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Mental Health Pathfinders: GLP-1 Medications: What Psychiatrists Need to Know · The Medical Mind

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  Thank you for joining us for this episode of Mental Health Pathfinders.
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  I'm your host, Aaron Connors. We've all seen the commercials for popular weight loss
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  medications that are helping people quiet the food noise they often experience while
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  they're trying to lose weight.
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  You know, that persistent voice telling you that you're still hungry could suddenly
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  become much quieter or even disappear.
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  GLP1 medications have been used for years to help people living with diabetes.
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  But we're now learning more about their potential to support people living with
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  mental health and substance use disorders as well.
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  Joining me today to talk about this is Dr.
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  Charles Nemiroff, Chair for the Dell Medical School Department
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  of Psychiatry and Behavioral Sciences at the University of Texas at Austin.
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  He also serves as director for the Dell Medical School Institute
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  for Early Life Adversity Research and co-director for the Center
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  for Psychedelic Research and Therapy.
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  Dr. Nemroff also serves on the APA's Council on Research.
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  Thanks for being here today. We really appreciate it.
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  Erin, it's always
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  great to be with you and look forward to our conversation.
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  Great. Well let's jump right in.
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  You know, I I read a recent Gallup poll that showed about eleven percent
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  of US adults are currently taking these GLP one medications,
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  specifically for weight loss, and that's roughly one in nine adults.
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  This can barely be a game changer for people who are struggling to lose weight.
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  Are you seeing an increase of people in your own practice asking
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  for these medications?
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  The the development of GLP one ~ agonist for the treatment of obesity
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  and its complicating ~ medical syndromes like diabetes,
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  metabolic syndrome, et cetera,
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  has absolutely been a game changer for all of medicine.
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  And psychiatry is not exempt from that.
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  Let's remember that one-third of psychiatric patients have
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  one doctor and one doctor only,
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  and that's their psychiatrist.
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  And so as psychiatrists, we need to know about these medications because they
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  can be lifesavers literally. And we know that patients treated with these
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  medications, that the weight loss associated with them markedly reduces risk
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  for cardiovascular disease, stroke,
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  type two diabetes, and a variety of other complications of being obese.
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  So this is a game changer.
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  For all of medicine and psychiatry and its patients are not exempt.
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  And we do know that there are with certain psychiatric medications there
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  are w one of the side effects can be some weight gain.
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  So obviously this could be something could help a lot.
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  There's no question that particularly the first generation
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  of atypical antipsychotics, such as allanzepine and quatiapine,
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  were associated with very clear weight gain and an increase
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  ~ in the incidence of type two diabetes.
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  and we know for a long time that psychiatric patients,
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  for a variety of reasons, partly because they
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  generally have poor nutrition,
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  partly because they don't exercise,
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  as you might want them to already at risk for heart disease,
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  stroke, diabetes, et cetera. And so given the fact that
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  we have a little bit of responsibility and that we've prescribed these medications
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  that have been associated with an untoward amount of weight gain,
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  ~ it's incumbent upon us to do everything we can for our patients.
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  And in this case, ~ GLP ones can be a total game changer as far
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  as ~ the the the risk is concerned.
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  Yeah, and for all of us when we lose a little weight,
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  we actually feel a lot better.
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  So that should be helping people with their mental health issues sometimes too.
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  Yeah, there's no doubt that that ~ obesity is associated with a higher rate
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  of depression. That's been shown time and time again.
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  Patients with bipolar disorder tend to ~ have l higher
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  BMI than those in the general population.
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  And so one of the interesting questions that you just raised is
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  ~ by virtue of feeling better about yourself if you lost 20 or 25 pounds.
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  Is that going to have an antidepressant effect,
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  sort of secondarily? And I think ~ my clinical impression is that that's the case,
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  but we haven't had any randomized controlled clinical trials in that regard.
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  Tell us a little bit how these medications actually work.
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  Well, so this is one of the great ~ stories in modern medicine,
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  which is ~ the the GLP one receptors are found in the brain
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  and in the periphery. And so in the periphery they have effects like slowing
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  gut mo motility, so that that is associated with increased feelings
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  of satiety, but they also have ~
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  ~ direct brain effects and there are these receptors are found in the brain as well.
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  And so I think there's a dual mechanism of action.
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  I think these drugs are working on the GI tract,
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  but I think they're also ~ working on the brain ~ in in a behavioral
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  way to reduce ~ craving for food.
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  You know, I know I know some people that are on these medications and they often
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  say to me that they really don't enjoy drinking alcohol anymore now that they're
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  on these medications. Is that a typical side effect?
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  And if so, how should clinicians think about GLP ones alongside maybe some
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  established treatments such as medications for alcohol and opioid use disorders?
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  So let's let's start off and and say that there is increasing interest
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  in these drugs to address cravings.
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  And that could be ~ originally we started with food cravings.
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  But we can also talk about other cravings,
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  alcohol being one of them, gambling might be another.
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  ~ there are a number of cravings,
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  obviously substance use disorder,
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  opiates, ~ etcetera.
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  So ~ this has opened up an entire new avenue of research,
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  and that is ~ are GLP1s potentially part
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  of the augmentarian for the treatment of alcohol use disorder.
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  There are currently two medications that are approved by the FDA
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  for alcohol use disorder. One is a campersate,
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  and the other is ~ an opiate antagonist,
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  right? Naltrexone.
