Should a Psychiatrist Ever Prescribe a GLP-1?

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Nine out of twenty. That's how many patients were taking GLP-1 agonists when Dr. Brittany Albright counted at the end of a clinic day. Not in a weight loss clinic. In a psychiatry practice.

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The overlap makes sense. About 43% of patients with major depression have obesity. The relationship runs both ways—obesity significantly increases depression risk.

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While GLP-1s aren't FDA-approved for psychiatric conditions, the question is whether psychiatrists—as physicians—should prescribe medications that address the metabolic dysfunction contributing to their patients' psychiatric symptoms.

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To find out, Osmind’s Chief Medical Officer, Will Sauvé, MD, sat down with Brittany Albright, MD, Founder of Sweetgrass Psychiatry and Osmind Medical Advisor for the latest episode of Psychiatry Tomorrow.
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Here’s what you'll learn:

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• Why GLP-1 receptors throughout the mesolimbic system make these medications psychiatric tools, not just metabolic ones
• Evidence-based patient selection criteria (mechanism over BMI)
• How to navigate the scope of practice question
• Clinical decision frameworks for real-world implementation
• Why force multipliers matter for the approaching workforce crisis
• FAQs for clinical guidance

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Read on or listen to the full Psychiatry Tomorrow episode below:

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The Neurobiological Case for GLP-1s for Mental Health

GLP-1 isn't only produced in gut L-cells. It's also synthesized in the nucleus tractus solitarius, a brainstem region projecting throughout the mesolimbic system—ventral tegmental area, nucleus accumbens, the entire dopamine reward pathway carries GLP-1 receptors.

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Dr. Will Sauvé: "There's kind of no other way it can be. Of course it's going to modify things like compulsive behavior and addictive behavior."

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The evidence: JAMA Psychiatry published a paper in February showing semaglutide significantly reduced drinking episodes in alcohol use disorder. Another study demonstrated effectiveness for binge eating disorder. Patients report decreased tobacco cravings, decreased food cravings.

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The parallel: Naltrexone blocks opioid receptors, reducing rewarding effects of alcohol. GLP-1 agonists appear to work through similar reward pathway modulation via different receptors.

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Wait, so are we just repurposing diabetes drugs? No, this is targeting the mechanism linking metabolic and psychiatric disease.

Who Actually Needs a GLP-1?

Albright's criteria: BMI 27 or higher plus medical comorbidity. The decreased cravings across substances become the side benefit.
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The exception: Patients on antipsychotics gaining weight despite metformin. At that point, GLP-1s become appropriate even below typical BMI thresholds.
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The gut check: Sauvé encountered a patient wanting GLP-1s for weight loss without excess weight. His questions cut through:

• Do you have cravings? No.
• Do you have trouble fasting? No.
• Do you engage in compulsive eating? No.
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"I think it might be addressing a problem that you don't have," he told her.

Match the prescription to the pathology, not the trend.

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One Clinical Example

Patient: Schizoaffective disorder on paliperidone LAI. BMI 26.5. Gaining weight despite 10mg tirzepatide. Elevated prolactin.
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Approach: Switch antipsychotic to xanomeline-trospium for better metabolic tolerability. Keep the GLP-1.

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The GLP-1 addresses metabolic dysfunction. The antipsychotic switch addresses prolactin. Both target pathophysiology contributing to psychiatric symptoms.

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Are Psychiatrists Allowed to Prescribe GLP-1s?

Albright's response is direct: "Are we not allowed to prescribe metformin then? That's part of the APA guidelines for patients on antipsychotic medications. Are we not allowed to prescribe valproic acid because that's an anti-seizure medication?" (To be fair, valproic acid IS FDA approved for mania since 1995).

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The medications work in the CNS. They directly impact psychiatric disease states. Research shows patients with bipolar disorder and obesity experience more frequent and severe mood episodes. "We're kidding ourselves if we're not treating obesity," she says.

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You trained in biochemistry and physiology. You understand molecules made in the liver and molecules made in factories. This falls squarely within your scope of practice.

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Is it Serotonin Deficiency or Inflammation?

Albright asks every group: "What are you learning about what causes depression?" The answer: "It's a deficiency of certain neurotransmitters." The serotonin hypothesis persists despite being debunked decades ago.

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The field is moving toward inflammation models. Chronic stress creates inflammation. Hyperglycemia creates inflammation. These mechanisms contribute to depression, anxiety, PTSD. Treatments should target these mechanisms: TMS, esketamine, ketamine, GLP-1s.

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As Dr. Stahl predicted years ago: Depression is probably at least five different illnesses with the same symptom presentation. One patient has circuit insufficiency. Another has chronic neuroinflammation. Same symptoms, different pathologies, different treatments needed.

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How Can Psychiatrists Meet the Demand?

By 2030, over 50% of US adults will have obesity. Current psychiatric workforce: roughly 75,000 psychiatrists and APPs. Current demand: 60 million people needing psychiatric care.

You cannot fix this seeing four patients an hour writing scripts.
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Force multipliers:
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• TMS: Patients receive independent treatment for weeks after assessment
• Metabolic education: Scales through group interventions
• Lifestyle programs: Wild 5 Wellness offers free 30-day coverage of five neuroinflammation-reducing interventions, providing participants with full access to the program's core wellness practices and supportive resources at no cost for the duration.
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Albright practices what she teaches. She was seventeen hours into a fast during the podcast interview. "I'm not going to ask my patients to do something that I can't or I won't do."

