Individuals with serious mental illnesses (SMI) such as schizophrenia and bipolar disorder experience higher rates of morbidity and premature mortality than the general population, which has been attributed in part to their increased prevalence of obesity and cardiovascular disease. Weight gain and other metabolic side effects of antipsychotic medications (APMs) and mood stabilizer medications (MSMs) have been implicated in the high rates of these disorders, of which women with SMI are disproportionately affected and which may be impacted by other side effects of specific concern to women. In preliminary work, we observed that female Veterans with SMI were more likely to be prescribed APMs and MSMs with a lower risk of weight gain/metabolic side effects than men. However, the relative influence of patients versus prescribers on APM/MSM prescribing decisions and the impact of these decisions on both the physical and mental health of female Veterans is not known.
The objectives of this study are (1) to understand how female Veterans' and VA mental health prescribers' knowledge, attitudes and experiences with weight gain/metabolic side effects of APM/MSMs, as well as with other side effects specific to women (e.g., menstrual abnormalities, reproductive and sexual dysfunction, potential teratogenicity), influence medication decision-making; (2) to understand female Veterans' and VA mental health prescribers' experiences of the effects of APM/MSM treatment choices on adherence to treatment and the physical and mental health of women; and (3) to develop and assess the acceptability and feasibility of brief surveys employing conjoint analysis to elicit patient preferences for side effects of APMs and MSMs for use in shared decision-making with prescribers.
To achieve these objectives, we will conduct qualitative interviews with 30 female Veterans with SMI and 20 outpatient mental health prescribers. The results of these interviews combined with a comprehensive review of the literature will inform the development of brief surveys that will elicit patient preferences for side effects of APMs and MSMs, the acceptability and comprehension of which will be evaluated via cognitive interviewing. Eighty Veterans will complete revised versions of the surveys to generate preliminary estimates of preference values for side effects of APM and MSM treatments.
Qualitative interviews with 30 female Veterans with SMI and 18 mental health prescribers were completed, transcribed, coded, and analyzed, resulting in the identification of 11 themes. Veteran interviewees described weight gain and concern about it, with resulting psychological and physical distress. Many expressed a willingness to accept weight gain as a trade-off for medications' positive effects, also echoed by MH prescribers. However, both described stressful struggle with this trade-off, including identifying effective weight management strategies. Since factors including age, medical conditions, lifestyle and environment contribute to weight gain, both also emphasized that this complexity of causal attribution complicates weight management. Both described primarily using reactive rather than proactive/preventative approaches, and a dearth of access to relevant resources. Women expressed weight-loss resolve by trying many different strategies, often enduring substantial frustration making motivation difficult to maintain. Prescribers expressed concern about their limited time and resource access to substantially help Veterans.
Understanding how certain side effects of APM/MSMs that are of particular concern to women (e.g., weight gain) influence prescribing choices and outcomes of treatment will facilitate more informed shared decision-making by women Veterans and VA clinicians around the risks and benefits of these treatments. Ultimately, this will enable the VHA to better address the unique physical and mental health treatment needs of female Veterans with SMI.
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Grant Number: I21HX001652-01A1
None at this time.