A Call for Improved Prevention and Reduction of Obesity Among Persons With Serious Mental Illness

The Medical Directors Council of the National Association of State Mental Health Program Directors (NASMHPD) has recently released a policy paper, Obesity Reduction and Prevention Strategies for Individuals With Serious Mental Illness ( 1 ).

NASMHPD represents state executives responsible for the $29.5-billion public mental health service delivery system serving 6.1 million people annually in all 50 states, four U.S. territories, and the District of Columbia. The NASMHPD Medical Director Council's membership comprises state medical directors of state mental health authorities from across the country.

The NASMHPD Medical Directors Council produced the policy paper, which is a review of the prevalence, impacts, prevention, and treatment of obesity for persons with serious mental illness. The report is a follow-up to its 2006 report, Morbidity and Mortality in People With Serious Mental Illness ( 2 ), which addressed research findings that persons with serious mental illness served by the public mental health system die 25 years earlier than the general population, primarily from chronic and treatable medical illnesses ( 3 ). Diseases such as metabolic syndrome, heart disease, hypertension, and diabetes are major contributors to the higher rates of death of persons with serious mental illness and are strongly linked to obesity. As a result of these findings and the growing concern regarding psychiatric medications as a cause of obesity, the NASMHPD Medical Directors Council decided to develop a policy paper on the problem of obesity in the subpopulation with serious mental illness.

Statement of the problem

Obesity is a public health crisis in America. Approximately 65% of adults in the United States are either overweight or obese ( 4 ). Persons with serious mental illness are two to three times as likely to be obese as the general population, with reports that over three-quarters of women with schizophrenia are overweight or obese ( 5 , 6 , 7 ).

Obesity, in addition to causing poor health and contributing to early death, is a major obstacle to realizing the hope of recovery for the people we serve. Obesity by itself increases stigma and social isolation and reduces self-esteem, causing additional obstacles to reentering an active life in the community beyond those already posed by mental illness. A person's mental illnesses, substance use disorders, and physical illnesses must be treated concurrently in order to achieve the highest level of recovery. These conditions adversely affect an individual's self-esteem, quality of life, relationships, employability, and integration into community life. Unless the health care system begins to address system issues and commonly held beliefs about this subpopulation, people with serious mental illness will not be able to achieve the level of recovery they want and deserve.

In the process of researching and developing the report, the NASMHPD Medical Directors Council became convinced that psychiatrists are doing far too little to prevent and reduce obesity for either the physical health or the mental health recovery of patients they serve. Too often we underestimate and overlook the perceptions our patients have about their weight and their desire to reduce their weight. By not addressing these important health and social concerns when treating these patients, we limit the extent and strength of our therapeutic alliance with them.

The fact is that significant weight gain may be caused by second-generation antipsychotic medications and many other psychiatric medications ( 8 ). Experience has indicated that several commonly prescribed second-generation medications in particular are associated with weight gain and metabolic syndrome. With proper prevention and intervention strategies, persons with a serious mental illness and their health care providers can minimize the impact of the various contributing factors to weight gain and related medical complications that can otherwise reduce life expectancy.

Obesity prevention strategies for people with serious mental illness

Most psychiatric clinics and community mental health centers do not offer obesity prevention and intervention strategies to their patients even though these patients are at high risk for obesity and many of the psychotropic medications prescribed for treatment of their mental illnesses cause weight gain. The NASMHPD report reviews evidence-based prevention approaches to obesity specifically for persons with serious mental illness and recommends that community mental health centers and psychiatric clinics provide these services.

There is a prevailing assumption that weight loss interventions are not effective for persons with serious mental illness. The report debunks this assumption. Weight loss treatment programs are as effective for persons with serious mental illness as they are for the general population. Half of persons with serious mental illness in weight loss programs lose clinically significant amounts of weight ( 9 ).

Medications specifically for the treatment of obesity can result in a weight reduction of 10% ( 10 , 11 ). Yet most psychiatrists are unfamiliar with these medications and uncomfortable with prescribing them. Psychiatrists could benefit from additional training on prescribing medications, such as phentermine and sibutramine.

Because behavioral and medication treatments for obesity rarely yield more than a 10% to 15% weight reduction, bariatric surgery is the treatment of choice for patients with morbid obesity. These individuals likely face significant medical dangers as a result of their weight. Psychiatrists in the public mental health system must make sure that their patients with morbid obesity have access to this potentially life-saving intervention. These psychiatrists should also assist their patients in making informed choices about the risks and benefits of bariatric surgery. Bariatric surgery is covered by Medicare, Medicaid, and other third-party insurers ( 12 , 13 ).

In addition to reviewing the prevalence of, impacts of, and available research on weight reduction interventions for persons with serious mental illness, the report makes policy recommendations to support psychiatrists in addressing the epidemic of obesity among persons with serious mental illness.

Further research on obesity among persons with serious mental illness is necessary. Better data will allow improved identification of high-risk groups, including women, children, senior citizens, and persons from specific ethnic-racial minority groups. Improvements in national obesity surveillance and monitoring systems will assist greatly in tracking the prevalence and potential causes of obesity within the subpopulations. These systems will also allow for the development and dissemination of specialized programs better tailored to improve weight reduction within these subpopulations.

Federal tax policy can be used to promote health and healthy activities. For individuals who are employed and able to participate in pretax spending accounts for medical expenses, the dues and fees for membership to a local gym or local recreation center could be included as a valid reimbursable expense. Studies have shown that programs that provide financial incentives toward improving health have resulted in reduced health care costs in the long term.

Federal fiscal policy should also cover weight management interventions and laboratory tests for monitoring weight in Medicaid, Medicare, and third-party health insurance programs. Such interventions should include psychoeducation, behavioral interventions, pedometers, scales, medications for weight loss, and, if necessary, bariatric surgery.

Agencies such as the Food and Drug Administration should study the effects that psychotropic medications and weight loss medications have on people with serious mental illness. Such information, including recommendations of appropriate treatment alternatives, should be disseminated to the public comprehensively and expeditiously.

At a state level, mental health professionals need to be educated on the importance of weight monitoring and weight management among people with serious mental illness. Common misconceptions and stereotypes that people with serious mental illness are not able or willing to participate in weight reduction programs need to be recognized and confronted. Providers need to be encouraged to treat both the physical health and the mental health of their patients. This means coordinating care between primary and mental health professionals with good communication and collaboration.

These are just a few of the recommendations in the report, and these strategies are targeted to improve the quality of life of people with a co-occurring serious mental illness and obesity. The epidemic of obesity among people with serious mental illness can be addressed appropriately through effective and available interventions. Psychiatrists who disregard the physical health of their patients and focus only on treating the patient's psychiatric condition are not only being neglectful, they are also contributing to this epidemic.

Acknowledgments and disclosures

The authors acknowledge the NASMHPD executive director, commissioners, and staff.

Dr. Parks is a consultant and speaker for Janssen Pharmaceuticals. The other authors report no competing interests.