CVAHEC Student Project Reports

Talia Hoffstein
Freeman Scholar Program

Last fall I began medical school eager to do whatever it took to pursue a career in psychiatry. However, a few days into classes, I found myself immersed in histology and gross anatomy, and I became brutally aware of how easy it is to lose sight of one’s future goals when the present situation seems so far removed from them. I knew I needed to combine the medical education I was receiving in school with a more clinical outlook.

I decided to collaborate with a classmate, Dyveke Pratt, and together we decided that we wanted to create a community program geared at weight loss for people in antipsychotic therapy.

At the time, it seemed simple. These drugs were causing weight gain, which was contributing significantly to morbidity in this population - there were plenty of studies to support that. So this is how we presented our initial idea to the Freeman Foundation – we were going to create a weight loss group.

Equipped with a good intentions and not much else, Dyveke and I set out to create our curriculum. We planned to start out with a well established weight loss plan and modify it to make it more appealing to people with schizophrenia.

The obvious next question was “why are these drugs causing weight gain in these people?” This is where we encountered our first obstacle – how could we try to curtail a problem when we didn’t even know what was causing it?

Though there were plenty of studies showing that antipsychotic drugs cause weight gain, there was no data that attempted to explain the mechanism. Was it because these people didn’t know how to eat a balanced diet? Did they not know they were supposed to exercise? Did they know all of this, but just have problems carrying it out? Or were there more complex cognitive mechanisms at work?

This is where Dyveke and I realized our project was not as simple as we thought it would be. We needed data before we could create a curriculum, but that data didn’t exist. We soon realized that the only option was for us to collect our own data, to answer these questions ourselves.

Once again, our task seemed easy. We were going to do a study examining whether the weight gain observed in schizophrenic people could be attributed to a lack of awareness of their obesity. In other words, we suspected that these people did indeed know how to lose weight, and they knew the risks associated with obesity, but that they didn’t perceive themselves as obese.

We found a group in California that was doing similar research, and contacted them. However, we soon learned that as simple as out research project sounded, it was much more difficult to carry out.

We needed subjects. No problem, we thought, there were plenty at the hospital. So we went to the psychiatry ward at Fletcher Allen. Only then did we realize that administering a battery of written tests and consent forms to acutely psychotic individuals would be more difficult that we had anticipated.

This seemingly straightforward realization opened a whole Pandora’s box of new problems – did our subjects need to be psychotic or just taking antipsychotic therapy? Did they need to be on anti-psychotic therapy at all, or was a diagnosis that predisposed them to such therapy in the future enough? Did we need to normalize for symptoms of psychosis, or was the drug regimen enough to match them on? And finally, were psychotic individuals able to give informed consent to participate in our study at all?

And so, in a matter of a few hours, what had seemed like a perfectly reasonable task suddenly seemed impossible, nonsensical, and doomed. This was the point in our summer project where I learned the most valuable lessons. This is when I learned how to take a problem and break it down into its smallest pieces, and make sense of those before trying to put them back together. I learned to look for alternatives without compromising what I wanted. I learned the importance of asking other people for help, and working together to solve a common problem.

In the end, Dyveke and I found a community psychiatric residence where the majority of patients are on antipsychotic therapy but not acutely psychotic. There are only six people living there at a time, so to use them as subjects, gathering data from enough subjects to be significant will take time, and will depend on the turnover rate.

We decided that our protocol was too long, and people would not be as eager to complete the study, so we simplified. We cut out measures, simplified our questionnaires, and found pictures to replace some of the words. And in the end, after having spent hours agonizing over every question we were rewording and every scale we cut out, we came up with a new protocol.

It was very simple – so simple we didn’t quite understand why we hadn’t come up with it three months earlier. But I now realize that the most valuable experience for me this summer was the process itself. Though I look at out protocol and think that it’s so simple and easy to understand, it occurs to me that the simplest things aren’t always the most obvious things, and aren’t the ones that come to mind first.

I learned that it’s often necessary to travel through the complexities before I can find the simplicities. So while Dyveke and I did not accomplish the goals we had set out for ourselves this summer, I don’t consider this a failure but rather a relief – the obstacles we encountered were necessary steps in order for us to see the flaws in our project and improve them.

Dyveke and I did succeed in creating a much tighter project, which we have recently submitted for IRB approval and intend on carrying out in the next few months.