The Canadian Network for Mood and Anxiety Treatments (Canmat) Task Force Recommendations for the Management of Patients with Mood Disorders and Comorbid Metabolic Disorders
Restricted accessReview articleFirst published online February, 2012
The Canadian Network for Mood and Anxiety Treatments (Canmat) Task Force Recommendations for the Management of Patients with Mood Disorders and Comorbid Metabolic Disorders
One goal of the Canadian Network for Mood and Anxiety Treatments (CANMAT) is to develop evidence-based and best practice educational programs and recommendations. Our group conducted a comprehensive literature review to provide evidence-based recommendations for treating metabolic comorbidity in individuals with major depressive disorder (MDD) and bipolar disorder (BD).
Methods
We searched PubMed for all English-language articles published January 1966 to November 2010 using BD and MDD cross-referenced with metabolic syndrome, obesity, diabetes mellitus, hypertension, and dyslipidemia. That search was augmented by a review of articles reporting outcomes of an intervention targeting components of metabolic syndrome in individuals with MDD or BD.
Results
Consensus exists for the recommendation that individuals with MDD and BD should be routinely screened for risk factors that increase risk for metabolic syndrome. For excess weight, the best-studied pharmacologic approaches are metformin and topiramate, with emerging evidence for liraglutide and modafinil. For binge eating disorder, the best evidence in mood disorders was for cognitive-behavioral therapy as well as topiramate, zonisamide, and in select cases selective serotonin reuptake inhibitors. For dysglycemia, dyslipidemia, and hypertension, evidence supports cognitive-behavioral interventions and anti-diabetic, antilipidemic, and antihypertensive treatments.
Conclusions
Comprehensive care of individuals with mood disorders should include routine evaluation of the risk and presence of metabolic syndrome and its components. Systematic evaluation of preventative and targeted treatments of metabolic syndrome in mood disorder populations is insufficient.
McIntyreRS, RasgonNL, KempDE, . Metabolic syndrome and major depressive disorder: co-occurrence and pathophysiologic overlap. Curr Diab Rep. 2009;9(1):51–59.
2.
McIntyreRS, DanilewitzM, LiauwSS, . Bipolar disorder and metabolic syndrome: an international perspective. J Affect Disord. 2010;126:366–387.
3.
TaylorV, MacQueenG.Associations between bipolar disorder and metabolic syndrome: a review. J Clin Psychiatry. 2006;67:1034–1041.
4.
KrishnanKR.Psychiatric and medical comorbidities of bipolar disorder. Psychosom Med. 2005;67:1–8.
5.
McIntyreRS, SoczynskaJK, KonarskiJZ, . Should depressive syndromes be reclassified as “metabolic syndrome type II”?Ann Clin Psychiatry. 2007;19:257–264.
6.
KapczinskiF, VietaE, AndreazzaAC, . Allostatic load in bipolar disorder: implications for pathophysiology and treatment. Neurosci Biobehav Rev. 2008;32: 675–692.
7.
McIntyreRS, KennaHA, NguyenHT, . Brain volume abnormalities and neurocognitive deficits in diabetes mellitus: points of pathophysiological commonality with mood disorders?Adv Ther. 2010;27:63–80.
8.
NgF, MammenOK, WiltingI, . The International Society for Bipolar Disorders (ISBD) consensus guidelines for the safety monitoring of bipolar disorder treatments. Bipolar Disord. 2009;11:559–595.
9.
FriedmanJI, WallensteinS, MoshierE, . The effects of hypertension and body mass index on cognition in schizophrenia. Am J Psychiatry. 2010;167:1232–1239.
10.
YimCY, SoczynskaJK, KennedySH, . The effect of overweight/obesity on cognitive function in euthy-mic individuals with bipolar disorder [published online ahead of print May 11, 2011]. Eur Psychiatry. doi:10.1016/j.eurpsy.2011.02.004.
11.
DrussBG, BradfordWD, RosenheckRA, . Quality of medical care and excess mortality in older patients with mental disorders. Arch Gen Psychiatry. 2001;58:565–572.
12.
GansRO.The metabolic syndrome, depression, and cardiovascular disease: interrelated conditions that share pathophysiologic mechanisms. Med Clin North Am. 2006;90(4):573–591.
13.
National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002;106:3143–3421.
14.
FordES, GilesWH, DietzWH.Prevalence of the metabolic syndrome among US adults: findings from the third National Health and Nutrition Examination Survey. JAMA. 2002;287:356–359.
15.
HuG, QiaoQ, TuomilehtoJ, . Prevalence of the metabolic syndrome and its relation to all-cause and cardiovascular mortality in nondiabetic European men and women. Arch Intern Med. 2004;164:1066–1076.
