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R ecently I’ve been teaching my eight-year-old about the principle of ‘offsetting’. “If we pay 99p for a second-hand book rather than £7.99 for a new one, you’ll still have enough money left for a small Lego set,” I tell him. He likes it because it feels like he’s constantly getting a bonus (“I get two things instead of one!”), and I like it because it’s preparing him for a fundamental reality of life – that most of us have to make sacrifices in order to get what we want or need.
The principle of offsetting (‘To balance one influence against an opposing influence, so that there is no great difference as a result,’ according to the dictionary definition) has been on my mind for other reasons, too, chiefly in relation to my bipolar medication.
In order to have a ‘normal’ life, free from suicidal feelings, deep depressions and worrying hypomania, I take a second generation antipsychotic (SGA, formerly known as atypical antipsychotics or AAPs) medication called quetiapine. This daily pill calms me down, lifts me up, gives me blissful sleep and has got me on an even keel I didn’t think was possible. Most importantly it has, as you may recall from one of my earlier blogs, got me through some hideous times and (I feel it is safe to say) saved my life. But, as is the case with most medication, there has been a price.
Rewinding back to Spring 2012, I (vaguely) remember going to a psychiatrist for the first time. I was walking a high, wobbly tightrope that I now recognise as a mixed affective state of bipolar (depression and hypomania playing a seemingly never-ending and exhausting game of see-saw together). I was so ill, functioning so poorly, that at the time I remember saying to him, ‘If I was an animal like a dog or a horse, they’d put me down.’ If he’d offered to do the same for me, I think I’d have found it hard to resist.
Instead, he said: “I’m going to put you on this drug and I can guarantee that within two weeks you’ll feel better.” It sounded too good to be true (I looked for the rabbit and the hat, too, but I couldn’t see them). Then it came – the price. “You’re likely to put on a lot of weight with this medication,” he told me, ‘but you’re so unwell you need it.’ At that stage I didn’t care. If he’d told me that doing naked cartwheels down nearby Marylebone High Street would have made me better, I’d have done it – and back again.
And so I went on the drugs and I’ve been on them ever since. And he’s right – I have put on weight. It’s gone up by 20 per cent in 18 months, in fact. A study of 90 people started on SGAs for a variety of diagnoses found significant weight gain in 70 per cent of them, averaging at about 12lb (Mareno C et al, Bipolar Disord 2010;12(2):172–184).
Not only that, but I’m starting to get fat on the inside, too – my cholesterol has started to creep up and so have my blood lipids (these factors, too, are also known side-effects). And experts agree that for people like me on these drugs, this is a big problem.
A November 2014 study in the Journal of Clinical Psychiatry reported that the frequency of metabolic syndrome in patients with bipolar disorder is significant enough as to warrant systematic screening, particularly among those, like me, who are receiving atypical antipsychotic treatment (the researchers from Hopital La Salpetriere in Paris found that 89.4 per cent of those with high cholesterol in their study weren’t receiving treatment for it. “Under-treatment of hypertension and diabetes in patients with bipolar disorder are the areas of greatest concern, because of the high rates of CVD [cardiovascular disease]-related mortality and morbidity in this population,” said the report’s authors
But as far as I’m concerned, the worm has started to turn (or is, at least, deviating slightly from its initial route). Whereas before, I’d accepted that there was an element of somewhat skewed ‘offsetting’ (“I’m putting on some weight but I’m finally getting my life back”), I have now placed it under scrutiny. The luxury of an extended period of relative good health has afforded me the breathing space to do this. I now have, if you like, a clearing in the woods from which I now have a slightly different vantage point.
At this stage in the blog I want to stress that this isn’t about me bashing these drugs – after all (and apologies for labouring the point) I think they have saved my life. And until something different comes along, I’ll be staying on them. Besides, I think there’s enough medication-bashing going on and this is a disservice to people who really need it (a 2006 study, part-funded by the National Institute of Mental Health, found that whilst most Americans think that psychiatric drugs work, they probably wouldn’t ever use them because they fear they will face stigma from others. A drugs-bashing blog won’t help the cause, I feel).
But it IS about me pondering upon whether the lives of mental health patients like me could be enhanced and even lengthened by not just accepting that side-effects like weight gain and raised cholesterol and blood lipids are our ‘lot’.
At the moment, people like me who are on these SGAs seem to be facing a Hobson’s choice – take the drugs to feel less ill and agitated but increase your risk of cardiac problems; or come off them and watch your life start unravelling around you (and possibly risk feeling suicidal or even acting upon it).
I am a member of a Facebook group consisting of thousands of people with bipolar and on a daily basis someone talks about the distress of putting on weight and apparently being able to do little about it. Many like me would say we have been saved by our meds but there’s no doubt it comes at a price. In the words of a song I remember hearing as a kid, ‘If the right one doesn’t get you then the left one will.’
SO WHAT CAN WE DO?
As someone who was once told that their tombstone would read ‘A study says…’, I’ve been compelled to do do some research to see if there are any solutions. Could it be that we can actually take these life-restoring meds without having to accept an apparently inevitable path to weight gain and cardiometabolic ill-health? Could there be something to help us to – dare I say it – virtually ‘have it all’? The studies look promising.
