Obesity often brings about, or exacerbates, depression and anxiety. Yet some of the most effective drugs for managing depression are also known to cause weight gain. Your patients, then, may worry about the cause-and-effect of popular treatments.
This pushback may be brought up early on regarding these types of medications, or a patient may express concern over drug-induced weight gain in follow-up appointments.
If you are prescribing selective serotonin reuptake inhibitors including Celexa (citalopram), Lexapro (escitalopram), Prozac (fluoxetine) or Zoloft (sertraline), which can ease symptoms of moderate-to-severe depression by keeping specific chemical messengers active in the brain, your patients likely will have questions about weight gain. Expressing candor over the possible side effects is warranted, but a discussion about what patients can do to counter such risk is important. These drugs can be life changing, so here’s how to offer your patients guidance.
Prioritizing Patient Care
Improved mood is vital to patients that experience depression, but many will be concerned about potential weight gain, or of gained weight since you first prescribed the drugs.
Physicians should have a transparent discussion about the potential side effects of antidepressants, as weight is one of the leading reasons patients stop taking antidepressants, or decline to start altogether, said Brintha Vasagar, MD, a family physician and chief medical officer of Progressive Community Health Centers in Milwaukee. But she said it’s also important to remember that depression itself can also contribute to weight gain, and the average amount is small — < 4 lb.
When it comes to deciding on a medication, choices should be personalized by the patient.
“Many patients are worried about starting an antidepressant because they worry weight gain will worsen their mental health,” Vasagar added. “This is a very individual decision, and it can be helpful to share that the average weight gain with antidepressant use is small, though this varies from person to person.”
She noted that duloxetine (Cymbalta) and bupropion (Wellbutrin) have shown the lowest average weight gain and can be good medication choices for patients who are anxious about this side effect.
It can also prove helpful to suggest lifestyle tips to offset potential weight gain, such as:
• Avoiding alcohol, which is both a good choice for depression and has the added benefit of reducing caloric intake.
• Partaking in regular exercise, which has been shown to help depression and helps burn calories.
• Making healthier dietary choices, like cutting down on ultra-processed foods, which can benefit both mental health and weight.
• Trying meditation can benefit both mental health and weight.
Primary care physicians should continue with patients to find a plan that works best for each person.
“Some patients will be able to navigate weight side effects using the above tips, while others will want to change or stop medications,” Vasagar said. “It’s important to let patients decide which symptoms are intolerable and find the balance between improvement in mental health and side effects.”
If such tweaks aren’t preventing weight gain to the patient’s satisfaction, the next steps should be discussed. Your patients should have a voice in their healthcare decisions.
“I will explain the risks and benefits of medication for depression and encourage counseling. For patients who struggle with weight despite lifestyle changes, we have a candid conversation about which symptoms are most distressing to them and make a joint decision of the best path forward,” said Vasagar.
Understanding the Pivotal Role of Primary Care Doctors
Mark Loafman, MD, a family physician with Cook County Health, Chicago, said patients deserve to be counseled about medication’s side effects. But he said it’s challenging to do so without discouraging patients from giving treatment a chance to see how it works.
“We can’t help but observe how this differs when discussed in the doctor’s office vs pharmaceutical industry ads in media. The ads always include a rapid-fire list of ‘pretty scary side effects’ while the images portray a healthy-looking patient having the best time,” said Loafman. “Our doctor-patient chats about risks and benefits don’t carry that kind of marketing appeal which I am sure influences the way we discuss potential side effects.”
As a primary care doctor, he considers weight gain and current weight when choosing medications.
“We can make adjustments in treatment if issues arise during treatment,” he said. “Patients should be open about their concerns and follow their weight during treatment, which will help their doctor include weight in the overall treatment plan.”
How to Handle Follow-Ups
Primary care and family doctors should be a coach and facilitator for their patients and should be ready to either make a change in treatment or include weight-loss treatment as part of the overall treatment plan, Loafman said. Considerations can include how well the medication is working from a mental health perspective, whether there are other medications that may also work without causing as much weight gain, and if there are other side effects or reasons to consider a medication change.
And if a patient does experience weight gain, there are additional options.
“We have some really good weight-loss treatment options now, so if the behavioral health treatment is working well except for weight gain, it is very appropriate to include weight-loss treatment as part of the overall treatment plan,” he added.
In his own practice, Loafman said he follows a comprehensive primary care approach outlined above, including weight, diet, and lifestyle as part of the overall treatment plan, making an effort to discuss weight, body shape, and lifestyle with compassion and empathy, and also encouraging patients to set reasonable goals and address their success or lack there-off without blame and shame.