The Mystery Suspect in the U.S. "Obesity Epidemic"

If you wanted to make someone feel helpless, hopeless, even crazy, one good way to do it would be this: Teach them that others will value them mostly for being thin and being nurturant, put them in situations where they are too agitated or sad to be cheerleaders and caretakers for family and friends, and when they ask for help in getting back to their duties, give them a pill that may calm them down or pep them up but will have a good chance of increasing their weight. This has been the fate of women in untold numbers but certainly in the millions, and women’s position in American society makes them more likely than men to feel ashamed for their part in what is being called this country’s obesity epidemic.

Hardly a week goes by without some media story about the causes of this epidemic, which is described as including two-thirds of American adults classified as overweight – more than 130 million, nearly half of whom are labeled “obese,” usually described as, for women, having a greater than 30% body fat composition. The most-touted causes are fast food, large meal portions, and sedentary lifestyles. Prominent individuals like former President Bill Clinton and various government agencies have heavily invested time, energy, and money in getting junk food vending machines out of public schools and urging Americans to eat less, eat more healthily, and get up off the couch and into the gym.

Undoubtedly, all these factors can play roles in weight gain. But there is a largely unnoticed suspect in this epidemic, and that is the skyrocketing use of psychotropic drugs that Americans ingest. The increase in the average American’s weight has paralleled the warp speed increase in use of anti-depressants, anti-anxiety drugs, and the drugs marketed as anti-psychotics. It seems astonishing in light of recent, high-profile media exposés of drug companies’ concealment of adverse effects of their products.

Psychologist David Cohen estimates that 50 million Americans -- 1 in 6 Americans -- take psychotropic medication, and it is unknown how many of these are taking more than one kind simultaneously. Polypharmacy, the addition of increasing numbers of such drugs in the hope that a patient’s symptoms will abate or the negative effects of earlier drugs will disappear, is increasingly common. What’s worse, a series of scandals in recent years has revealed that the U.S. Food and Drug Administration, which is charged with ensuring that only safe and effective drugs hit the market, has approved many drugs without holding the drug companies to good standards of research. One of the most common but least talked-about negative effects of a wide variety of psychotropic drugs – including many of those marketed to treat depression, anxiety, and psychosis – is weight gain, often tremendous weight gain.

A huge, unaddressed question is what explains the silence of government officials responsible for health issues and most of the media on the relationship between psychiatric drugs and the obesity epidemic. Is it related to reliance of many media on drug company advertising dollars and to connections between government and the drug lobby?

The mechanisms of weight gain from psychiatric drugs are far from well understood and appear to be complex. Proposed explanations include some drugs’ possibly leading to food cravings by impairing the central nervous system’s energy intake control and other drugs’ possibly affecting metabolism. What is even less understood is the way that multiple psychotropic drugs interact with each other within a patient.

In a New York Times exposé in December, 2006, Alex Berenson reported that Eli Lilly had told its sales force to play down the fact that 30% of patients gain at least 22 pounds after a year or more on their drug Zyprexa, which is FDA-approved for treatment of schizophrenia and bipolar disorder but also often prescribed for dementia, psychotic depression, autism and developmental disorders, and, less often, delirium, aggressive behavior, personality disorders, and posttraumatic stress disorder. Some studies show weight gains of 15 to 20 pounds on many drugs sold to treat depression, and one study showed a tripled incidence of obesity in patients on lithium compared to the general population.

So here is what leaves many patients, especially women, totally in the dark when they find they are ravenous or, for whatever reason, that their body no longer handles food and weight as it did: The combination of some companies’ concealment of data about weight gain, some doctors’ lack of information, and some doctors’ tendency to fail to mention or minimize such negative effects – on the grounds that patients will refuse to try the drugs or imagine they are experiencing negative effects, an attitude doctors often seem more likely to have toward women than men patients.

