This is an exclusive BHB+ story.
Emerging research has found new benefits that GLP-1s like Ozempic, Wegovy and Mounjaro may bring to addiction treatment, serious mental illnesses and eating disorders.
The strongest evidence among the three behavioral health focus areas thus far has primarily been showcased in the power GLP-1s hold in curbing cravings for those with alcohol use disorder (AUD), but a new study of 600,000 veterans that spanned three years found even when they began taking the drug for diabetes, they were also 15% to 20% less likely to misuse a range of substances, including opioids.
Adjacent to that, there is a growing wave of research and emerging benefits related to off-label uses in mental health care. Not only has it demonstrated effectiveness in reducing cravings for binge eating disorders and other behaviors, but GLP-1s have also been praised for their ability to curtail one of the major downsides of antipsychotic medications: weight gain and other metabolic challenges for patients undergoing serious mental illness (SMI) treatment.
“I have a lot of optimism,” Dr. Scott Fears, chief medical officer at Amae Health, told Behavioral Health Business. “Especially for folks with SMI, many of our medications cause weight gain and put people at risk for metabolic syndrome. The visceral fat profile gets worse, and prior to GLP-1s, we have had very limited options.”
Amae Health is a San Francisco-based behavioral health service provider focused on treating individuals with SMIs. The company is also known for its metabolic psychiatry track, which includes primary care, psychiatric interventions, and dietitian expertise to tailor dietary and exercise programs for SMI care. Fears and Amae Health’s co-founder and CEO Stas Sokolin, told BHB that as part of its metabolic psychiatry program, two patients have also been on GLP-1 medications with positive results.
In one of those instances, an SMI patient who had diabetes and other comorbidities lost all the weight that was induced by their antipsychotic medication with the combination of a GLP-1 and metabolic psychiatry. More than one year later, the patient was able to stop diabetes and blood pressure medications.
In another instance, it seemed that the addition of a GLP-1 medication for another SMI patient helped them better adhere to their metabolic psychiatry plan and decreased some of the noise, anxiety and fear related to eating and grocery shopping that can often be even more palpable for this patient population.
“It really is a big quality of life difference, because we are putting so much effort into getting SMI patients to engage more with the real world,” Sokolin said. “So many patients stop antipsychotics because of weight gain and other metabolic effects. I think being able to mitigate that is just wonderful. You’re mitigating one of the more impactful side effects that make somebody stop taking medicine.”
Growing Use Cases
Charlie Health, a Bozeman, Montana-based provider of virtual, high-acuity mental health and substance use treatment, is planning to offer GLP-1s for patients soon, specifically for aid in treating alcohol use disorders (AUD) and eventually may apply it to nicotine use disorder as well, the company’s senior medical director, Dr. Eli Muhrer, told BHB.
“We have not yet prescribed a GLP-1 for alcohol use disorder, but how we’re going to do it is in phases,” Muhrer said. “We’re very close. We’ll start offering GLP-1s for alcohol use disorder in adults. We want to make sure that safety-first is really our guiding principle here. We want to make sure we’ve really thought about everything.”
Right now, the criteria for receiving a GLP-1 prescription are primarily related to obesity, diabetes, cardiovascular disease, obstructive sleep apnea and metabolic dysfunction-associated steatohepatitis, among other things — not for mental or behavioral health conditions. As a result, a patient needs to already have a qualifying criteria and/or go through a compounding pharmacy, which is how Charlie Health will approach it.
“Let’s say we start someone on their GLP-1 for alcohol use disorder and it really helps reduce the number of heavy drinking days and reduces alcohol craving,” Muhrer said. “Well, what do they do when they are discharged from our short-term program? It’s only between eight and 12 weeks they’ll spend with us, so we’re ensuring that we can do a warm handoff to a provider or a group that will be able to continue to not only prescribe it, but monitor and titrate the medication accordingly. Those are the two most important pieces: how they actually get the medications at an affordable price, and two, how they get ongoing care long term if they find it helpful.”
Like Amae Health, since Charlie Health also works with high-acuity, complex mental health patients, Muhrer underscored the added benefit of GLP-1s providing aid to metabolic syndrome and side effects and reducing weight gain from antipsychotics and related medications.
The Hazelden Betty Ford Foundation, one of the largest nonprofit addiction treatment organizations in the U.S., is also close to making GLP-1s more accessible for its patients who meet the current clinical criteria and present with AUD, Dr. Alta DeRoo, chief medical officer, told BHB.
