Antidepressants least likely to cause weight gain
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Antidepressants least likely to cause weight gain
Q:
I am a fit and healthy person (30-something female) who was diagnosed
with depression one year ago and put on Paxil (paroxetine) 30 mg once
daily. I was sexually abused as a child (ages 7-12), and my case went to
trial about a year ago. During the trial he pled guilty, but the
totality of the stress overcame my usual coping mechanisms (vitamin B6,
exercise, journalling). During the past year I continued to exercise at
a fairly intense level (weight-lifting, aerobics, training for 10 K
runs), and my diet did not change (in fact, I experienced less craving
for carbohydrates during that time). Nevertheless, I gained 30 lbs over
the year which is extremely disheartening (depressing?).
I started to taper off the Paxil by dropping to 20 mg once daily for two
weeks and then to 10 mg for the last five days and have crashed and
burned. I have every physical symptom of withdrawal (nausea, dizziness,
diarrhea, sweating, loss of concentration), and as well the symptoms of
depression have returned (tearfulness, insomnia, low self-worth). My
doctor has switched me to Effexor (venlafaxine, 37.5 mg bid), but I am
understandably concerned about continuing to gain weight.
It seems clear to me now that I will have to continue on some kind of
antidepressant in order to function -- does anyone have any information
on which antidepressants are the least likely to cause weight gain? Or
any other useful suggestions? Please don't tell me to drink water, eat
less or exercise more -- the trainers at the gym are already commenting
on how much exercise I am doing!
I am now on Effexor 225 mg daily -- I take 112.5 mg in the am and 112.5
mg in the pm. I seem to be doing OK on the Effexor, but have gained a
little bit more weight (8-10 lbs). At this point I am 5'4" and weigh 195
lbs, which is way over what I should be and is not good for my health. I
have actually had to cut back my running and do other aerobic exercise
(cycling, stairmaster, etc.) because of this increased weight causing
pain in my knees. Any help or suggestions would be greatly appreciated!
Additionally, I did not tell you that the only reason that I began to
taper off the Paxil was because of my distress over the weight gain.
Otherwise it was fine.
A:
Date: Tue, 23 Dec 1997 14:15:27 -0500
From: Michael Mavroidis
Subject: Antidepressants least likely to cause weight gain
I am pretty sure that Wellbutrin (bupropion) is the antidepressant least
likely to promote weight gain. Also, trazodone has some use in this
regard if a sedating medication is desired. I have seen the propensity
of tricyclics to cause weight gain attributed to their
anti-histamine-1-receptor activity.
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From: Ivan Goldberg, New York
Date: Tuesday, December 23, 1997 4:37 PM
Subject: Antidepressants least likely to cause weight gain
It is mistakenly believed that antidepressants cause weight gain by
increasing appetite rather than having an impact on metabolism. Many
patients report gaining weight despite reports by them and their
companions that they are eating less than their usual amounts of food.
Back in the olden days, when it was possible to measure metabolism via
the BMR machine, someone studied the impact of antidepressants on basal
metabolism. In many patients a 15% reduction in basal metabolism was
found. This means that if such an individual did not wish to gain weight
while taking antidepressants, a 15% reduction in caloric intake would be
necessary just to maintain their weight.
BTW, it is impossible to increase one's total daily caloric expenditure
by increasing exercise.
It's time we stop blaming the victim and stop telling patients that if
they are gaining weight they must be eating more than they think.
Fernstrom Madelyn H, Epstein Leonard H, Spiker Duane G, Kupfer David J.
Resting metabolic rate is reduced in patients treated with
antidepressants. Biological Psychiatry 1985, 20: 692-695.
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From: Sanjeev K Singhal, Texarkana, AR
Subject: Antidepressants least likely to cause weight gain
Date: Tue, 23 Dec 1997 21:27:13 -0600
Some time back there was a posting on this list in which someone spelled
out why weight gain occurs on the various psychotropics that we use. It
is not only antidepressants, but mood stabilizers and antipsychotics as
well, which are responsible for weight gain. It might be too
reductionistic to assume that weight gain caused by drugs with
mechanisms of action as different as Depakote and Zyprexa is because of
the same explanation.
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Date: Tue, 23 Dec 1997 23:13:25 -0500
From: Ivan Goldberg, New York
Subject: Antidepressants least likely to cause weight gain
The purpose of my message was not to propose a single mechanism for a
all medication-related weight gain. It is pretty clear that in at least
some people, valproate, lithium, and TCAs do cause an increase in
appetite. My post was designed to remind people that in addition to a
possible increase in appetite, there also is a metabolic mechanism that
may be responsible for some weight gain observed in people taking
psychopharmaca.