16.
LaaksonenDE, LakkaHM, NiskanenLK, . Metabolic syndrome and development of diabetes mellitus: application and validation of recently suggested definitions of the metabolic syndrome in a prospective cohort study. Am J Epidemiol. 2002;156:1070–1077.
17.
DesprésJP, LemieuxI, BergeronJ, . Abdominal obesity and the metabolic syndrome: contribution to global cardiometabolic risk. Arterioscler Thromb Vasc Biol. 2008;28:1039–1049.
18.
GrundySM, CleemanJI, DanielsSR, ; American Heart Association; National Heart, Lung, and Blood Institute. Diagnosis and management of the metabolic syndrome: an American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. Circulation. 2005;112:2735–2752.
19.
RasgonNL, AltshulerLL, FairbanksL, . Reproductive function and risk for PCOS in women treated for bipolar disorder. Bipolar Disord. 2005;7:246–259.
20.
LindleySE, SchroderCM, O'HaraR, . Insulin resistance in schizophrenia, major depression, and bipolar disorder. In: RasgonNL, ed. Insulin resistance syndrome and neuropsychiatric disease.New York, NY: Informa Healthcare; 2008:49–86.
21.
ThomasC, HypponenE, PowerC.Obesity and type 2 diabetes risk in midadult life: the role of childhood adversity. Pediatrics. 2008;121: e1240–e1249.
22.
De AlmeidaKM, MoreiraCL, LaferB.Metabolic syndrome and bipolar disorder: what should psychiatrists know? [published online ahead of print February 26, 2011]. CNS Neurosci. doi:10.1111/j.1755-5949.2011.00240.
23.
FagioliniA, FrankE, ScottJA, . Metabolic syndrome in bipolar disorder: findings from the Bipolar Disorder Center for Pennsylvanians. Bipolar Disord. 2005;7:424–430.
24.
McIntyreRS, WoldeyohannesHO, SoczynskaJK, . The rate of metabolic syndrome in euthymic Canadian individuals with bipolar I/II disorder. Adv Ther. 2010;27:828–836.
25.
KempDE, GaoK, ChanPK, . Medical comorbidity in bipolar disorder: relationship between illnesses of the endocrine/metabolic system and treatment outcome. Bipolar Disord. 2010;12:404–413.
26.
CalkinC, van de VeldeC, RuzickováM, . Can body mass index help predict outcome in patients with bipolar disorder?Bipolar Disord. 2009;11:650–656.
27.
OsbyU, BrandtL, CorreiaN, . Excess mortality in bipolar and unipolar disorder in Sweden. Arch Gen Psychiatry. 2001;58:844–850.
28.
VinogradovaY, CouplandC, Hippisley-CoxJ, . Effects of severe mental illness on survival of people with diabetes. Br J Psychiatry. 2010;197:272–277.
29.
SpeakmanJR.Obesity: the integrated roles of environment and genetics. J Nutr. 2004;134:(8 suppl)2090S–2105S.
30.
FlegalKM, CarrollMD, OgdenCL, . Prevalence and trends in obesity among US adults, 1999-2000. JAMA. 2002;288:1723–1727.
31.
HedleyAA, OgdenCL, JohnsonCL, . Prevalence of overweight and obesity among US children, adolescents, and adults, 1999-2002. JAMA. 2004;291:2847–2850.
32.
OgdenCL, FlegalKM, CarrollMD, . Prevalence and trends in overweight among US children and adolescents, 1999-2000. JAMA. 2002;288:1728–1732.
33.
MustA, SpadanoJ, CoakleyEH, . The disease burden associated with overweight and obesity. JAMA. 1999;282:1523–1529.
34.
LambertTJ, VelakoulisD, PantelisC.Medical comorbidity in schizophrenia. Med J Aust.2003;178 suppl:S67–S70.
35.
EvansDL, CharneyDS.Mood disorders and medical illness: a major public health problem. Biol Psychiatry. 2003;54:177–180.
36.
OsbyU, CorreiaN, BrandtL, . Mortality and causes of death in schizophrenia in Stockholm county, Sweden. Schizophr Res. 2000;45:21–28.
GaddeKM, XiongGL.Bupropion for weight reduction. Expert Rev Neurother. 2007;7:17–24.
39.
BowdenCL, CalabreseJR, KetterTA, . Impact of lamotrigine and lithium on weight in obese and nonobese patients with bipolar I disorder. Am J Psychiatry. 2006;163:1199–1201.
40.
