My attending told me she’d gotten a call from an outpatient psychiatrist who was complaining about our choice of medications while patients are acutely psychotic in the hospital. “You put them on Zyprexa and they all get fat!”

When you’re in the acute hospital setting (and this is one of my big beefs with residency training in the US), you kind of forget that patients go out into the real world after you discharge them. So when you want to quickly get control of their symptoms, you use a strong antipsychotic, which has the risk of pretty severe weight gain–sometimes 30-40 pounds. Now, I absolutely believe that a person being not psychotic is a higher quality of life than being a little overweight, but 30-40 pounds is quite a lot; you get into the range that people are going to develop diabetes and have bad cholesterol levels.

The problem is that whatever you start a patient on in the hospital, they’re likely to stay on as an outpatient. (If something works, you don’t mess with it!) So where’s the balance? Do you put someone on a newer antipsychotic like Geodon that has less weight gain? If it doesn’t work, do you switch to a weight-gaining one? I wish I knew the answer.

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