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Date: Tue, 23 Dec 1997 19:33:44 -0800
From: Deborah Pines
Subject: Antidepressants least likely to cause weight gain
I have an adolescent who was placed on Wellbutrin and proceded to gain a
great deal of weight (I'm home, don't ask!).
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Date: Wed, 24 Sep [sic] 1997 12:17:50 +0200
From: Giorgio Padoan, Italy
Subject: Antidepressants least likely to cause weight gain
I have seen a man on venlafaxine (150 mg/day) increase his weight about
16% despite a reduction of the appetite and the quantity of calories
assumed daily. In these cases, I think, there is an evident metabolic
effect induced by the antidepressant drug.
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Date: Wed, 24 Dec 1997 05:33:23 -0500
From: Ivan Goldberg, New York
Subject: Antidepressants least likely to cause weight gain
At 11:33 PM 12/23/97 -0800, Wachob wrote:
And what happens when people go off the meds that cause weight gains? Is
the weight "permanent" or does the person tend to lose some of it when
the meds are decreased?
People tend to lose the weight over a period of months after they stop.
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From: Brent Menninger
Subject: Antidepressants least likely to cause weight gain
Date: Wed, 24 Dec 1997 06:27:59 -0600
Respectfully, I suggest that intensive psychotherapy be tried. With your
demonstrated work ethic you might be able to overcome the physical
symptoms due to your depression that you have noted. A support group for
those who have suffered abuse is often helpful. Remember, this is free
advice...
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Date: Wed, 24 Dec 1997 09:00:15 -050
From: Frances Stewart, Portsmouth, VA
Subject: Antidepressants least likely to cause weight gain
At 04:13 PM 12/23/97 -0500, Ivan Goldberg wrote:
BTW, it is impossible to increase one's total daily caloric expenditure
by increasing exercise.
That's not consistent with what I was taught about exercise physiology
or the research I've read.
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Date: Wed, 24 Dec 1997 11:15:33 -0500
From: Ivan Goldberg, New York
Subject: Antidepressants least likely to cause weight gain
What I meant to say is that no matter how much one does exercise during
the day, it is impossible to increase the number of calories that one
burns sufficiently to compensate for the 15-20% reduction in BMR that
can result from taking antidepressants.
Of course, increasing exercise increases the number of calories burned,
but unfortunately not enough to prevent many patients from gaining
weight.
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Date: Wed, 24 Dec 1997 08:46:00 -0800 (PST)
From: Ronald Shlensky
Subject: Antidepressants least likely to cause weight gain
My experience in over 30 years of running is that the running may have
burned some calories but that it primarily affected my metabolism in
some subtle manner which slimmed me down to my correct weight for size,
etc., and has allowed me to eat more or less as I choose... though I do
eat intelligently.
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Date: Wed, 24 Dec 1997 14:07:11 -0500 (EST)
From: James A. Thomson, Jr, Charlottesville, VA
Subject: Antidepressants least likely to cause weight gain
I've seen many women patients, ages 19-55, who have had good responses
to Paxil (paroxetine) only to have horrendous weight gain after being on
it for many months, sudden explosions of added pounds. Switched to other
SSRIs, Prozac (fluoxetine) or Zoloft (sertraline), they recaptured the
antidepressant response and quickly lost the weight. Paxil seems to be a
different animal than the others in some women.
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From: Sanjeev K Singhal, Texarkana, AR
Subject: Antidepressants least likely to cause weight gain
Date: Wed, 24 Dec 1997 15:27:42 -0600
Exercise does increase the basal metabolic rate. The effect, however, is
indirect. Exercise increases the muscle mass, which is one of the
factors in the BMR. The greater the muscle mass, the higher the BMR.
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Date: Wed, 24 Dec 1997 20:03:04 -0400
From: Adrian L. Charles, Barbados
Subject: Antidepressants least likely to cause weight gain
In addition, aerobic exercise increases the BMR by resetting its "set
point"... independently of muscle mass.
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Date: Thu, 25 Dec 1997 00:03:52 -0500
From: John M. Rathbun
Subject: Antidepressants least likely to cause weight gain
I'd like to weigh in with an opinion based on 27 years of reading about
psychotropic induced weight gain. I think this is very material to the
management of our patients on psychotropics.
It is said that you have to run for an hour to burn off the calories in
a piece of toast. This misses the point, and it's a disservice to tell
people such a thing.
