Behavioral Treatment

Behavioral interventions such as calorie restriction, exercise, and behavioral modification are key elements to successful, sustained weight loss (NHLBI 2000; NHLBI also has posted on its Web site a practical guide for obesity evaluation and management: www.nhlbi.nih.gov/guidelines/ obesity/practgd_c.pdf). There is little in the way of published data on behavioral interventions for weight loss in psychotic patients, and the few studies tend to be methodologically weak. In one small (n = 14) 14-week study, patients in a residential setting achieved, on average, 10 pounds more weight loss when given behavioral interventions compared with a control group (Rotatori 1980).

Work by Wirshing and colleagues demonstrated that simple stepwise behavioral interventions were modestly successful in risperidone- and olanzapine-treated subjects, but had little effect in clozapine-treated subjects (Wirshing et al. 1999). The interventions are listed below.

1. Patients were instructed to weigh themselves and report their weight to the clinic nurse at each visit (every 1­4 weeks).

2. If this simple behavioral intervention failed (a gain of 10 pounds was generally considered sufficient to warrant further intervention), patients were instructed to keep a detailed diary of all food intake over a several-week period; the diary was reviewed and recommendations made for changes in diet. If the food diary failed to maintain or decrease weight, patients were referred to a clinical nutritionist.

3. If the previous measures failed, individuals were sent to the Wellness Clinic at the medical center, which involved a more rigorous evaluation of both dietary and exercise habits and added education, exercise classes, and group support.

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Although it is true that not all subjects availed themselves of these services, there is no reason to think that any one drug group would have more or fewer "noncooperative" patients. Final weight gains reported by Wirshing and colleagues for olanzapine and risperidone were 2.4 ± 1.3 kg and 2.3 ± 0.8 kg, respectively, compared with maximum weight gains achieved on these medications of 6.8 ± 1.0 kg (olanzapine) and 5.0 ± 0.6 kg (risperidone). In addition to this work, there have been reports suggesting that there may be some benefit to programs such as Weight Watchers in addressing novel antipsychotic­associated weight gain, although the dropout rate was quite high (10 of 21) in one recent study, and only the men experienced significant weight loss (Ball et al. 2001).

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