The United States is facing an obesity epidemic, with three of 10 adults affected (1). Obesity is even more prevalent among those with psychiatric disorders (2). Several studies have indicated that depression, bipolar disorder, schizophrenia, and borderline personality are associated with obesity (3–7). Those with severe mental illness die up to three decades earlier than the general population (8, 9). Heart disease is the leading cause of death in these patients, and significant weight gain is a major risk factor for heart disease morbidity and mortality (10).
Persons with psychiatric diseases are more susceptible to weight gain from a variety of risk factors than individuals without these disorders. Obesity is more prevalent among people with lower incomes (2, 11), and a significant portion of psychiatric patients live below or near the poverty line. Individuals with psychiatric illnesses also have less access to health care and seek care from physicians less often (12, 13). Additionally, individuals with psychiatric disorders seldom exercise and often do not have healthy eating habits (14–16). Some psychiatric medications also contribute to weight gain (17–19), including antidepressants, monoamine oxidase inhibitors, selective serotonin reuptake inhibitors, mood stabilizers, and especially some atypical antipsychotics (20). People with psychiatric problems are typically not targets for health promotion programs (21). Thus psychiatrists are disproportionately facing problems of obesity management with many of their patients.
Numerous studies have examined physicians’ perceptions and practices in dealing with obese patients (22–25). However, a comprehensive literature search failed to find an assessment of psychiatrists’ perceptions and practices regarding treating their obese patients. Thus, the purpose of this study was to assess psychiatrists’ perceptions and practices in treating their obese patients.
A power analysis was conducted to assess the number of respondents needed to be able to generalize the findings to adult psychiatrists who are members of APA. Using a 75/25 split (engaged in weight-control activities versus not) in responses to weight control activities, with a 5% sampling error and a 90% confidence level, a sample of 200 respondents would be sufficient (26). The survey was mailed to 500 psychiatrists to ensure achieving adequate power, and a systematic national random sample of psychiatrists (excluding child and adolescent psychiatrists) from the 2007 APA membership list was provided by APA.
A four-page, 35-item questionnaire in which some items had multiple components was developed based on several health behavior models and the 5As strategy for addictive behaviors.
The Stages of Change model (one item) included the following as possible response options: precontemplation, in which psychiatrists have no intention to engage in a behavior (i.e., assisting obese patients to lose weight) in the foreseeable future; contemplation, in which psychiatrists are considering changing their behavior within the next 6 months; preparation, in which psychiatrists are intending to take action within the next month and making preparations to do so; action, in which psychiatrists have engaged in a behavior for less than 6 months; maintenance, in which psychiatrists have maintained the behavior over an extended period of time (6 months or longer); or relapse, in which psychiatrists have slipped back to an earlier stage of not helping obese patients lose weight (27, 28).
Self-Efficacy Theory explains a person’s belief in his or her capacity to perform a specific behavior in a particular situation (29) and has two main components: efficacy expectations and outcome expectations. Here, efficacy expectations (five Likert items: 1=not confident at all, 5=highly confident) are the beliefs that one can help obese patients lose weight. Outcome expectations (five Likert items: 1=very unlikely, 5=very likely) are the beliefs that given behaviors will lead to desired outcomes (e.g., helping obese patients will result in patient weight loss).
The Health Belief model has been used to help explain health behaviors and to frame health behavior interventions (30). A meta-analysis of studies of the Health Belief model found that the best predictor of health behavior was perceived barriers (31). One item with 11 potential barriers, plus “other,” was included to address this component.
The United States Preventive Services Task Force (USPSTF) has stated that the 5As framework used in behavioral counseling interventions, such as smoking cessation, could help clinicians guide interventions for weight loss (32). We used the 5As to examine psychiatrists’ perceptions and practices in treating obese patients. Ten items with a 10-point scale ranging from 0% to 100% in increments of 10% assessed the frequency of using the 5As. For obese patients the 5As were ask (systematically identify all obese patients at every visit); advise (strongly urge all obese patients to lose weight); assess (determine willingness to make a weight loss attempt); assist (aid the patient in losing weight); and arrange (schedule follow-up contact and referral). Initial interventions paired with maintenance interventions help ensure that weight loss will be sustained over time (32). The instrument also assessed psychiatrists’ perceived level of preparation for advising and treating obese patients (two items).