Fitness professionals and body builders are believed to metabolize from
5000 to 10,000 Kcal daily, depending on how many hours a day they work
out and how much muscle mass they accumulate. Muscle tissue is
metabolically active, and a pound of muscle mass translates into a
certain number of calories burned in 24 hours, depending on whether it's
in a state of chronic partial activation (known as "muscle tone") or
not.
Our organism is designed for wandering around picking up fruits, nuts,
berries, grubs, roots, and wild grains. Occasionally one might catch a
skinny rabbit, throw it into the pot, and feed the whole family for a
week on the broth.
Modern life involves little that can be called exercise in the sense of
sustained fitness-building activity, paired with a diet that's rich
beyond the dreams of kings a hundred years ago. It's a deadly
combination.
Take a person who's too nervous or depressed to eat and give them a
treatment that makes them feel better, and they have the same problem as
the rest of us: too many calories in and not enough out. They may also,
as mentioned earlier, have appetite stimulation and some additional
suppression of metabolism. Don't underestimate the amount of energy
burned up by excess muscle tension in agitated or chronically anxious
persons, however.
If you could get these people to walk a couple of miles briskly every
day, their mood will benefit, and they'll likely age slower. Most of the
deterioration in appearance we attribute to old age is actually the
effect of deconditioning: atrophied muscles, demineralized bones, and
brittle connective tissue. Even people in their 80s can begin to reverse
these changes with a few weeks of exercise, with a doubling of motor
strength in a month or so.
Few people who work out a couple of hours every day are overfat. Please
note, however, that heavily muscled people will appear overweight with
life insurance tables and body mass index. Only skin calipers or some
other method of determining body composition can tell you if these
people are overfat.
It's hard to motivate people to exercise, especially when they're
overweight, out of shape, and demoralized. The commonest mistake I see
is to start out with the exercise program you could do 20 years ago,
which leads to a lot of injuries and makes it impossible to continue.
Many people with "chronic fatigue" or "fibromyalgia" are actually
suffering mainly from severe deconditioning coupled with chronic excess
muscle tension, probably arising as a variant of depression. Using
antidepressants, cognitive-behavioral psychotherapy, therapeutic massage
(often aided by a pulse of tramadol), and a graduated exercise program
that starts out very small, I've helped people who were literally in a
wheelchair with CFS build up their fitness to where they walk four miles
a day in under an hour. I have some 75 year old ladies in my practice
who walk four miles every day and wouldn't give it up for anything. One
of these delightful gals runs four miles every day!
The other group you can really help with an exercise program is
diabetics. The usual medical treatment for this condition in our
community is really deadly. I explain to them how muscle eats sugar and
fat eats insulin, and conversely how exogenous insulin leads to
increased appetite and accumulation of fat, a literal death spiral. I've
seen insulin dependent diabetics (poorly controlled on over 100 units a
day) throw away their syringes and control their sugar with diet and
exercise.
Exercise is the key to fat loss programs, IMO. If you try to lose weight
by diet alone, your metabolism slows down, you feel miserable, and
eventually you lose control. Moderate restriction combined with a
moderate increase in metabolic rate through exercise produces fat loss
without starvation.
Many persons with eating disorders have naive ideas about their
physiology which need to be countered through education. I've seen
attractive young athletes with 15% body fat complaining about their "fat
thighs" which were plainly very lean but heavily muscled. They can learn
to distinguish healthy weight from fat, to feel good about their strong,
athletic legs, and to nourish themselves adequately. Without such
education, many young women will continue to restrict, binge, and purge
(note the order; they think it's binge, purge, and restrict, but
actually the restriction comes first and triggers the rest).
Please pardon the long post. I think this is an extremely important area
in which psychiatrists are uniquely able to help our patients, since we
have (or should have) the interpersonal sensitivity to motivate our
patients together with the biological background to provide credible
information. Of course, psychoeducational approaches take more than five
or ten minutes to implement, so Milliman and Robertson would discourage
us from using them. The long term costs of such negligent practice will
be staggering.
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Date: Thu, 25 Dec 97 16:57:41 EST
From: David Epstein, NJ
Subject: Antidepressants least likely to cause weight gain
It was a great post. Even so, I think it should be borne in mind that at
least some cases of CFS can be biologically distinguished from
depression (I point this out because I still hear some folks dismiss CFS
as "just subclinical depression," and if the post were misread, it could
contribute to that argument). The articles below are what I'm talking
about...
