Treating Weight Gain From Psychiatric Medications with Dr Matt Bernstein

Bret: 
Welcome to the Metabolic Mind Podcast. I’m your host, Dr. Bret Scher. Metabolic Mind is a nonprofit initiative of Baszucki Group where we’re providing information about the intersection of metabolic health and mental health and metabolic therapies, such as nutritional ketosis as therapies for mental illness.

Thank you for joining us. Although our podcast is for informational purposes only and we aren’t giving medical advice, we hope you will learn from our content and it will help facilitate discussions with your healthcare providers to see if you could benefit from exploring the connection between metabolic and mental health.

Welcome back to Metabolic Mind. I’m your host, Dr. Bret Scher. And today, we have another installation in our series on targeting psychiatry medication-induced weight gain, which is a significant problem in the world of psychiatry. And not just weight gain, but also metabolic abnormalities, metabolic health dysfunction, and the trouble that patients have trying to lose the weight and doctors have trying to help them lose the weight.

But now, with this new class of medications, the GLP-1 receptor agonists, medications like. Wegovy or Ozempic, it seems like there’s a potential new treatment option, but not without its concerns. And we’ve done other videos about the potential concerns.

But we want to get you some experience understanding clinicians, whether they want to use or don’t want to use, what they feel the benefits and potential risks are, and some what goes through their mind because they want to help patients. They want to help their clients prevent or lose the weight they gain from the medications and prevent the metabolic abnormalities.

So, where do these medications fit in? Today, I am joined by Dr. Matthew Bernstein, a psychiatrist at Ellenhorn, who has quite a bit of experience, unfortunately, with psychiatry medication-induced weight gain, as do most psychiatrists treating serious mental illness. So, let’s hear what Dr. Bernstein thinks about these new class of medications, and where they fit into the whole treatment paradigm.

First before the interview, please remember this channel is for informational purposes only. We’re not establishing a doctor patient relationship or providing any individual or group medical or healthcare advice. Please don’t take anything as what we say as medical advice. But rather this is for informational purposes for you to take it back to your clinical team and discuss with your physicians what is right for you.

Alright, so now with that, let’s get on with the interview.

Dr. Bernstein, I’m really interested to get your perspective on how big of a problem is weight gain in your patients taking psychiatric medications. 

Matt: 
Just first of all, it’s really nice to be back again on Metabolic Mind. I think you guys are doing great work. 

Bret: 
Thank you. 

Matt: 
Yes, it’s a really big problem.

it can be an enormous problem for certain individuals, especially when people need to take anti-psychotic medications or what we call the atypical anti-psychotic medications and, or mood stabilizing medications where the amount of weight gain that certain individuals experience can be really enormous.

The average amount of weight gain with one of the tried and true effective anti-psychotic medications, olanzapine or also known as Zyprexa, in the first year it can be on average 30 pounds. 

Bret: 
Wow. 

Matt: 
But that’s an average and some people will gain quite a bit more than that in the first year. Some people don’t gain any weight at all on olanzapine or Zyprexa or drugs like that. And so, it really depends on the individual. The other part about this that’s really tricky for everyone involved is that some of the most effective of these medications are also the ones that have the worst metabolic side effects.

And weight being a big part of that. And for some reason, that just seems to be the case with a lot of these classes of medications. The more effective ones have the worse side effects. And it’s something that as a psychiatrist and all the patients I work with and families, we all feel like we’ve just had to live with in certain ways.

This trade off between benefits for mental health and the really negative side effects on the body. 

Bret: 
Yeah, I mean it’s interesting how you phrase it like that, the trade off. Because these medications are being used for a reason. They can help with psychiatric symptoms, no question about it. They can be lifesaving in many cases.

But you also mentioned metabolic side effects. So, not just the weight gain. I think we talk so much about the weight gain because you can see it, and people can measure it, but the metabolic abnormalities, the metabolic side effects that come along with it. And we know people with psychiatric diagnoses, especially bipolar disorder, are going are more likely to have poor metabolic health and worse cardiovascular outcomes.

So, it really does seem unfair that the medications that can have the biggest benefit also have the worst side effects. So, when you see this and knowing this is a problem, what have you tried to use in your practice? What is the common approach for you and your colleagues to try and either pre-empt or combat this?

Matt: 
There hasn’t been much that’s been effective. Again, that’s why I talked about how difficult it is and how frustrating it is. There’ve been some studies on metformin, which is a drug that’s used in diabetes, as you know well. And there are a few studies showing there’s some mild benefits from metformin in preventing and sometimes even helping with weight gain from psychiatric medications.

