It was Joanna Acevedo’s psychiatrist who first raised the idea of a weight-loss drug. Since 2018, Acevedo has relied on antipsychotic medications to manage her bipolar disorder. The drugs kept her paranoia at bay — really, they kept her alive, she said. They also led her to gain 32 kilograms. By age 26, she had become prediabetic.
At a routine appointment this winter, Acevedo told her psychiatrist that she just didn’t feel comfortable with her body anymore. She had brought it up before, but this time, he made a suggestion that surprised her. Had she heard about the new weight-loss drugs?
He referred her to a weight-loss clinic to get a prescription for Wegovy — an injectable medication that contains the same compound as the sought-after drug Ozempic.
These drugs have transformed how doctors treat diabetes and obesity. Now, some psychiatrists are turning to the drugs to counteract the weight gain that often comes with nearly all antipsychotics and some drugs used to treat depression and anxiety. The New York Times heard from 13 leading mental health facilities and psychiatric departments at major health systems in the United States. Six said they were recommending or prescribing drugs such as Ozempic to their patients. Seven said they were not ready to do so, citing concerns about safety and side effects and expressing a belief that prescribing weight-loss drugs was beyond their purview.
Their responses reflect a new debate in mental health care about whether to prescribe a drug patients will most likely take indefinitely, with only a limited understanding of how people with serious mental illness fare on these medications.
“We are talking about a very vulnerable population,” said Dr Mahavir Agarwal, a psychiatrist and scientist at the Centre for Addiction and Mental Health in Toronto. Agarwal is conducting some of the earliest research into using semaglutide, the substance in Wegovy and Ozempic, to help patients on antipsychotics lose weight. “There’s next to no data” on people with depression, bipolar disorder or other mental illnesses taking semaglutide, he said — and until there’s more evidence, “you’re sort of flying blind”.
Some doctors, though, argue that patients can’t wait. People often stop taking psychiatric medications, or refuse to start them altogether, because they don’t want to gain weight. A 2019 review found that patients gained more than 7 per cent of their body weight on antipsychotics and 5 per cent on certain antidepressants. There is not a clear-cut explanation for the link between psychiatric medications and weight gain, but experts theorise that the drugs may increase appetite and slow metabolism. Not everyone gains weight on psychiatric drugs, and it’s difficult to isolate the role that other factors — like diet, exercise and health conditions — may play.
Those who gain significant weight, such as Acevedo, can face an increased risk of prediabetes, heart disease and other issues.
This was a big scourge for our population,” said Dr Dost Öngür, chief of the division of psychotic disorders at McLean Hospital in Massachusetts, where, he said, all mental health providers now evaluate whether patients with psychotic disorders should take drugs including Wegovy and Ozempic.
For Acevedo, even the sometimes painful side effects from weekly Wegovy injections — she vomited five times a day in her first month on the drug — were worth it.
“I felt like I had no other options,” said Acevedo, who later switched to Ozempic. On antipsychotics, she no longer had intermittent delusions that the people around her weren’t who they said they were. “I’m not ruled by an illness that is actively trying to kill me,” she said. But she felt as if she was trading one aspect of her health for another. The more weight Acevedo, a longtime athlete, gained, the harder it was to move. Since she started on a weight-loss drug, she’s lost 14kg, and her blood sugar levels have fallen. She’s taken up weightlifting. “Being able to feel like I could be powerful in my body again — that’s a really important thing for me,” she said.
“Without the Ozempic, I’m not able to take my psychiatric meds,” she said. “They sort of work hand in hand.”
A ‘game changer’
In summer 2022, Dr Jennifer Kruse, a faculty psychiatrist at University of California, Los Angeles, sent an email to colleagues offering to see patients interested in weight-loss drugs. “I think these new agents may really be a game changer,” she wrote. Her schedule quickly became packed.
In the past, some psychiatrists have prescribed medications such as metformin and liraglutide to help patients combat weight gain. But none has proven as powerful as the new drugs.
