To the Editor: Rates of overweight and obesity are higher among individuals with schizophrenia and related disorders than in the general population (1). Evidence suggests that treatment with second-generation antipsychotic medications elevates the risk of weight gain, hyperglycemia, and hyperlipidemia and that the risk varies across agents (2,3,4,5).
Few studies have examined how individuals with schizophrenia view weight gain or weight management programs. We conducted focus groups to explorethe views of patients with schizophrenia about weight gain; their knowledge about medical complications of obesity, such as diabetes and hyperlipidemia and the impact of antipsychotic medications on weight; and their interest in weight control interventions.
We conducted three focus groups in February and March 2005 for veterans with schizophrenia or schizoaffective disorder at the Bronx Veterans Affairs (VA) Medical Center who were taking antipsychotic medication. The center's institutional review board approved the study, and participants provided written informed consent. Focus groups lasted approximately 90 minutes, and the moderator followed a guide that contained general questions and suggested follow-up probes. Two independent reviewers coded each transcript, compared results, and resolved discrepancies by consensus. Participants completed brief anonymous questionnaires that asked about their age, height, weight, and previous weight loss efforts.
Twenty-three adults—22 men and one woman—participated in the groups. The mean±SD age of participants was 50±7.9 years. The mean body mass index was 30.9±4.3. Fourteen of the participants were African American, five were Hispanic, and four were non-Hispanic white. Twenty participants had tried losing weight, including 16 of the 17 individuals whose physicians recommended that they do so.
Most participants reported that weight was very important and that they weighed themselves regularly, cared about their physical health, and wanted to control weight to minimize medical complications and to look good. For some, weight control was secondary to symptom control. Participants considered a "comfortable" weight to be one that was compatible with performing daily activities without strain. Several participants worried that being thin would make them vulnerable targets on the city streets.
Opinions diverged about how much control people have over their weight. Participants believed medication and aging made weight loss more difficult and that antipsychotics contribute to weight gain by increasing appetite, decreasing energy level, and causing clumsiness (making exercise less fun). Aging also motivated some to take better care of themselves.
Additional barriers to weight loss included environmental factors, such as exposure to advertising for fast foods, readily available food delivery, and problematic home settings, such as group homes or families that undermined weight loss efforts. Participants acknowledged difficulty eating regular meals, limiting portions, and making healthy food choices.
Participants expressed interest in interventions, including nutrition and exercise programs. Most preferred combining individual and group sessions; several wanted to involve family members. Participants wanted specific, concrete information, including personalized menus and hands-on cooking demonstrations. They stated that they would feel more comfortable exercising at the VA than at commercial gyms. They wanted convenient hours and a motivating atmosphere. Opinion was split on the optimal site for nutrition and exercise programs: primary care or a mental health setting.
The key finding from our focus groups is that participants—individuals with schizophrenia who were being treated with antipsychotic medication—have concerns about weight gain and weight management that are very similar to those of the general population. They worry about their appearance and their physical health and find it difficult to adhere to diet and exercise plans. Furthermore, they believe that antipsychotic medication contributes to weight gain and makes losing weight more difficult. [A sample of quotations from participants about some of the topics discussed in the focus groups is available in the online version of this letter at ps.psychiatryonline.org.]
This study represents a first step; focus groups are nonrepresentative samples, and our participants were mainly urban-dwelling male veterans. Regardless, our results suggest that a sizable constituency of individuals with schizophrenia is concerned about weight gain and interested in weight management programs.
The authors are affiliated with the Mental Illness Research, Education, and Clinical Center at the Bronx VA Medical Center in Bronx, New York. Dr. Weissman and Dr. Essock are also with the department of psychiatry at Mt. Sinai School of Medicine in New York City.
The authors thank Shoshanna Sofaer, Ph.D., for her contributions to the study and Nina Schooler, Ph.D., for helpful comments on the manuscript. The VA National Center for Prevention and Health Promotion and the Mental Illness Research, Education, and Clinical Center of Veterans Integrated Service Network 3 provided funding for the study.
1.Allison DB, Fontaine KR, Heo M, et al: The distribution of body mass index among individuals with and without schizophrenia. Journal of Clinical Psychiatry 60:215-220, 19992.Lieberman JA, Stroup TS, McEvoy JP, et al: Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. New England Journal of Medicine 353:1209-1223, 20053.Allison DB, Casey DE: Antipsychotic-induced weight gain: a review of the literature. Journal of Clinical Psychiatry 62(suppl 7):22-31, 20014.Sernyak MJ, Leslie DL, Alarcon RD, et al: Association of diabetes mellitus with use of atypical neuroleptics in the treatment of schizophrenia. American Journal of Psychiatry 159:561-566, 20025.Lindemayer JP, Czobor P, Volavka J, et al: Changes in glucose and cholesterol levels in patients with schizophrenia treated with typical or atypical antipsychotics. American Journal of Psychiatry 160:290-296, 2003