The last section contained 11 demographic items that assessed characteristics which might impact how psychiatrists assisted patients on weight management.
Face validity of the questionnaire was established by basing it on a comprehensive review of the literature on obesity and physicians’ perceptions of obesity. The instrument was forwarded to six experts in obesity and survey research to assess its content validity. Stability reliability of the instrument was established through testing and retesting a small convenience sample of 15 psychiatrists 1 week apart. The stability reliability coefficient for the 5As items was r=0.80; for efficacy expectations, r=1.00; for outcome expectations, r=0.88; and for barriers, r=0.95.
To maximize the return rate (33), psychiatrists were mailed a personalized, hand-signed cover letter explaining the purpose of the study; a copy of the survey (printed on colored paper); a prestamped (with colorful stamps) self-addressed return envelope; and a one-dollar bill as a token of appreciation (incentive). Two weeks after the first mailing, a second wave was sent. Finally, a color-matched postcard was mailed 2 weeks following the second mailing to motivate nonresponders to respond. The instrument and procedures were approved by the authors’ University Human Subjects Review Board.
Data analyses were performed using SPSS version 14.0 statistical software. Descriptive statistics (means, standard deviations, proportions, and percentages) were used to describe the findings of respondents, their practice characteristics, and their perceptions on advising about and treating obesity. Independent group t test analyses, analysis of variance (ANOVA), chi-square, Pearson correlation coefficients, and logistic regression modeling were used. Adjusted odds ratios (AOR) were calculated to determine which factors best predicted psychiatrists who engaged in weight management with their obese patients.
Characteristics of Respondents
Twenty questionnaires were returned and excluded for a variety of reasons (e.g., retired, worked in research or administration, did not currently treat patients, inaccurate addresses, deceased). Of the remaining 480 potential responses, 236 surveys were returned (response rate of 49%).
The psychiatrists were distributed fairly evenly between women and men (Table 1). The majority were Caucasian/non-Hispanic white and between 40 and 49 years old. Most (84.3%) had been practicing full-time for 10–19 years.
Psychiatrists’ Perceptions of Their Weight
Body mass index (BMI) assessments using self-reported heights and weights were compared with an item on perceived weight status of the psychiatrists. This analysis indicated that 77% correctly perceived their weight status (n=182), 21% perceived themselves in a lower BMI category compared with their actual BMI assessment (n=49), and 2% perceived themselves in a higher BMI category compared with what their BMI indicated (n=5). There was a significant difference in perceived weight status of psychiatrists in implementing the 5As technique in obese patients (t=2.035, df=221, p=0.04). The psychiatrists who perceived themselves as underweight or normal weight were more likely to assist their patients by changing their psychiatric medications than psychiatrists who were obese (68% [n=160] versus 60% [n=141], respectively).
Professional Training in Weight Management
The majority (65.2%) of psychiatrists did not receive formal training in weight loss for obese patients (n=154). Of those who received training, it was most likely from their medical schools or continuing education courses. Three-quarters of the psychiatrists evaluated their training on weight loss issues during psychiatric residency as not adequate at all or not very adequate, and the vast majority believed that formal training in weight loss for obese patients should be part of psychiatric residency training (Table 1).
Psychiatrists trained in weight management in medical schools had significantly higher efficacy expectations regarding their ability to help patients with weight management when compared with those who received no training (t=−3.44, df=188, p=0.001).
Psychiatrists’ Level of Efficacy and Outcome Expectations
The vast majority of psychiatrists were confident in their ability to use the 5As techniques in assisting patients to lose weight. The majority of psychiatrists were confident or highly confident (high efficacy expectations) in asking obese patients if they were concerned with their weight (86%, n=203), advising obese patients on weight management (77.9%, n=184), assessing obese patients’ willingness to lose weight (75%, n=175), assisting their obese patients in their attempts to lose weight (e.g., recommending weight loss medications such as Orlistat or referring patients to outside agencies such as Weight Watchers, Jenny Craig, or Physicians Weight Loss Centers) (55.1%, n=130), and arranging follow-up visits for their obese patients (68.7%, n=162).