So, I’ve used quite a bit of metformin over the years. and you need to use higher doses to have it work at all. And then, unfortunately, the benefits are often pretty subtle, if there are benefits at all. So, that’s one approach. I think there’s always the, you know, trying to help people with their diet, reducing their calorie intake, trying and eat healthier foods, trying to exercise.

But to be honest, that often doesn’t get us anywhere. We can try and try, but with a sort of just standard generic diet and exercise recommendation and maybe plus metformin, the results in my hands are not very good. And the studies bear that out. That the results are not very good in terms of reversing this weight gain and metabolic issues that occur.

And I think you’re right to point out that it’s not just weight gain. We’re talking about glucose dysregulation, hyperlipidemia, increased cardiovascular risk. People with severe mental illness have a 15 to 20 year lower lifespan than the average person, and a big part of that is these metabolic issues.

It’s not all of it, but it is a big portion of it. And a big part of the metabolic problem is due to the medications. So, it’s a really difficult situation. 

Bret: 
Yeah, I can sense your frustration just the way you describe it. Because as a doctor, you want to help your patients. And when you feel like you’re limited in what you can do, it is frustrating.

The one point I think was important that you made though, you mentioned that the studies show metformin can be beneficial. But then in clinical practice, your experiences, it’s minimally, if effective at all. And that, I think, we see that a lot in this field. That you can see some benefits in a randomized controlled setting, but in clinical practice, not so much.

And certainly with the generic lifestyle advice that frequently we give, but now there’s this new kid on the block, so to speak, right? The GLP-1 receptor agonists, Wegovy, Ozempic, that have revolutionizing the medication approach to weight loss. Now, we’ve done another video about some concerns about using these medications in some of the psychiatric diagnosis.

One, they were excluded from the FDA approval trials. Two, there have been some reports of increased suicidal ideation. But on the flip side, some people in psychiatry have said they’ve used them with very good results. So, with that as a lead in, how has the availability of this class of medications changed your thinking about how to approach psychiatry medication-induced weight gain?

Matt: 
That’s a great lead in to the topic. I’ve been thinking about it long and hard for the last couple of years, and really following the debate about these medications really closely because it’s such an important issue for my clients and my patients. So I’ve been really mixed about it in many ways.

Number one, I just disclosure is that as a psychiatrist, I haven’t prescribed one of these medications yet. I’ve been considering a sort of outside of the scope of practice of a psychiatrist so far. However, I may change my mind about that as I’m getting further and deeper into this. There may be a role and there may be a role for psychiatrists to be prescribing these medications in certain circumstances.

No, I think, I agree there’s concerns about the medications, the GLP-1 agonists and some of the newer ones, which are GLP-1 and GIP agonists. Combined, they’re even more effective. Tirzepatide, I think, is the name of that one, and it has even more effective weight loss. I’ve had a couple of my patients go on these medications by my encouragement.

I’ve asked them to ask their primary care doctor. They’ve often been referred to a weight loss clinic, and they’ve been put on these medications because the weight gain has been such an issue. And it’s frankly, they’re living in a dangerous position with their weight, but also it’s impeding on their quality of life so much. To not have control over their appetite, to keep gaining weight.

It’s really impinges on quality of life for some people. And so, I’ve encouraged some people to go on them. And my biggest concern with the medications has been, and it still is, when someone goes on one of those weight loss medications, but does not change their diet, does not change into an exercise regime.

My worry is that they’re losing as much lean body mass as they are losing fat mass at times, and that’s really observable with certain people. But also, that’s born out in studies. Whenever they’ve reported body composition, seems to be about a one-to-one ratio of losing lean body mass to losing fat mass.

And talking to weight loss experts, they would ideally want to have a three-to-one ratio of losing fat to losing lean body mass. So, I really worry about the people who are losing lots of weight with these medications, not eating enough protein, having a calorie deficit, and then losing lots of lean body mass over the course of a year or two.

Then, never being able to make that back up in the future, potentially, and setting themselves up for a lot of health issues due to the low muscle mass over the course of their lifetime. I worry that we’re going to have an epidemic of sarcopenia in 10 or 20 years from all the people taking these medications.

Bret: 
Yeah, I think that’s a real concern and a very good point. And because another study had shown once people go off the medications, they gain all the weight back. But they’re not gaining the muscle back that they lost. They’re gaining only fat mass that they lost and more. So, that is also concerning.