PasumarthyL, SrourJ.Nonalcoholic steatohepatitis: a review of the literature and updates in management. South Med J. 2010;103:547–550.
41.
AlsuwaidanMT, KucyiA, LawCW, . Exercise and bipolar disorder: a review of neurobiological mediators. Neuromolecular Med. 2009;11:328–336.
42.
BarbourKA, EdenfieldTM, BlumenthalJA.Exercise as a treatment for depression and other psychiatric disorders: a review. J Cardiopulm Rehabil Prev. 2007;27:359–367.
43.
Alvarez-JimenezM, HetrickSE, Gonzalez-BlanchC, . Non-pharmacological management of antipsychotic-induced weight gain: systematic review and meta-analysis of randomised controlled trials. Br J Psychiatry. 2008;193:101–107.
44.
ToplakH, HamannA, MooreR, . Efficacy and safety of topiramate in combination with metformin in the treatment of obese subjects with type 2 diabetes: a randomized, double-blind, placebo-controlled study. Int J Obes (Lond). 2007;31:138–146.
45.
RaisonCL, KleinHM.Psychotic mania associated with fenfluramine and phentermine use. Am J Psychiatry. 1997;154:711.
46.
AlgerSA, MaloneM, CerulliJ, . Beneficial effects of pharmacotherapy on weight loss, depressive symptoms, and eating patterns in obese binge eaters and non-binge eaters. Obes Res. 1999;7:469–476.
47.
RothmanRB, HendricksEJ.Phentermine cardiovascular safety. Am J Emerg Med. 2009;27:1010–1013.
48.
McClendonKS, RicheDM, UwaifoGI.Orlistat: current status in clinical therapeutics. Expert Opin Drug Saf. 2009;8:727–744.
49.
GreenwayFL, FujiokaK, PlodkowskiRA, . Effect of naltrexone plus bupropion on weight loss in overweight and obese adults (COR-I): a multicentre, randomised, double-blind, placebo-controlled, phase 3 trial. Lancet. 2010;376:595–605.
50.
Padwal ContraveR., a bupropion and naltrexone combination therapy for the potential treatment of obesity. Curr Opin Investig Drugs. 2009;10:1117–1125.
51.
WaddenTA, ForeytJP, FosterGD, . Weight loss with naltrexone SR/bupropion SR combination therapy as an adjunct to behavior modification: the COR-BMOD Trial. Obesity (Silver Spring). 2011;19:110–120.
52.
FryeMA, GrunzeH, SuppesT, . A placebo-controlled evaluation of adjunctive modafinil in the treatment of bipolar depression. Am J Psychiatry. 2007;164:1242–1249.
53.
MakrisAP, RushCR, FrederichRC, . Wakepromoting agents with different mechanisms of action: comparison of effects of modafinil and amphetamine on food intake and cardiovascular activity. Appetite. 2004;42:185–195.
54.
MaayanL, VakhrushevaJ, CorrellCU.Effectiveness of medications used to attenuate antipsychotic-related weight gain and metabolic abnormalities: a systematic review and meta-analysis. Neuropsychopharmacology. 2010;35:1520–1530.
55.
WangPW, YangYS, ChandlerRA, . Adjunctive zonisamide for weight loss in euthymic bipolar disorder patients: a pilot study. J Psychiatr Res. 2008;42:451–457.
AstrupA, RössnerS, Van GaalL, . Effects of liraglutide in the treatment of obesity: a randomised, double-blind, placebo-controlled study. Lancet. 2009;374:1606–1616.
58.
FlintA, RabenA, AstrupA, . Glucagon-like peptide 1 promotes satiety and suppresses energy intake in humans. J Clin Invest. 1998;101:515–520.
59.
LiZ, MaglioneM, TuW, . Meta-analysis: pharmacologic treatment of obesity. Ann Intern Med. 2005;142:532–546.
60.
BlackburnGL, HutterMM, HarveyAM, . Expert panel on weight loss surgery: executive report update. Obesity (Silver Spring). 2009;17:842–862.
61.
KellyJJ, ShikoraS, JonesDB, . Best practice updates for surgical care in weight loss surgery. Obesity (Silver Spring). 2009;17:863–870.
62.
TaylorVH, MisraM.Bariatric surgery in patients with bipolar disorder: an emerging issue. J Psychiatry Neurosci.2009;34:E3–E4.
63.
NickelMK, LoewTH, BachlerE.Change in mental symptoms in extreme obesity patients after gastric banding, Part II: six-year follow up. Int J Psychiatry Med. 2007; 37:69–79.
64.
LoveRJ, LoveAS, BowerS, . Impact of antidepressant use on gastric bypass surgery patients’ weight loss and health-related quality-of-life outcomes. Psychosomatics. 2008;49:478–486.