The psychiatrists had considerably less faith in the outcomes of using the 5As in helping their patients lose weight. Fewer than half believed that asking obese patients if they were concerned with their weight (33.9%) or advising obese patients on weight management (49.6%) would result in their patients losing significant amounts of weight. More than half believed assessing obese patients’ willingness to lose weight (52.5%, n=124), assisting them in their attempts to lose weight (63.6%, n=150), or arranging follow-up visits (57.2%, n=135) would result in their patients losing significant amounts of weight.
Regular Application of 5As in Advising/Treating Obese Patients
The majority of psychiatrists identified and documented obesity in the majority of their visibly obese patients (69%, n=163); gave a clear, strong, and personalized message to lose weight (68.7%, n=162); assessed whether their patients were willing to make an effort to lose weight (68.2%, n=161); and assisted their obese patients by changing their psychiatric medications to help them control their weight (66.5%, n=157). Fewer than half of psychiatrists used behavioral counseling for the majority of their obese patients who were interested in losing weight (49.6%, n=117); assisted their patients by encouraging them to use problem-solving skills for weight loss (45.8%, n=108); and provided and/or arranged for social support to help their patients lose weight (27.3%, n=64). One-quarter (27.6%, n=65) of psychiatrists referred the majority of their obese patients to outside agencies, and 31.8% scheduled follow-up visits for the majority of their obese patients (n=35).
Assistance in the form of recommending weight loss drugs was used by 3% of psychiatrists for their obese patients (n=7). An overwhelming majority of psychiatrists (97.1%) believed that weight gain from psychotropic medications was a health concern (n=229). Additionally, an overwhelming majority (91.5%) believed that weight gain associated with psychotropic medications was a barrier to medication adherence (n=216).
There were no significant differences in the percent of obese patients advised regarding weight loss by the psychiatrists’ gender, age, percent of patients with low socioeconomic status, or practice location. The majority of psychiatrists (62.3%, n=147) more often advised obese patients to lose weight when comorbid conditions such as diabetes, hypertension, and coronary artery disease were present than when patients did not have comorbid conditions.
The majority of psychiatrists (73.3%, n=173) reported that they were in the maintenance stage of change, and a small percentage (5.1%, n=12) reported that they were in the action stage in helping their obese patients lose weight. Less than one-fourth reported that they were not regularly helping their obese patients lose weight (precontemplation stage, 7.2%, n=17; contemplation, 12.7%, n=30; preparation, 0.8%, n=2).
Perceived Barriers to Assisting Obese Patients
When asked to identify potential barriers from a list of 12 (including “other”), 64.8% of psychiatrists responded (n=153), indicating time constraints (22.9%, n=54), poor patient compliance (22.5%, n=53), lack of clear guidelines and practice tools (13.6%, n=32), limited medical training on the issue (13.1%, n=31), and fear of offending patients (12.3%, n=29). Pearson correlation coefficient analyses found significant relationships between the number of perceived barriers identified and the psychiatrists’ level of efficacy expectations (r=−0.40, p<0.001) and outcome expectations (r=−0.15, p=0.03). In other words, the greater their belief that they could assist patients using the 5As (efficacy expectations), the lower their number of perceived barriers. Additionally, fewer barriers were present when psychiatrists more strongly believed that helping their patients would result in weight loss (outcome expectations).
Factors Associated with Stages of Change Model in the Management of Obesity
Logistic regression modeling was conducted to determine if gender, years of practice, location of practice, perceived barriers, efficacy expectations, outcome expectations, and having received formal training in weight control were significant predictors of whether a psychiatrist was in the maintenance or action stages in treating obesity. Adjusted odds ratios (AOR) were calculated, adjusting for all the other variables in the regression analysis with 95% confidence intervals (CI), and two variables were found to be predictors. Those who perceived more barriers were significantly less likely than those with few barriers to be in the maintenance or action stages in treating obesity (AOR=0.15, 95% CI=0.07–0.34, p<0.01). Furthermore, those with formal training in weight control were significantly more likely to be in the maintenance or action stages in treating obesity (AOR=0.40, 95% CI=1.38–8.41, p=0.008).