As a clinician, I have heard from countless patients that when they told their prescribing physicians about weight gain after starting psychiatric drugs, they were usually told to stop eating so much and start exercising more. Often, especially the women, were told that there is a simple mathematical relationship: The more you eat, and the less you exercise, the more weight you gain. Thus, even the little that is understood about the drugs themselves – rather than patients’ lack of self-control and discipline – radically altering weight-gain and hunger mechanisms – is too frequently omitted from the picture. Women, who tend more than men to be socialized to blame themselves for every problem, are particularly susceptible to blaming themselves and feeling deeply ashamed about weight gain.

Virtually everyone who starts taking a psychotropic drug does so because they are suffering. To compound that suffering by uninformed and inaccurate exhortations to “watch your weight,” when your weight is increasing for reasons that are largely beyond your control and that have not even been explained to you is devastating and inexcusable.

Precisely because of the silences about this topic, there is no way of calculating how much these drugs are adding to people’s weight, but prescriptions for Zyprexa alone run in the millions, and in 2004, 32.6 million Americans filled prescriptions for drugs marketed as antidepressants, stimulants, antipsychotics, and tranquilizers, up from the 1997 figure of 21 million. (Stimulants often lead to loss of appetite, but the other drug classes often have the opposite effect, and these figures do not even include inpatients who take drugs.) The total number of antidepressant purchases alone skyrocketed from 88.3 million in 1997 to 161.2 million in 2004, and the number of people who reported making such purchases increased from 15.3 million to 24.8 million.

It is alarming enough that inadequately tested psychiatric drugs are leading to weight gain, diabetes, heart problems, and death in adults, but at least their central nervous systems (CNS) are mature. What is worse is that these same drugs are even less likely to have been tested on anyone younger than adults, and there are exceedingly few longterm studies on toddlers, schoolchildren, and adolescents, whose central nervous systems have a long way to go to reach maturity. The lack of information about possible effects on the CNS of toddlers through adolescents is especially worrying in light of the huge increases in prescriptions for these age groups of not only antidepressants and stimulants but even of drugs prescribed as mood stabilizers and anti-psychotics.

The ballooning, unchecked size and power of pharmaceutical companies over the past two decades in the United States – power born partly of the legalization of direct-to-consumer drug advertising, a phenomenon that many people from Canada and other countries find shocking – is, of course, a major contributor to this set of problems. So is woefully inadequate government oversight. But one has to wonder whether most Americans have failed to make the drugs-weight connection partly due to the saturation of Americans in the psychiatrizing of every problem – whether the consequences of violence, poverty, oppression, an absurdly overworked populace and intense alienation and isolation of citizens from each other and from a sense of community or whether from more individual and family emotional difficulties – and to their having been persuaded that drugs will provide quick, effective fixes that are the only things their time and incomes will afford.

More than for men, it is hard for women to feel good about themselves if they don’t find a way to get back in the caretaking saddle as fast as possible. But research has shown that a woman walking into a therapist’s or family practitioner’s office is more likely than a man with exactly the same emotional problems or concerns to be diagnosed as mentally ill, and the process of psychiatric diagnosis has been shown to be almost totally unscientific, thereby allowing bias even freer rein. A racialized or victimized woman is even more likely to be pathologized than other women. Once psychiatrically labeled, decades of research have shown that a woman is more likely than a man to be prescribed psychotropic medications and to have her complaints about negative effects (cannily called “side” effects by drug company marketers) ignored or blamed on her.

People labelled as mentally ill often learn to attribute all their problems - including eating more - to being mentally ill. This makes it especially troubling that in an article last May in the American Journal of Psychiatry, two doctors proposed that obesity be classified as a mental illness. One likely consequence of that would be another massive increase in the prescribing of psychotropic drugs, resulting, no doubt, in another upsurge in obesity statistics.

As a beginning step, everyone who considers taking a psychiatric drug ought be to enabled to make a decision about filling that prescription that is fully informed. This means that government, the media, and certainly physicians need energetically to educate themselves and the public about these matters and to insist that pharmaceutical companies disclose the extent of weight gain their drugs cause.