Should Therapists Have Scales in their Offices? By Judith Wurtman, PhD on 10/16/18 - 1:29 PM

We were scanning electronic records of patients visiting the mental health clinic of a large local hospital to find subjects for our IRB-approved research study on antidepressant associated weight gain. Our goal was to find subjects whose weight was normal prior to starting on antidepressants and who had gained weight during the subsequent 3 or four months. But there was a problem: no one weighed the patients. Thus, there was no way to learn whether the drugs were influencing weight.

Almost twenty years ago while directing a weight loss center at a psychiatric hospital affiliated with Harvard University, we were surprised by the number of clients claiming substantial weight gain while on their psychotropic medication. Unlike typical clients seeking weight loss advice, whose struggles with overeating may have a complex etiology, these clients were of normal weight, ate healthily, exercised routinely and had no issues with food until their treatment with antidepressants began. Their complaints were similar; uncontrollable urges for carbohydrate-rich foods and an inability to feel full after eating.

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Our clinic was able to stop and to some extent reverse their weight gain with a food plan that increased serotonin synthesis prior to lunch and dinner to potentiate satiety before eating began. The increase in serotonin also decreased their desire to snack on sweet or starchy foods

Unfortunately, now several years later, patients are still gaining weight on psychotropic drugs and although the literature is filled with articles confirming this side effect, patients may be denied this information along with interventions to halt or slow the process. One angry patient told me that her therapist accused her of justifying her urge to eat cookies as an effect of her medication and another, who was compelled to shop for plus size clothes after taking an antidepressant, said her physician never heard of weight gain as a side effect of her drug.

Many patients see their formerly normal, fit bodies transformed, and adding to their feelings of frustration and sometimes embarrassment, is the difficulty in explaining to others why they are now overweight or obese. One of our clients who went to Weight Watchers wasn’t believed when she said she had been thin before going on an antidepressant. “They assumed I was in denial about the reason I was always snacking.” Another told me that his mother keeps nagging him about his overeating and won’t believe that the combination of a mood stabilizer and antidepressant are responsible.

Ideally, patients should be alerted to the weight gaining potential of the drug(s) they are being prescribed. Since it is unlikely that the therapist has a scale in the office, information about weight changes or inability to fit comfortably into clothing worn before starting the drugs will have to come from the patient and tracked during subsequent visits.

Cravings for sweet and /or starchy carbohydrates and a decrease in satiety are the most commonly reported causes of overeating. A coach of a college women’s soccer team told me that after being put on an antidepressant, she craved French fries for the first time in her life and had trouble resisting eating them as a snack every day. A patient on a mood stabilizer often ate two dinners because an hour or so after the first was completed, he felt hungry again.

The therapist might suggest that the patient eat a small, 25-30-gram carbohydrate snack such as a ready-to-eat breakfast cereal (oat or wheat squares, or cheerios for example) 30-45 minutes prior to a meal or when craving a between-meal snack. The carbohydrate causes insulin to be secreted thereby potentiating tryptophan uptake into the brain and subsequent synthesis of serotonin. Carbohydrate craving is dampened, and satiety increased as a result. The snack should be very low in fat or fat–free to decrease calories and contain no more than 2-3 grams of protein as the latter nutrient prevents serotonin from being made. The patient may still want to overeat; after all, one is fighting drug-induced appetite with cheerios, but usually, a sense of fullness is reported.

Urging the patient to start to exercise as soon as possible by using a smartphone app or wristband to record physical activity has benefits of course beyond calorie utilization, but is very important in preventing weight gain. Asking to see records of weekly or monthly ‘steps walked’ or other activity may encourage compliance.

Weight gain on psychotropic drugs may undermine some of the beneficial effects of the drugs themselves and the psychotherapy, especially since those who gain the weight rarely announce its cause and thus are perceived as individuals who are unable to control their food intake and may be too lazy to exercise. Thus, stopping or minimizing this side effect will benefit the mental and physical health of the patient. Alert to these possibilities, psychotherapists may be in a better position to work with the prescriber, nutritional specialist or other members of the treatment community.

File under: The Art of Psychotherapy, Therapy Training