Factors Associated with High Efficacy and Outcome Expectations in Weight Management
Logistic regression modeling was conducted to determine if gender, years of practice, location of practice, perceived barriers, outcome expectations, having received formal training in weight control, and being in the maintenance or action stages in managing obesity were significant predictors of high efficacy expectations or high outcome expectations regarding assisting with weight management. Adjusted odds ratios (AOR, 95% CI) adjusting for all of the other variables in the regression analysis were calculated, and two variables were found to be predictors. High outcome expectations were a significant predictor of high efficacy expectations (AOR=3.38, 95% CI=1.37–8.33, p=0.008), and having formal training in weight control approached significance as a predictor of high efficacy expectations (AOR=3.14, 95% CI=0.96–10.30, p=0.059). Also, only high efficacy expectations were a significant predictor of high outcome expectations (AOR=3.14, 95% CI=1.30–7.61, p=0.01).
The perceived lack of quality formal training during psychiatric residency on treating obese patients seems to indicate that practicing psychiatrists confront assisting obese patients with losing weight on a daily basis. Research has indicated that physicians who believed they could help patients lose weight were more likely to follow recommendations for the treatment of obesity (25). The psychiatrists’ high efficacy expectations and outcome expectations in the current study indicate that many believed in their ability to advise and treat their obese patients and believed in a positive outcome of implemented treatments. The question may be asked if the quality of the treatment of the obese patients would be different if psychiatrists had formal education on weight management. In other words, their optimistic assessment of their skills may cause some of them to assume that the lack of weight loss by many of their patients was because of lack of patients’ effort (victim blaming) rather than their reduced skills in assisting patients who desire (or need) to lose weight.
It appears that most psychiatrists were appropriately attentive to patients’ concerns regarding weight gain by switching to different psychiatric medications. However, this may indicate that some psychiatrists were not using the best methods of addressing weight problems. Additionally, if the original medications were better treatments for some patients than the new medications, simply switching patients to other medications rather than addressing the more complicated issue of weight gain may not be the best medicine. It should be asked, what would be needed to help these patients lose weight?
Very few (3%) psychiatrists recommended weight loss medications to the majority of their obese patients who were interested in losing weight. This may indicate that psychiatrists were less inclined to use a more aggressive treatment such as pharmacotherapy. When other methods to lose weight fail, the use of antiobesity drugs may be warranted (34, 35). Drug treatment is often indicated but is limited by the number of well-tolerated antiobesity drugs (34). Additionally, these drugs are relatively expensive, and many of the mentally ill may be financially challenged to take additional medications.
A little more than one-fourth (27.6%) of psychiatrists referred the majority of their obese patients who were interested in losing weight to outside agencies. Yet, evidence on commercial weight loss programs indicates that they may offer some help. All of these programs prescribe a moderately restricted diet and provide behavioral counseling, including recommendations for physical activity. For those patients who are unsuccessful in their weight-loss efforts with these commercial programs, gastric bypass surgery may be sought. Psychiatrists will increasingly be involved with the presurgical evaluation of patients for gastric bypass and also the management of these patients, who often have psychiatric comorbidities.
The results of this study revealed that the number of perceived barriers and formal training in weight control were significant predictors of whether a psychiatrist was treating obese patients for weight control. Efficacy expectations were also a significant predictor of outcome expectations in weight management by psychiatrists, that is, those with high expectations that they could do all of the 5As were significantly more likely to believe their efforts would result in patient weight loss and perceived fewer barriers to treatment of patients who were obese. Psychiatrists who had formal training on weight management in medical schools had higher efficacy expectations regarding their capability to help their patients with weight management. Psychiatrists with high efficacy and outcome expectations will most probably advise and treat more patients with weight problems and be more successful. In fact, research has found that primary care physicians trained in the management of obesity were far more likely to assist their patients than physicians who were not (35). Thus we strongly recommend that psychiatric residency programs develop a formal curriculum as part of their postgraduate training. Unfortunately, few models for postgraduate medical training programs in the management of obese patients currently exist in the professional literature (36).
Finally, the findings of this study need to be examined in light of the potential limitations. First, the response rate was limited (49%). Second, this survey may suffer from the problems affecting all survey research: accurately remembering past behaviors and responding in a socially desirable manner to some issues. Third, the assessment of the psychiatrists’ perceptions and practices were cross-sectional; thus, conclusions regarding causal relationships between the responding psychiatrists and their characteristics cannot be drawn. Fourth, the psychiatrists surveyed for this study did not include child and adolescent psychiatrists, and therefore the results may not be applicable to them or to psychiatrists outside the United States.