65.
BlackDW, GoldsteinRB, MasonEE.Psychiatric diagnosis and weight loss following gastric surgery for obesity. Obes Surg. 2003;13:746–751.
66.
KalarchianMA, MarcusMD, LevineMD, . Relationship of psychiatric disorders to 6-month outcomes after gastric bypass. Surg Obes Relat Dis. 2008; 4:544–549.
67.
McElroySL, KotwalR, KeckPEJr, . Comorbidity of bipolar and eating disorders: distinct or related disorders with shared dysregulations?J Affect Disord. 2005;86:107–127.
68.
McElroySL, FryeMA, HellemannG, . Prevalence and correlates of eating disorders in 875 patients with bipolar disorder. J Affect Disord. 2011;128:191–198.
69.
GuerdjikovaAI, McElroySL, WelgeJA, . Lamotrigine in the treatment of binge-eating disorder with obesity: a randomized, placebo-controlled monotherapy trial. Int Clin Psychopharmacol. 2009;24:150–158.
70.
McElroySL, GuerdjikovaAI, MartensB, . Role of antiepileptic drugs in the management of eating disorders. CNS Drugs. 2009;23:139–156.
71.
KotwalR, GuerdjikovaA, McElroySL, . Lithium augmentation of topiramate for bipolar disorder with comorbid binge eating disorder and obesity. Hum Psychopharmacol. 2006;21:425–431.
72.
McElroySL, GuerdjikovaA, KotwalR, . Atomoxetine in the treatment of binge-eating disorder: a randomized placebo-controlled trial. J Clin Psychiatry. 2007;68:390–398.
73.
McElroySL, HudsonJI, MalhotraS, . Citalopram in the treatment of binge-eating disorder: a placebo-controlled trial. J Clin Psychiatry. 2003;64:807–813.
74.
GuerdjikovaAI, McElroySL, KotwalR, . Highdose escitalopram in the treatment of binge-eating disorder with obesity: a placebo-controlled monotherapy trial. Hum Psychopharmacol. 2008;23:1–11.
75.
McElroySL, GuerdjikovaAI, WinstanleyEL, . Sodium oxybate in the treatment of binge eating disorder: an open-label, prospective study. Int J Eat Disord. 2011;44:262–268.
76.
DavidsonKW, KupferDJ, BiggerJT, ; National Heart, Lung, and Blood Institute Working Group. Assessment and treatment of depression in patients with cardiovascular disease: National Heart, Lung, and Blood Institute Working Group Report. Psychosom Med. 2006;68:645–650.
77.
Frasure-SmithN, LespéranceF.Recent evidence linking coronary heart disease and depression. Can J Psychiatry. 2006;51:730–737.
78.
DobbelsF, de GeestS, VanheesL, . Depression and the heart: a systematic overview of definition, measurement, consequences and treatment of depression in cardiovascular disease. Eur J Cardiovasc Nurs. 2002;1:45–55.
GlassmanAH, O'ConnorCM, CaliffRM, . Sertraline treatment of major depression in patients with acute MI or unstable angina. JAMA. 2002;288:701–709.
81.
O'ConnorCM, JiangW, KuchibhatlaM, . Safety and efficacy of sertraline for depression in patients with heart failure: results of the SADHART-CHF (Sertraline Against Depression and Heart Disease in Chronic Heart Failure) trial. J Am Coll Cardiol. 2010;56:692–699.
82.
LawMR, WaldNJ, ThompsonSG.By how much and how quickly does reduction in serum cholesterol concentration lower risk of ischaemic heart disease? BMJ. 1994;308(6925):367–372.
83.
LaraN, BakerGB, ArcherSL, . Increased cholesterol levels during paroxetine administration in healthy men. J Clin Psychiatry. 2003;64:1455–1459.
84.
AssmannG, SchulteH, FunkeH, . The emergence of triglycerides as a significant independent risk factor in coronary artery disease. Eur Heart J.1998; 19 suppl M:M8–14.
85.
AustinMA, HokansonJE, EdwardsKL.Hypertriglyceridemia as a cardiovascular risk factor. Am J Cardiol. 1998;81:7B-12B.
86.
McIntyreRS, SoczynskaJK, KonarskiJZ, . The effect of antidepressants on glucose homeostasis and insulin sensitivity: synthesis and mechanisms. Expert Opin Drug Saf. 2006;5:157–168.
87.
NewcomerJW, HauptDW, FucetolaR, . Abnormalities in glucose regulation during antipsychotic treatment of schizophrenia. Arch Gen Psychiatry. 2002;59:337–345.