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  That can be given either ~ in a daily pill or in a monthly injection.
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  And although those ~ medications are FDA approved,
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  not everybody responds to them,
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  number one. And honestly,
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  physicians under prescribe them.
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  Most of the patients I see that with alcohol use disorder,
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  and I say, have you ever been treated with one or the other
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  of these FDA-approved treatments for reduced craving?
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  The answer is usually no, I've not.
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  So ~ having said that,
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  there are also lots of patients that don't respond to those medicines.
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  and so there have been some studies.
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  There was a recent publication in JAMA Psychiatry looking at GLP1s
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  for the treatment of alcohol abuse,
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  and there does seem to be ~ positive findings here.
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  And as you anecdotally reported,
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  ~
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  from friends who say they've lost their taste for alcohol.
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  And, you know, alcohol remains a huge public health problem.
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  And it confounds ~ all of the ~ by itself it's a problem
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  and it confounds patients who have other psychiatric diagnoses.
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  You know, those who have social anxiety disorder and the drinking in order
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  to try to reduce their anxiety.
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  So I think this is very promising.
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  ~
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  The question is, do these drugs
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  ~ result in any sort
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  of pan meaning widespread reduction in the ability to experience pleasure?
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  Right? Do they produce some level of anhedonia?
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  Right? Because if they reduce the pleasure you get from food and
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  the pleasure you get from alcohol,
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  is it possible that they reduce
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  Pleasure induced by other things?
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  And thus far, the answer seems to be no.
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  So, at least in my patient population,
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  largely depressed patients, I've not had anybody say to me,
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  you know, now that I'm on these meds and I've lost weight,
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  that I've had a reduction in my ability to experience pleasure in other areas.
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  And in the safety data that was submitted by the companies that manufacture these
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  drugs.
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  Nothing was picked up in that regard.
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  There was not an increase, for example,
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  in suicide rates in patients on GLP ones.
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  So we might might have thread the needle here and have a drug that reduces cravings
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  for all sorts of things that are not good for you,
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  ~ yet does not reduce your ability to have fun.
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  And that's great. But are there any other concerns in taking these medications,
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  possibly maybe overusing them for certain people?
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  So I'm glad you asked me that.
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  So I I have a number of patients who've come to me and and said
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  at times somewhat sheepishly, Hey,
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  incidentally, I got my primary care doctor to prescribe ~ a GLP one for me.
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  And my response is, Well, wait a minute,
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  your BMI is about twenty-one. You're not overweight,
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  much less obese. Why are you doing that?
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  Well, I really wanted to lose some weight.
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  And then you start thinking to yourself as a physician,
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  wait a minute, does my patient have body dysmorphic disorder?
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  ~ Is he or she looking at themselves in a way that that isn't realistic?
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  ~ Is the are these drugs being abused in that way?
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  And you know, all medical advances have their upside and their downside.
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  And so have I seen patients that I think are
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  Bordering on becoming anorexic while they're using these drugs?
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  Yeah, I have seen that and it is concerning.
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  Yeah, and I think some people might think this is a forever thing that once
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  you start taking them, you have to stay on them so you don't gain that weight back.
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  Is is that really the case?
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  Well, I I think there there are there are three outcomes
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  in taking these medications. Outcome one is that you lose weight,
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  outcome two is that you don't lose weight,
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  and then outcome three is that you lose weight and then you stop taking it,
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  and then what happens? So there are reports of people that have been able
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  to maintain their weight, ~ where they want it to be after they stop using
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  the medication, but then there are
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  At least an equal number of reports of patients that quickly regain their weight
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  after they stop. But on the other hand,
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  if you have type 2 diabetes,
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  you're going to be taking metformin for your life.
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  If you have type 1 diabetes, you're going to be taking insulin.
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  Why wouldn't you take a drug that was going to keep you in a normal
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  BMI range and reduce your risk for heart disease and stroke?
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  So if other if s other psychiatrists are thinking about recommending
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  GLP ones to their patients, what's your advice and and what kind
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  of information is available for them out there?
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  Well, there now a whole variety of different forms of these medications.
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  So they originally all be been given by injection,
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  self injection, and now ~ there are orally available
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  GLP ones that I I understand are accounting for at least a third of
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  the market right now. ~ there are also companies that
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  ~ that formulate the drugs for you.
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  So instead of getting it through a a traditional prescription,
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  there are online services that will provide ~ the medication
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  to you directly. I never I don't know enough about those companies
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  to know whether they pass all the quality standards that are necessary.
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  So I'm not gonna, you know, say that's a great thing or not.
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  Generally ~ those companies sprang up because the
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  Prescription medications were so expensive,
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  and a large number at the time of third party payers were not paying for it,
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  ~ other than for diabetes. But now I think that's changed,
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  and I think the cost has come down.
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  So I would you know recommend going with the pharmaceutical company ~ product,
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  which has gone through a lot of regulatory ~ steps.
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  I think this is a topic we're going to be hearing about for a long time.
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  It's just fascinating to see how these medications are working for patients.
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  You bet.
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  Charles Namaroth, thanks for joining us today.
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  We really do appreciate it.
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  It's my absolute pleasure and always good to be with you Aaron.
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  See ya.
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  And to our listeners, you can find new and past episodes
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  of Mental Health Pathfinders on your favorite podcast platform.
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  Thanks for listening.