38 Psychosomatic Medicine C LINICAL P SYCHIATRY N EWS • August 2008 Some See Psychosocial Barriers to Weight Loss BY SUSAN LONDON national conference sponsored by the ments of increasing intensity (based on ers to seeking treatment: money, time, Contributing Writer Academy for Eating Disorders. She also level of professional involvement): treat- stigma, shame, and a belief that one is too said little is known about barriers that ment on one’s own by taking steps such heavy for the treatment. S EATTLE — Money and time are the might prevent treatment seeking from as reducing caloric intake, reading self-help Of the 154 respondents, 76% were white, leading barriers to seeking weight-loss taking place. books, using self-help online programs, 16% were black, 2% were Hispanic, and the treatment among overweight and obese An anonymous online survey offered to turning to commercial programs such as rest were of other or mixed ethnicities, Ms. adults, but stigma and a belief that one is overweight or obese men and women Weight Watchers, seeking help from pro- Ciao said at the conference, cosponsored by too heavy for treatment become more in- aged 18 years or older addressed some of fessionals other than medical doctors such the University of New Mexico. Eighty-six fluential barriers as people get heavier. these issues, according to Ms. Ciao, a grad- as nutritionists and psychotherapists, turn- percent were women. The respondents’ Little is known from the literature about uate student at the University of Hawaii, ing to medical doctors, and having weight- mean age was 30 years (range was 18-67 patterns of treatment seeking for obesity Honolulu. loss surgery. years). Their mean body mass index (BMI) over time, Anna C. Ciao said at an inter- The survey asked about seven treat- The survey also asked about five barri- was 33 kg/m2 (range was 25-80); 41% were overweight, and 59% were obese. Among the seven treatments, treatment BRIEF SUMMARY - require cardiac surveillance at all dosage levels of the drug. See WARNINGS.) Elderly patients and patients with cardiac Cardiovascular: Orthostatic hypotension, hypertension, tachycardia, palpitation, myocardial infarction, arrhythmias, heart Consult full prescribing information before use. disease or a prior history of cardiac disease are at special risk of developing the cardiac abnormalities associated with block, ECG changes, precipitation of congestive heart failure, stroke. on one’s own was the most commonly the use of imipramine pamoate. It should be kept in mind that the possibility of suicide in seriously depressed patients Psychiatric: Confusional states (especially in the elderly) with hallucinations, disorientation, delusions; anxiety, is inherent in the illness and may persist until significant remission occurs. Such patients should be carefully supervised restlessness, agitation; insomnia and nightmares; hypomania; exacerbation of psychosis. Tofranil-PM® during the early phase of treatment with imipramine pamoate and may require hospitalization. Prescriptions should be sought, desired, and planned. Overall, 77% imipramine pamoate capsules written for the smallest amount feasible. Neurological: Numbness, tingling, paresthesias of extremities; incoordination, ataxia, tremors; peripheral neuropathy; extrapyramidal symptoms; seizures, alterations in EEG patterns; tinnitus. (75 mg, 100 mg, 125 mg and 150 mg) Hypomanic or manic episodes may occur, particularly in patients with cyclic disorders. Such reactions may necessitate of respondents had sought this treatment; For oral administration discontinuation of the drug. If needed, imipramine pamoate may be resumed in lower dosage when these episodes are Anticholinergic: Dry mouth, and, rarely, associated sublingual adenitis; blurred vision, disturbances of accommodation, Rx only relieved. Administration of a tranquilizer may be useful in controlling such episodes. mydriasis; constipation, paralytic ileus; urinary retention, delayed micturition, dilation of the urinary tract. 36% desired it but had no current plans, and Prescribing Information An activation of the psychosis may occasionally be observed in schizophrenic patients and may require reduction of Allergic: Skin rash, petechiae, urticaria, itching, photosensitization; edema (general or of face and tongue); drug fever; Suicidality and Antidepressant Drugs dosage and the addition of a phenothiazine. cross-sensitivity with desipramine. 