88.
LustmanPJ, AndersonRJ, FreedlandKE, . Depression and poor glycemic control: a meta-analytic review of the literature. Diabetes Care. 2000;23:934–942.
89.
TohenM, CalabreseJR, SachsGS, . Randomized, placebo-controlled trial of olanzapine as maintenance therapy in patients with bipolar I disorder responding to acute treatment with olanzapine. Am J Psychiatry. 2006;163:247–256.
90.
SuppesT, VietaE, LiuS, . Maintenance treatment for patients with bipolar I disorder: results from a north american study of quetiapine in combination with lithium or divalproex (trial 127). Am J Psychiatry. 2009;166:476–488.
91.
VietaE, SuppesT, EggensI, . Efficacy and safety of quetiapine in combination with lithium or divalproex for maintenance of patients with bipolar I disorder (international trial 126). J Affect Disord. 2008;109:251–263.
92.
McIntyreRS, CohenM, ZhaoJ, . Asenapine versus olanzapine in acute mania: a double-blind extension study. Bipolar Disord. 2009;11:815–826.
93.
KempDE, CalabreseJR, TranQV, . Metabolic syndrome in patients enrolled in a clinical trial of aripip-razole in the maintenance treatment of bipolar I disorder. J Clin Psychiatry. 2010;71:1138–1144.
94.
KempDE, KarayalON, CalabreseJR, . Ziprasidone with adjunctive mood stabilizer in the maintenance treatment of bipolar I disorder: Long-term changes in weight and metabolic profiles [published online ahead of print July 26, 2011]. Eur Neuropsychopharmacol. doi: doi:10.1016/j.euroneuro.2011.06.005.
95.
YangCC, JickSS, JickH.Lipid-lowering drugs and the risk of depression and suicidal behavior. Arch Intern Med. 2003;163:1926–1932.
LesterD.Serum cholesterol levels and suicide: a meta-analysis. Suicide Life Threat Behav. 2002;32:333–346.
98.
American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2004;27 suppl 1:S5–S10.
99.
MusselmanDL, BetanE, LarsenH, . Relationship of depression to diabetes types 1 and 2: epidemiology, biology, and treatment. Biol Psychiatry. 2003;54:317–329.
100.
AkomolafeA, BeiserA, MeigsJB, . Diabetes mellitus and risk of developing Alzheimer disease: results from the Framingham Study. Arch Neurol. 2006;63:1551–1555.
101.
YaffeK, BlackwellT, KanayaAM, . Diabetes, impaired fasting glucose, and development of cognitive impairment in older women. Neurology. 2004;63:658–663. 102.
102.
AkbaralyTN, KivimakiM, ShipleyMJ, . Metabolic syndrome over 10 years and cognitive functioning in late midlife: the Whitehall II study. Diabetes Care. 2010;33:84–89.
103.
YaffeK, WestonAL, BlackwellT, . The metabolic syndrome and development of cognitive impairment among older women. Arch Neurol. 2009;66:324–328.
104.
van der HeideLP, RamakersGM, SmidtMP.Insulin signaling in the central nervous system: learning to survive. Prog Neurobiol. 2006;79:205–221.
105.
RitchieK, CarriereI, RitchieCW, . Designing prevention programmes to reduce incidence of dementia: prospective cohort study of modifiable risk factors. BMJ. 2010;341:c3885.
106.
van der Feltz-CornelisCM, NuyenJ, StoopC, . Effect of interventions for major depressive disorder and significant depressive symptoms in patients with diabetes mellitus: a systematic review and meta-analysis. Gen Hosp Psychiatry. 2010;32:380–395.
107.
KempDE, Ismail-BeigiF, GanocySJ, . Use of insulin sensitizers for the treatment of major depressive disorder: a pilot study of pioglitazone for major depression accompanied by abdominal obesity [published online ahead of print July 20, 2011]. J Affect Disord. doi: 10.1016/j.jad.2011.06.033.
108.
BusheCJ, BradleyAJ, DoshiS, . Changes in weight and metabolic parameters during treatment with antipsychotics and metformin: do the data inform as to potential guideline development? A systematic review of clinical studies. Int J Clin Pract. 2009; 63:1743–1761.
109.
EhretM, GoetheJ, LanosaM, . The effect of metformin on anthropometrics and insulin resistance in patients receiving atypical antipsychotic agents: a metaanalysis. J Clin Psychiatry. 2010;71:1286–1292.
110.
American Diabetes Association. Screening for type 2 diabetes. Diabetes Care. 2003;26:(suppl 1)S21–S24.
