heard all this before.

can i take dietary supplements to help combat the effects of anti-depressants on my metabolism?

unless you get an ok from your doctor and/ or pharmacist, absolutely not. we have this idea that "natural" equates to safe. arsenic and cyanide come from natural sources, but i don't want to sprinkle any on my breakfast. natural supplements can play with your internal chemistry the same as pharmaceuticals and their interactions can be very scary. if you're taking any prescriptions drugs- any- you need to tell your doctor what natural supplements you take and to determine if the combination is safe.

how much weight am i likely to gain?

too complicated to answer. as much testing that is done and continues to be done on all these drugs, there is an equivalent mass of contradictory anecdotal evidence. effexor, for instance, is widely perceived to cause weight gain, but testing has shown that subjects actually experience weight loss more often than gain (to the point where the drug was being investigated as a possible anorectic, until someone pointed out that giving people an extremely harsh drug so that they could lose a few pounds might not be the best idea). research indicates that the average weight gain for people on ssri's is minimal (when averaged out over all test subjects, including those who did not gain weight). even for known offenders like paxil and remeron (a combination anti-depressant and anti-psychotic), the average gain is only a few pounds. just be aware that only about 25% of patients experience weight gain as a side effect, so to make the average 3-4lbs, those 25% put on more like 15lbs to bring the total average up.

with side effects in general, predicting them is fiendishly difficult. it's a good idea to watch what you eat a little if you're starting with a psychiatric med, just in case. i don't mean starving yourself- that can mess with your neurotransmitters as well (didn't i tell you this was complicated?) and affect how the meds work.

will i lose the weight i've gained if i switch or discontinue medications?

yes. i hate saying that, because it's encouraging people to stop taking medication they may need, but studies show that, if you remove the problem drug, the extra weight goes with it. that's not such a big problem if you're on anti-depressants only- it's easy enough to substitute one with another until you find one you can live with and that works (keep in mind that you may end up in a situation where effective treatment means being on a drug that promotes weight gain).

if you're bipolar or on any other psychiatric meds, your options are limited. lamotrigine is weight neutral, but doesn't work on everyone. lithium and valproates are effective even on extreme cases of bipolar disorder, but they're among the worst offenders for weight gain and it can be very difficult to get the weight off while you're still on the drug. again, try to monitor what you eat, try to keep active and report any weight issues to your doctor.

there are not a lot of good answers to this problem, but the usual suspects- diet and exercise- do help, even if they don't help quite as much as they did before you started taking drugs. as for what happens if you do gain weight, keep it in perspective. a small gain shouldn't send you into hysterics. if it does, chances are you need the medication more than you think. keep track of it, but 5 or 6lbs is a pretty low price to pay for literal peace of mind. evaluate weight gain as a proportion of your total body weight. my fiance is 6'5". ten pounds on him is unnoticeable. i'm 5'2". ten pounds on me is the equivalent of adding a leg. as with most things, moderation and balance are key.

finally, here are a few articles that may help you learn more about how everything works:

the lesser known "depakote" mona lisa
a huffington post article by judith wurtzman, outlining the case for taking weight gain seriously as a side effect of anti-depressants.[thanks to dom for the link.]

a really interesting chart from a web site about eating disorders that outlines the effects of common anti-depressants specifically on weight and appetite. the chart was last updated in 2007, but it is incredibly well annotated, which allows for some follow up.

a piece from nbc that serves as a decent outline on drugs that cause weight gain, including both anti-depressants and anti-psychotics.

the bipolar forum and the anti-depressant forum from there are hundreds of discussion forums on these topics scattered throughout the internet and they're a good place to supplement your understanding of these medications and find out how other people have coped.


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