The psychiatrist of Joanna Acevedo was the one who first suggested the idea of a medication for weight loss. Since 2018, Acevedo has relied on antipsychotic medications to control her bipolar disorder. The drugs kept her paranoia at bay; in fact, they kept her alive, she said. They also caused her to gain 32 kilograms of weight. At 26 years old, she became prediabetic.
This winter, Acevedo told her psychiatrist in a routine appointment that she no longer felt comfortable in her body. She had mentioned it before, but this time the psychiatrist made a suggestion that surprised her. Had she heard about the new weight loss medications? He referred her to a weight loss clinic to be prescribed Wegovy, an injectable medication that contains the same compound as the coveted drug Ozempic.
These drugs have transformed the way doctors treat diabetes and obesity. Now, some psychiatrists are turning to these drugs to counteract the weight gain that almost all antipsychotics and some medications used to treat depression and anxiety typically cause. The New York Times consulted 13 of the most important mental health centers and psychiatry departments in the major healthcare systems in the United States. Six stated that they recommended or prescribed drugs like Ozempic to their patients. Seven said they were not prepared to do so, citing concerns about safety and side effects and expressing the belief that prescribing weight loss drugs was outside of their scope.
Their responses reflect a new debate in the field of mental health about the appropriateness of prescribing a medication to patients that they may take indefinitely, with limited knowledge of how people with serious mental illnesses react to these medications. “We are talking about a very vulnerable population,” said Mahavir Agarwal, a psychiatrist and scientist at the Center for Addiction and Mental Health in Toronto. Agarwal is conducting some of the first research on the use of semaglutide, the substance contained in Wegovy and Ozempic, to help patients taking antipsychotics lose weight. According to Agarwal, there is “hardly any data” on people with depression, bipolar disorder, or other mental illnesses taking semaglutide, and until more evidence is available, “we are acting blindly”.
However, some doctors argue that patients cannot wait. Often, people stop taking psychiatric medications or refuse to start taking them because they do not want to gain weight. A 2019 review found that patients gained over seven percent of their body weight with antipsychotics and five percent with certain antidepressants. There is no clear explanation for the link between psychiatric medications and weight gain, but experts theorize that the medications can increase appetite and slow down metabolism. Not everyone gains weight with psychiatric drugs, and it is difficult to determine the role that other factors such as diet, exercise, and health status may play.
People who gain a lot of weight, like Acevedo, may be at higher risk for prediabetes, heart disease, and other problems. “It was a big blow to our population,” said Dost Öngür, director of the Psychotic Disorders Division at McLean Hospital in Massachusetts, where, he said, all mental health providers evaluate whether patients with psychotic disorders should take drugs like Wegovy and Ozempic.
For Acevedo, even the sometimes painful side effects of Wegovy’s weekly injections – she vomited five times a day during her first month with the drug – were worth it. “I felt like I had no other options,” said Acevedo, who later switched to Ozempic. With the antipsychotics, she stopped having intermittent delusions that the people around her were not who they said they were. “I am not governed by a disease that vigorously tries to kill me,” she pointed out. But she felt like she was trading one aspect of her health for another. The more weight Acevedo gained, a longtime athlete, the more difficult it became for her to move. Since starting to take a weight loss medication, she has lost almost 14 kilograms and her blood sugar levels have dropped. She has started lifting weights. “To feel powerful with my body again is very important to me,” she said.
“Without Ozempic, I can’t take my psychiatric medications,” she explained. “They go hand in hand”.
Changing the rules of the game
In the summer of 2022, Jennifer Kruse, a psychiatrist at the University of California, Los Angeles, sent an email to her colleagues offering to see patients interested in weight loss drugs. “I think these new drugs can change the rules of the game,” she wrote. Her schedule quickly filled up.
In the past, some psychiatrists have prescribed medications like metformin and liraglutide to help patients combat weight gain. But none have proven to be as potent as the new drugs.
Psychiatrists who prescribe Wegovy, Ozempic, and a similar drug, Mounjaro, insist that they monitor the mood of their patients taking these medications. It is not a “first-line medication”, says Shebani Sethi, who heads the Metabolic Psychiatry program at Stanford and often sees patients referred by psychiatrists. Before prescribing a drug like Wegovy, she examines patients for eating disorders and takes into account their medical history and body composition. She requires patients to do resistance exercises to counteract the potential loss of muscle mass with the medications.
But if a patient understands the risks, “I am quite willing,” she said. “If they want it, I prescribe it”.
And patients are pushing to get 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 medication helped her and she continued taking it after her daughter went into remission, when she finally switched to Prozac. But no matter how many miles she rode on her Peloton or around her neighborhood in North Carolina, or how rigorously she followed her doctor’s dietary recommendations, her weight kept increasing. By last spring, she had gained 31 kilograms.
“I was wondering, ‘What happened to me?'” she said.
Stopping the antidepressants was not an option; she had already tried that when her daughter finished chemotherapy. She would cry multiple times a day and panic every time the phone rang, terrified of bad news. The antidepressants allowed her to better control her brain. Wegovy allowed her to better control her body. The drug, which Romero started taking in February, made her so nauseous that she took a pregnancy test, but she has since lost all that weight.
What doctors still don’t know
Some doctors remain concerned. Ilana Cohen, a psychiatrist at Sheppard Pratt in Maryland, said that she and other colleagues at psychiatric hospital systems avoid these drugs, partly due to anecdotal reports of European patients having suicidal thoughts while taking them. European health authorities are reviewing data on drugs like Ozempic and the risk of suicidal ideation.
People with recent suicidal thoughts, a history of suicide attempts, serious illnesses such as schizophrenia or bipolar disorder, or who have had depression in the past two years were excluded from Wegovy clinical trials.
“These medications have not been well-studied or designed for this population,” Cohen said. Researchers are studying how these medications might affect people with mental disorders.
In clinical trials of Saxenda, an older weight loss medication approved by the FDA, slightly more participants taking the drug had suicidal thoughts compared to those taking a placebo, although there was not enough evidence to show that the drug was the cause. The FDA requires weight control medications that act on the central nervous system, like Saxenda and Wegovy, to include a warning about suicidal thoughts.
Other doctors expressed concern that these medications, which significantly reduce the amount of food patients desire or can consume, may…