Psychiatrists who prescribe Wegovy, Ozempic and a similar drug, Mounjaro, stress that they monitor their patients’ moods on the medications.
It’s not a “go-to drug”, said Dr Shebani Sethi, who directs Stanford’s Metabolic Psychiatry programme and often sees patients referred by psychiatrists. Before prescribing a drug including Wegovy, she screens people for eating disorders and considers their medical history and body composition. She requires patients to do resistance training to counteract the potential loss of muscle mass on the medications.
But if a patient understands the risks, “I’m pretty open,” she said. “If they want it, I’ll prescribe it.”
And patients are pressing for it.
Amanda Romero, 35, started taking the antidepressant Lexapro in 2015, after her 4-year-old daughter was diagnosed with cancer and the intrusive thoughts she had been experiencing for years intensified. The drug helped, and she stayed on it after her daughter went into remission, eventually switching to Prozac. But no matter how many miles she logged on her Peloton or around her North Carolina neighbourhood, or how strictly she stuck to her doctor’s diet recommendations, her weight kept creeping up. By last spring, she had gained 32kg.
“I just felt like, what happened to me?” she said.
Stopping antidepressants wasn’t an option; she had tried that when her daughter finished chemotherapy. She cried several times a day and panicked whenever her phone rang, terrified it was bad news.
The antidepressant let her feel more in control of her brain. Wegovy let her feel more in control of her body. The drug, which Romero started in February, did make her so nauseated that she took a pregnancy test — but she’s since lost all the weight.
What doctors don’t know yet
Some doctors remain concerned. Dr Ilana Cohen, a psychiatrist at Sheppard Pratt in Maryland, said she and other colleagues in the psychiatric hospital system were steering clear of the drugs, in part because of anecdotal reports that patients in Europe were having suicidal thoughts while on them. European health regulators are currently reviewing data on drugs including Ozempic and the risk of suicidal ideation.
Clinical trials of Wegovy excluded people with recent suicidal thoughts, a history of suicide attempts, severe conditions including schizophrenia or bipolar disorder, and those who had depression within the past two years.
“These medications really were not studied well or designed for this population,” Cohen said. Researchers are studying how these medications may work in people with mental health conditions.
In clinical trials of Saxenda, an older medication approved for weight loss, slightly more participants on the drug had suicidal thoughts compared with those on a placebo, although there was insufficient evidence that the drug was the cause. The Food and Drug Administration requires weight management drugs that work on the central nervous system — including Saxenda and later, Wegovy — to carry a warning about suicidal thoughts.
Other clinicians said they were concerned that the drugs, which significantly reduce how much patients want to, or can, eat, could compound problems for those with depression and anxiety, who may be at higher risk of anorexia.
“I don’t want to encourage a medication which might actually exacerbate or make it easier for a person to engage in disordered eating,” said Sofia Rydin-Gray, a clinical psychologist at Duke Psychiatry and Behavioral Sciences.
Some patients are torn, too, between a drug that comes with steep costs, and sometimes distressing side effects, and the alternative: unwanted weight gain.
Romero recently stopped taking Wegovy — the side effects and the more than US$1300 (NZ$2168) a month she paid out of pocket were too much, even though she knew she risked regaining weight.
Kristen Eckhardt, a 40-year-old in Hastings, Nebraska, started taking Ozempic in March after she gained 9kg and developed prediabetes while taking Vraylar for depression. She was grateful to feel more stable, she said — less despondent, less irritable around her kids. But the weight gain rattled her. “Your self-image really takes a beating,” she said.
She felt wrung out when she started Ozempic; her stomach ached constantly. Those side effects have improved, but her blood sugar and weight loss have plateaued.
“I’m really afraid to go off of the Ozempic, because I don’t want to gain the weight back. And I know better than to just stop taking mental health medications. That’s not the way to go,” Eckhardt said. “So for the time being, I am definitely on all of them.”
This article originally appeared in The New York Times.
Written by: Dani Blum
Illustration by: Derek Abella
©2023 THE NEW YORK TIMES