Favourable cognitive changes observed with metabolic improvements in a patient with severe mental illness.

A 41-year-old unemployed woman with longstanding major depressive and social anxiety disorder was referred to the Metabolic Clinic at the Centre for Addiction and Mental Health for weight gain concerns. She had maintained a weight of about 54 kg during adulthood, until she gained 41 kg over a period of 1.5 years during the course of several antipsychotic and antidepressant trials. The patient’s current psychotropics and metabolically active medications included quetiapine (300 mg/d at bedtime), ketamine (250 mg, inhaled every 3 days), zopiclone (22.5 mg/d at bedtime), baclofen (55 mg/d), lorazepam (2 mg at bedtime) and sumatriptan (100 mg/d as needed). She preferred to continue quetiapine given the stability of her psychiatric symptoms. Her psychotropic medications were managed by her treating psychiatrist. The patient weighed 95.6 kg at the time of consultation, translating to class III obesity and a body mass index (BMI) of 42.5 kg/m2. She met criteria for abdominal obesity, with a waist circumference of 108 cm. Bloodwork showed evidence of metabolic dysfunction, with elevated levels of fasting glucose (6.4 mmol/L), fast ing insulin (297 pmol/L), low-density lipoprotein (LDL) cholesterol (2.93 mmol/L), total cholesterol (5.87 mmol/L) and triglycerides (2.35 mmol/L). High-density lipoprotein (HDL) cholesterol was 1.87 mmol/L. We recommended metformin, a well-tolerated antihyperglycemic agent that has the strongest evidence of benefit for antipsychoticinduced weight gain.1 We initiated 500 mg/d and titrated the dose to 2500 mg/d. The patient concurrently implemented lifestyle modifications, including improved diet and increased physical activity, walking up to 5 times per week for up to 2 hours each time. With metformin and the lifestyle changes combined, the patient lost about 45 kg over 3 years. No adverse effects were reported, and her weight loss was gradual at 1–3 kg per month (Table 1). She weighed 49.2 kg at her most recent visit, and both her BMI and waist circumference normalized to 21.9 kg/m2 and 65 cm, respectively. Improvements in other metabolic par ameters were observed, including reduced triglycerides (down to 1.26 mmol/L), fasting glucose (5.6 mmol/L), and insulin (61 pmol/L) The information in this column is not intended as a definitive treatment strategy but as a suggested approach for clinicians treating patients with similar histories. Individual cases may vary and should be evaluated carefully before treatment is provided. The patient described in this column gave informed consent for its publication. Psychopharmacology for the Clinician