51% planned to pursue it in the near future. Antidepressants increased the risk compared to placebo of suicidal thinking and behavior (suicidality) in Concurrent administration of imipramine pamoate with electroshock therapy may increase the hazards: such treatment Hematologic: Bone marrow depression including agranulocytosis; eosinophilia; purpura; thrombocytopenia. children, adolescents, and young adults in short-term studies of major depressive disorder (MDD) and other should be limited to those patients for whom it is essential, since there is limited clinical experience. psychiatric disorders. Anyone considering the use of imipramine pamoate or any other antidepressant in a Gastrointestinal: Nausea and vomiting, anorexia, epigastric distress, diarrhea; peculiar taste, stomatitis, abdominal In contrast, surgery was the least com- child, adolescent, or young adult must balance this risk with the clinical need. Short-term studies did not Patients taking imipramine pamoate should avoid excessive exposure to sunlight since there have been reports of cramps, black tongue. show an increase in the risk of suicidality with antidepressants compared to placebo in adults beyond age photosensitization. Endocrine: Gynecomastia in the male; breast enlargement and galactorrhea in the female; increased or decreased libido, monly sought (8%), desired (18%), and 24; there was a reduction in risk with antidepressants compared to placebo in adults aged 65 and older. Both elevation and lowering of blood sugar levels have been reported with imipramine pamoate use. impotence; testicular swelling; elevation or depression of blood sugar levels; inappropriate antidiuretic hormone (ADH) Depression and certain other psychiatric disorders are themselves associated with increases in the risk of secretion syndrome. suicide. Patients of all ages who are started on antidepressant therapy should be monitored appropriately Imipramine pamoate should be used with caution in patients with significantly impaired renal or hepatic function. planned (8%) treatment. and observed closely for clinical worsening, suicidality, or unusual changes in behavior. Families and Other: Jaundice (simulating obstructive); altered liver function; weight gain or loss; perspiration; flushing; urinary Patients who develop a fever and a sore throat during therapy with imipramine pamoate should have leukocyte and frequency; drowsiness, dizziness, weakness and fatigue; headache; parotid swelling; alopecia; proneness to falling. caregivers should be advised of the need for close observation and communication with the prescriber. differential blood counts performed. “Despite these high levels of endorse- Imipramine pamoate is not approved for use in pediatric patients (see WARNINGS: Clinical Worsening and Withdrawal Symptoms: Though not indicative of addiction, abrupt cessation of treatment after prolonged therapy may Suicide Risk, PRECAUTIONS: Information for Patients, and PRECAUTIONS: Pediatric Use). Imipramine pamoate should be discontinued if there is evidence of pathological neutrophil depression. produce nausea, headache and malaise. ment of treatment seeking, a substantial Prior to elective surgery, imipramine pamoate should be discontinued for as long as the clinical situation will allow. CONTRAINDICATIONS OVERDOSAGE Information for Patients The concomitant use of monoamine oxidase inhibiting compounds is contraindicated. Hyperpyretic crises or severe Deaths may occur from overdosage with this class of drugs. Multiple drug ingestion (including alcohol) is common in number of people did not say yes to seek- convulsive seizures may occur in patients receiving such combinations. The potentiation of adverse effects can be Prescribers or other health professionals should inform patients, their families, and their caregivers about the benefits ® deliberate tricyclic overdose. As the management is complex and changing, it is recommended that the physician contact serious, or even fatal. When it is desired to substitute Tofranil-PM in patients receiving a monoamine oxidase inhibitor, and risks associated with treatment with imipramine pamoate and should counsel them in its appropriate use. A patient a poison control center for current information on treatment. Signs and symptoms of toxicity develop rapidly after tricyclic ing any kind of treatment,” Ms. Ciao said. as long an interval should elapse as the clinical situation will allow, with a minimum of 14 days. Initial dosage should be Medication Guide about “Antidepressant Medicines, Depression and other Serious Mental Illness, and Suicidal Thoughts overdose. Therefore, hospital monitoring is required as soon as possible. low and increases should be gradual and cautiously prescribed. or Actions” is available for imipramine pamoate. The prescriber or health professional should instruct patients, their families, and their caregivers to read the Medication Guide and should assist them in understanding its contents. Patients Children have been reported to be more sensitive than adults to an acute overdosage of imipramine pamoate. An acute Eleven percent had not sought