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Clinical Decision Framework For Prescribing GLP-1s

Ask these questions:

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1. Does this patient have cravings? (Alcohol, tobacco, food)
2. Do they engage in compulsive eating patterns?
3. Do they have insulin resistance markers?
4. Are they on antipsychotics causing weight gain?
5. Have standard metabolic interventions (metformin, lifestyle) failed?

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If yes to multiple questions: GLP-1s target the mechanism.

If no to most questions: The medication addresses a problem they don't have.

Bottom Line

• GLP-1 medications reduce cravings and compulsive behavior through mesolimbic system receptors. They're not just appetite suppressants.
• Select patients based on mechanism: insulin resistance, compulsivity, cravings. Not just BMI.
• By 2030, over half of adults will have obesity. Mental health and metabolic health cannot remain separate domains.
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The question isn't whether psychiatrists should treat metabolic dysfunction. The question is how we've gotten away with ignoring it for so long.
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Frequently Asked Questions about GLP-1s in Psychiatry

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Which GLP-1 medications can psychiatrists prescribe?

‍Psychiatrists can prescribe any GLP-1 agonist including semaglutide (Ozempic, Wegovy), tirzepatide (Mounjaro, Zepbound), dulaglutide (Trulicity), and liraglutide (Victoza, Saxenda) when clinically appropriate for patients with metabolic dysfunction, cravings, or compulsive behaviors. The real obstacle is getting insurance to cover it.

Are GLP-1 medications covered by insurance for psychiatric conditions?

‍Coverage varies. GLP-1s prescribed for FDA-approved indications (type 2 diabetes, obesity with BMI 27 or higher plus comorbidity) are generally covered. When prescribed for psychiatric indications like alcohol use disorder or binge eating disorder, prior authorization may be required with documentation of off-label rationale.

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Do GLP-1 medications help with alcohol use disorder?

‍Yes. A JAMA Psychiatry study published in February 2025 showed semaglutide significantly reduced drinking episodes in patients with alcohol use disorder through GLP-1 receptors in the mesolimbic dopamine system that modulate reward processing.

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Can GLP-1 medications replace psychiatric medications?

‍No. GLP-1 medications work alongside psychiatric medications to address metabolic-inflammatory contributions to psychiatric symptoms. They're particularly useful for patients on antipsychotics who develop metabolic complications or those with comorbid substance use and metabolic disorders.

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What's the minimum BMI for prescribing GLP-1s?

‍Standard criteria use BMI 27 or higher with metabolic comorbidity. However, for patients on antipsychotics experiencing weight gain despite metformin, GLP-1s may be appropriate below this threshold because they target medication-induced metabolic dysfunction.

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How long before GLP-1 medications help psychiatric symptoms?

‍Patients typically report decreased cravings and compulsive behaviors within 2-4 weeks. Metabolic improvements (insulin sensitivity, weight stabilization) occur over 3-6 months. Psychiatric symptom improvement parallels metabolic improvement timelines.

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Timestamped Show Notes

[00:00:00] Introduction - Brittany's home office with plants and dogs

[02:02] The "holistic" medicine debate

[04:02] Why Brittany opened Sweetgrass Psychiatry

[07:00] Bringing family medicine in-house

[10:01] The economics of integrating primary care

[11:08] Scaling to 30 clinicians

[13:41] Full suite of interventional services offered

[15:08] Nine out of twenty patients on GLP-1s

[16:15] Depression and metabolic syndrome: 50/50 overlap

[19:03] GLP-1s and the mesolimbic system

[20:24] JAMA Psychiatry study on semaglutide for alcohol use disorder

[21:17] Dr. Stahl quote: "Follow the FDA label and never get anybody better"

[22:10] When GLP-1s aren't appropriate

[24:01] Case study: patient on paliperidone gaining weight despite tirzepatide

[25:52] Discovery of nucleus tractus solitaris

[28:26] The "are we allowed to prescribe this?" debate

[29:10] Valproic acid, propranolol, and scope of practice

[30:01] Bipolar disorder, obesity, and mood episode frequency

[30:49] Moving beyond the monoamine hypothesis

[31:19] UK paper: no proof depression is serotonin deficiency

[33:23] Alternative treatments: TMS, ketamine, GLP-1s

[34:03] Dr. Stahl's prediction: MDD is five different illnesses

[36:11] 2030 projection: over 50% of adults with obesity

[37:27] Starting with clinicians practicing what they preach

[38:44] Wild 5 Wellness program

[40:34] Force multipliers: treating populations, not just individuals

[43:06] Equipping other clinicians rather than scaling

[43:48] Private practice summit planned for Vegas 2026

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Thank you for reading/listening. Please note that this article and podcast do not constitute medical, legal or financial advice or services. Our aim is to entertain and inform our readers. We recommend that you consult with a qualified healthcare provider prior to making any medical decisions or changing any medications or dosages. The opinions expressed in this podcast are solely those of the speakers and do not necessarily reflect the views or endorsement of their affiliated organizations.

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