“We’re going to be partnering with a space where we can appropriately choose patients who would benefit from the GLP-1s,” DeRoo said. “We’ll be choosing these patients, having a discussion with them, and partnering with a person or with an organization who can then prescribe those GLP-1s. The reason why we wouldn’t necessarily want to be the sole provider to initiate and continue the GLP-1s is because we do residential treatment for substance use disorders. We do that very well, but our doctors are addiction medicine doctors. If you’re going to continue a patient on a GLP-1, you need to monitor that patient and that really requires a relationship with a general practice provider.”
GLP-1 use is also growing within eating disorder treatment, but since this specific part of behavioral health is so closely tied to eating habits, proceeding with extra caution here is key, both Dr. Kimberly Dennis, co-founder, CEO, and chief medical officer at SunCloud Health and Stephanie Ryan, clinical director at Eating Disorder Treatment Centers (EDTC) shared with BHB.
“They show some promise in helping with binge-type eating disorders, but we don’t quite know yet which patients will benefit and which patients will be harmed,” Dennis explained. “There are some general principles that guide us. For example, even if they have a binge eating disorder, they may have a lot of restrictive eating behaviors that are part of their eating disorder. That’s probably not a person who is going to do very well on these medications, because they do — at the brain level, in addition to at the level of the gut — decrease your appetite.”
SunCloud Health is a Chicago-based provider of eating disorder treatment and substance use care at multiple locations throughout Illinois.
However, for others struggling with disordered eating, the addition of a GLP-1 could be a game-changer, Dennis explained. Right now, she and her team are approaching this with caution.
“The nice thing about trying these medications with people at our treatment center is that if they’re in residential care or if they’re in day treatment or even IOP, for that matter, they’re seeing treatment providers five days a week in residential every single day, with nurses there 24/7 and medical staff available, 24/7 as well,” Dennis said. “So we can monitor very closely what impact the medication is having on their eating behaviors.”
At Louisiana-based Eating Disorder Treatment Centers, Ryan echoed that.
“It just requires such extreme caution and oversight system-wide,” Ryan told BHB. “Having specific eating disorder-related guidance around prescribing will be important, not just for people who work with eating disorders, but for general practitioners.”
She is also concerned that the rise of GLP-1s for the eating disorder patient population can, at times, be a negative cultural signal that being thin is the best, most healthy way to exist, which can also hurt recovery.
“Another concern we have is how GLP-1s have entered through that metabolic medicine lens, but now it’s colliding with the cultural question towards fitness, and it’s being used also as a lifestyle maintenance tool,” Ryan said. “So I think seeing the progression of that and looking at outcome studies will be key before we make a decision of whether or not we want to include that in our care.”
Road to Reimbursement
Because GLP-1s are a new drug within health care in general and there are not yet any clinical standards for its use across substance use disorder care, serious mental illnesses or eating disorders, the road to eventual reimbursement for including it in care is one all practitioners told BHB they will be closely monitoring.
One of the biggest challenges for commercial health plans covering GLP-1s is member turnover, which makes it difficult to see a return on their coverage investment.
“You end up spending a meaningful amount of money, but you don’t get those cost savings if somebody switches jobs and therefore switches insurers,” Sokolin said. “That’s been a big issue. It is the biggest cost driver for health insurance in recent years. That’s kind of where the struggle is. It’s really a preventative medicine. I don’t know if they’re going to broaden it or not. I think if there are additional indications that are approved and there is research being done on that, that might broaden the approval aperture… then maybe then they’ll broaden the coverage.”
Without insurance or discounts, GLP-1s can cost as much as $1,300 per month out of pocket, rendering them inaccessible to many patient populations even outside of mental health. Lowering that barrier and deepening research and outcomes data across the potential behavioral health use cases could take several years before those indications change, Sokolin hypothesized.
Still, there is hope among providers that it may change and eventually become another tool in the lineup to improve behavioral health outcomes and adjacent effects.
“One of the challenges that I think that we’re going to have is payer reimbursement,” DeRoo added. “Right now, it’s only FDA cleared for obesity and diabetes and not yet for substance use disorders. I do think there’s a lot of promise for this. I would not be surprised if SUD eventually became a clinical indication for using a GLP-1.”
Lacking that, DeRoo said that the ideal patients who can benefit from GLP-1 off-label uses across mental health are those who already meet clinical criteria to receive a prescription for a GLP-1.
“If we could just augment their recovery and provide this additional tool for them, that would be ideal,” DeRoo said. “So right now, we are selecting those patients who we think would be good candidates for that.”