And, so far, this is what I have discovered. At the first instance, not surprisingly, weight gain is expected to be managed through diet and exercise. This would be a totally fair assumption were it not the case that atypical antipsychotics are also known for knocking you out and making you feel utterly exhausted. There are times when I’ve wanted to cry as I stand at the bottom of a staircase, barely managing to muster up the energy to make what should be an easy ascent. For me it has been a vicious cycle – meds result in weight gain and tiredness, these give me no energy for exercise, the weight gain increases and this makes me tired. And so on. I also reduced the amount I was eating but that didn’t seem to make any difference either.
CAN METFORMIN HELP?
Next I started to read up on metformin (glucophage)) which is an anti-glucose agent used in the treatment of diabetes and which has shown some effectiveness when used for weight loss. Some studies suggest that using metformin with SGAs merely slows down weight gain (Weaver et al, J Child Adolesc Psychopharmacol 2010;20(2):153-157) whereas others suggested that metformin doses of up to 2000mg daily resulted in a significant difference in weight gain and a decrease in waist circumference compared to the placebo group (Klein DJ et al, Am J Psychiatry 2006;163(12):2072-2079). In this instance metformin was particularly helpful in reducing the rate of weight gain and stabilising the weight rather than weight reduction.
In an article in PsychCentral Professional, Dr Caroline Fisher, a child and adolescent psychiatrist in Oregon, says that it may make sense to start metformin, particularly in patients with additional risk factors for metabolic syndrome (such as PCOS, obesity or family history of diabetes). “Weight loss may not be the most important outcome: rather, deceleration of weight gain and weight stabilization, decreased triglycerides, and potentially…reduction in the risk of metabolic syndrome” she says.
Armed with this information, I went to my GP who then referred me to an endocrinologist to discuss it. The endocrinologist didn’t seem particularly interested in my print-outs (in fact, he probably thought, “Oh no…not another Googling patient…”) and it was only when I mentioned I had another non-psychiatric condition that I’d previously received metformin for that he said, “Oh, in that case I can give it to you.”
I was pleased to have the prescription in my hands but it was something of a Pyrrhic victory – I wanted to be given metformin for the right reasons. I wanted to be given it because of antipsychotics and to be able to say to other patients like me, “Do the same – it might just help.” I wanted this because I know, statistically and anecdotally, that it’s not just me that’s having to put up with this offsetting for the sake of our mental health.
MY METFORMIN STORY SO FAR…
So has it made a difference? I have been on metformin for six weeks now and I’ve lost weight – 4lb to be precise. I have also reduced my waist measurement by three inches (Wu R, et al found in a 2008 study in JAMA that lifestyle intervention and metformin can not only reverse SGA-induced weight gain and increase insulin sensitivity but is also significantly superior when it comes to reductions in BMI and waist circumference).
I haven’t yet had my blood cholesterol and lipids tested but I’d like to hazard a guess that they’ll be creeping down, too, especially as I now have more energy to not only climb the stairs but also to seriously think about exercise for the first time in more than two years. This about-turn on several fronts is a total relief after more than two years of weight gain and the anxiety and low self-esteem that brought with it. The small downside has been a few bouts of an upset stomach but nothing too onerous.
I spoke to Professor Allan Young, head of the Centre for Affective Disorders at King’s College London’s Institute of Psychiatry, about metformin use with SGAs. He told me that although in other countries such as Canada, the guidelines allow for it to be given with antipsychotics, this isn’t the case in the UK (“The doctors in North America tend to be more adventurous,” he says).
However, he says: “There’s a reasonable body of evidence for its use with atypical antipsychotics and if patients come to me and say they want to be put on it, I put them on it. Although metformin isn’t without side-effects, it does help your cardiometabolic profile.” He says he has several patients who are on it, having presented him with evidence of its efficacy (incidentally, my diagnosing psychiatrist Dr Andy Zamar of the London Psychiatry Centre (www.psychiatrycentre.co.uk) has just told me he is now prescribing metformin with SGAs).
So can we look forward to all SGA users being given the option of having metformin as a matter of course in the next10 years? Newer SGA’s like Latuda look promising because they don’t increase weight or raise cardiometabolic factors to the same extent as existing SGA options.
But, as with all meds, it won’t necessarily suit everyone and many of us will remain on our current SGAs which will probably continue to cause our weight, blood lipids and cholesterol to creep up. For us, could adjunct metformin therapy be the answer and, if so, are we likely to see it being given as a matter of course in the next 10 years? Professor Young says: “Yes, on the balance of probability it’s likely metformin will be more used in the future.”
In the meantime, before it possibly becomes the norm, what can patients like me do to ensure we are given the opportunity to take metformin if we want it? Professor Young recommends printing out data in favour of its use and taking it to your prescribing doctor to show them that it has proven efficacy.
One 2014 study in the Journal of Multidisciplinary Healthcare states that ‘metformin has been identified as the medication having the strongest evidence for efficacy to reduce both weight gain and metabolic changes based on eleven available randomized control trials’ (Shulman, T et al, 2014). This could be a good place to start. Having at this early stage felt some benefits of metformin and SGA use, I would urge you to do it (although hopefully you’ll have more luck in convincing your doctor than I did).
With a good track record and increasing numbers of studies indicating it may be of benefit (plus, as your doctor probably knows, it’s cheap), this could be an opportunity to help get SGA-related weight gain and metabolic changes under control for people like you and me. I’m happy to offset lots of things in my life but maybe it’s time that offsetting mental wellness with feeling physically rubbish is something we should be challenging.
© 2014 Martha Roberts