So, very important point, and I really appreciate what you said about your concern of people taking the medication and not changing their lifestyle. So, let’s go back to our prior interview that we had where we talked about the use of ketogenic therapy to treat the symptoms of serious mental illness.

But now, what about the use of ketogenic therapy, which has traditionally been used for weight loss as well to target medication-induced weight loss? Is that something you’ve had some experience or some success with? 

Matt: 
I have, yeah. I can think of a few people in particular who have done some of these metabolic therapies with my advice and my help.

And their main goal was to lose the weight that they had gained on these medications even though I knew what my main goal was. To help with their mood and their brain health overall, their memory, their cognition, their anxiety. And so we would meet in the middle and it’s a win-win as opposed to what I was talking about this trade off with the medications where we may get a benefit with mental health, although not maybe a full benefit, but we were getting really awful metabolic side effects.

In this case, with ketogenic therapies, I see it as a win-win. The person, the individual, is losing weight, and they’re also getting all these brain health benefits at the same time. And so, whenever I can convince someone and we can meet in the middle that way, that would be my ideal scenario.

And I try to have that happen as much as possible. So, I think that’s the most exciting part about all of this for me, is that I think we have an option now that is a potential win-win for people. 

Bret: 
And frequently someone will say, oh, I’ve tried everything and nothing’s worked. So, I need the medication.

But I think we have to redefine what we mean by trying everything. Because I don’t think true metabolic therapies, ketogenic therapies have really fallen into that tried everything approach. 

Matt: 
Especially under supervision of clinicians. I think maybe people have tried some version of a ketogenic diet maybe on their own or maybe just based on maybe something they’ve learned from a friend or from the internet.

And they may not have had success, but it may not have been a very carefully planned intervention. There may not have been monitoring either, blood tests or ketone monitoring with either a finger prick or a breath meter.

I think we can even think about using things like continuous glucose monitors to make sure that we’re getting in the right direction on some of these parameters and learning the right things. So, I think there’s a difference between trying something also, and trying something with the help of a clinician, a doctor or a dietician or someone who’s trained in really getting someone through all the pitfalls that can occur.

So, I agree with you. Trying everything, I think even means trying it with clinical support. 

Bret: 
Yeah, I think that’s a good point, too, that the sort of the team approach and clinical support and focusing on this team approach. Maybe it’s also a team approach of a weight loss clinic or obesity medicine specialist using a weight loss medication plus using ketogenic therapies, plus making sure you’re maintaining muscle mass and doing some exercise.

And then over time, maybe the lifestyle persists ,and you can wean off the medications? Could you see like a team and stair step approach like that? 

Matt: 
That’s where I think I’m evolving to, Bret, is exactly what you just described, which is that there may be certain individuals where combining a ketogenic therapy for both brain health and metabolic health as well as one of these newer weight loss medications, GLP-1 GIP agonist medications might be the ideal approach for certain individuals.

And I’m thinking of someone who really is having trouble with, even following the prescription for the ketogenic diet, that their appetite is too high, or their cravings are too high and they need some help on that front. These medications might really play an important role for that person,. But I’d also think that it’s key when someone is using one of these medications that they have to be doing something else, in terms of their diet and exercise, to really minimize those potential issues and problems.

They need to have a whole team approach. And so, I think in certain circumstances, that combination might be really ideal for a period of time. And I can envision someone who’s done all that work on lifestyle while they’re on the medication, actually being able to eventually come off of the. GLP-1 agonists safely and not gain the weight back.

That would be the ideal approach because I don’t think it’s a great scenario for someone to have to be on one of these weight loss medications for the rest of their life. If there’s a way that they don’t need to be on it for the rest of their life. Some people, it may be that they do stay on it for the long term. But I think, ideally, we would rather not have someone stay on a medication like that for the long term.

Bret: 
Yeah, and without significant lifestyle changes, that clearly won’t be the case. So, they have to happen together. So yeah, I really appreciate your perspective, and for joining us today to give us your experience and your thoughts. Thank you very much and if there are any other any other last words before we go?

Matt: 
I just wanted to mention again that the group I work with, Ellenhorn, is putting on a conference about metabolic psychiatry for the audience to hear about. Again, it’s going to be broadcast online for the listeners who are interested. 

Bret: 
Yeah, and I’m really excited about that conference.

I’m excited to be there and participate as well. So, thank you for mentioning that. I look forward to it. Thanks for listening to the Metabolic Mind Podcast. If you found this episode helpful, please leave a rating and comment as we’d love to hear from you. And please click the subscribe button so you won’t miss any of our future episodes.

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