* Cleare AJ, Bearn J, Allain T, McGregor A, Wessely S, Murray RM,
O'Keane V. Contrasting neuroendocrine responses in depression and
chronic fatigue syndrome. Journal of Affective Disorders. 34 (4): 283-9,
1995 Aug 18.
Hypothalamic-pituitary-adrenal (HPA) axis and central 5-HT function were
compared in chronic fatigue syndrome (CFS), depression and healthy
states. 10 patients with CFS and 15 patients with major depression were
matched for age, weight, sex and menstrual cycle with 25 healthy
controls. Baseline-circulating cortisol levels were highest in the
depressed, lowest in the CFS and intermediate between the two in the
control group (P = 0.01). Prolactin responses to the selective
5-HT-releasing agent d-fenfluramine were lowest in the depressed,
highest in the CFS and intermediate between both in the healthy group (P
= 0.01). Matched pair analysis confirmed higher prolactin responses in
CFS patients than controls (P = 0.05) and lower responses in depressed
patients than controls (P = 0.003). There were strong inverse
correlations between prolactin and cortisol responses and baseline
cortisol values. These data confirm that depression is associated with
hypercotisolaemia and reduced central 5-HT neurotransmission and suggest
that CFS may be associated with hypocortisolaemia and increased 5-HT
function. The opposing responses in CFS and depression may be related to
reversed patterns of behavioural dysfunction seen in these conditions.
These findings attest to biological distinctions between these
disorders.
* Sharpe M, Hawton K, Clements A, Cowen PJ. Increased brain
serotonin function in men with chronic fatigue syndrome. BMJ. 315
(7101): 164-5, 1997 Jul 19.
* Demitrack MA. Neuroendocrine correlates of chronic fatigue
syndrome: a brief review. Journal of Psychiatric Research. 31 (1):
69-82, 1997 Jan-Feb.
Chronic fatigue syndrome remains one of the more perplexing syndromes in
contemporary clinical medicine. One approach to understanding this
condition has been to acknowledge its similarities to other disorders of
clearer pathophysiology. In this review, a rationale for the study of
neuroendocrine correlates of chronic fatigue syndrome is presented,
based in part on the clinical observation that asthenic or fatigue
states share many of the somatic symptom characteristics seen in
recognized endocrine disorders. Of additional interest is the
observation that psychological symptoms, particularly disturbances in
mood and anxiety, are equally prominent in this condition. At this time,
several reports have provided replicated evidence of disruptions in the
integrity of the hypothalamic-pituitary-adrenal axis in patients with
chronic fatigue syndrome. It is notable that the pattern of the
alteration in the stress response apparatus is not reminiscent of the
well-understood hypercortisolism of melancholic depression but, rather,
suggests a sustained inactivation of central nervous system components
of this system. Recent work also implicates alterations in central
serotonergic tone in the overall pathophysiology of this finding. The
implications of these observations are far from clear, but they
highlight the fact that, though chronic fatigue syndrome overlaps with
the well-described illness category of major depression, these are not
identical clinical conditions.
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Date: Thu, 25 Dec 1997 11:05:24 -0500
From: Paul Luisada
Subject: Antidepressants least likely to cause weight gain
I agree with Ivan: the weight gain is not due to increased consumption
or to a change to favor high calorie foods, which I also once thought.
In my experience, doses of T4 in the normal physiologic range
(sufficient to drop the TSH to nearly the minimum) do nothing to help
with antidepressant-induced weight gain. Doses slightly higher than that
(TSH essentially zero), given accidentally, don't change the picture. I
have no experience with hypermetabolic doses, but perhaps someone does.
If it's not through increasing consumption and not via thyroid hormone
effects, then how do the antidepressants influence metabolism?
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Date: Thu, 25 Dec 1997 08:46:42 -1000
From: Leslie Gise, Kula, HI
Subject: Antidepressants least likely to cause weight gain
There is a lot we do not know about exercise and weight gain. Sedentary
women have been compared to elite athletes and there are differences in
metabolism that we cannot explain. Elite athletes have a much more
efficient metabolism and eat much less than you would think for working
out so many hours a day! Sedentary women can certainly benefit from
walking, physically and mentally. Obese women certainly underestimate
their food intake. We need more studies.
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Date: Fri, 26 Dec 1997 11:39:00
From: Richard Brand, Bardonia, NY
Subject: Antidepressants least likely to cause weight gain
I have read of some "elite" football athletes (recent NY Times Sunday
Magazine section about today's larger players) and Olympic athletes who
eat an average 6-10,000 calories daily in order to maintain their weight
and stamina.
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Date: Sat, 27 Dec 1997 07:22:16 -0500
From: Willie K. Yee, New Paltz, NY
Subject: Antidepressants least likely to cause weight gain
I know that professional cyclists, e.g., those who ride in the Tour de
France, 150 Km or so per day for weeks, eat about 8000 cal/day during
the racing season.
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From: Ileana Taddei, Rome
Subject: Antidepressants least likely to cause weight gain
Date: Thu, 25 Dec 1997 23:49:36 +0100
Zimmermann et al have published the results of a pilot study which
suggests that opiate receptor blockade by naltrexone may be useful in
reducing hunger and food craving in patients treated with TCAs and
lithium (Biol Psychiatry, 1997, 41: 747-749). Appetite regulation is
also under opioidergic control. Acute blockade of opiate receptors
causes decreased food ingestion and diminishes hunger. Opioid function
might be modulated by TCAs, which can displace ligands from mu and k
receptors.
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From: Barry Schwartz
Date: Thu, 25 Dec 1997 22:36:10 -0500 (EST)
Subject: Antidepressants least likely to cause weight gain
I have been asking women who complain of weight gain, usually after they
are no longer depressed, "What did your mother weigh when she was your
age?" The answer is usually that Mom weighed more.
My theory: this is apparent weight gain because their weight earlier was
"controlled" via depression. They get "undepressed", and their appetite
returns to what it might normally be and it's perceived that the meds
caused the weight gain.
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Date: Fri, 26 Dec 1997 10:27:16 +0100
From: Giorgio Padoan, Italy
Subject: Antidepressants least likely to cause weight gain
Perhaps, at least in part, for the antidepressant drugs, the weight gain
could be also a consequence of an increase of bowel stasis, with an
increase of intestinal absorption.
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Date: Fri, 26 Dec 1997 09:35:26 -0800 (PST)
From: Ronald Shlensky
Subject: Antidepressants least likely to cause weight gain
It's clearly fluid retention at times.
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Date: Fri, 26 Dec 1997 21:24:52 -0500
From: John M. Rathbun
Subject: Antidepressants least likely to cause weight gain
Mr. Pizor raises an area which I inadvertantly overlooked regarding the
role of exercise programs in the rehabilitation of chemically dependent
persons. It reminds me of a young man who made an exemplary recovery
from mainlining opiates. After several unsuccessful treatment attempts,
he found himself at Hazelden playing basketball one afternoon. He
suddenly realized that he'd found a way to get "high" without using
drugs. As he told me five or ten years later, that was the defining
moment in his recovery. Good luck on your interesting study, Gordon!
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Date: Mon, 29 Dec 1997 08:01:28 -0600 (CST)
From: Russell Gardner, Galveston, TX
Subject: Antidepressants least likely to cause weight gain
I've had Wellbutrin produce weight gain. I use Effexor for those
patients concerned about that, so far without complaint.
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From: Chester Pearlman
Subject: Antidepressants least likely to cause weight gain
Date: 29 Dec 97 09:14 EST
The data in the citation by Dr. Goldberg (Fernstrom et al, Biol
Psychiatry 1985, 20: 692-695) are less generalizable than implied in his
discussion. The study involved two patients on tricyclics followed for a
month. The reductions in BMR (also "resting" RMR) were significant, but
only one gained weight during the study period. The authors concluded
that a patient might be expected to gain a pound every 9-12 days without
caloric restriction, but the five-year maintenance outcome report from
this group (Kupfer David J, Frank Ellen F, Perel James M, Cornes Cleon,
et al. Five-year outcome for maintenance therapies in recurrent
depression. Arch Gen Psychiatry 1992, 49: 769-773, 1992) does not
mention this or obesity. My patients who gained weight on tricyclics
often had associated factors, such as age-related decline in RMR and
stress-induced eating, which made the role of the drug questionable. All
had the difficulty with caloric restriction generally associated with
obesity.
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Date: Mon, 12 Jan 1998 10:51:47 -0500
From: Henry Rosenblat
Subject: Antidepressants least likely to cause weight gain
I have had 2 cases of depressed women with chronic pain who experienced
significant improvement with nortriptyline (75 mg and 125 mg), but had
rapid weight gain of about 20 pounds. In the hopes of reducing the
weight gain, but maintaining the valuable hypnotic effect, I reduced the
nortriptyline and added fluvoxamine (in my experience the only reliably
hypnotic SSRI) 25 mg. This resulted in the maintenance of the
antidepressant effect and the hypnotic effect with a drop in appetite to
a normal level.
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Revised: September 23, 1998
URL: http://uhs.bsd.uchicago.edu/dr-bob/rxqx/antidepressants-weight.html
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