The Ozempic Dilemma: Promises and Pitfalls in Psychiatry

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have rapidly emerged as an important medication class in current-day medicine. As their use expands, GLP-1 RAs have moved beyond endocrinology and primary care, becoming part of the cultural milieu. They are increasingly becoming relevant to psychiatric practice to address antipsychotic-induced weight gain and metabolic syndrome, with potential psychiatric applications beyond metabolic health.

In findings from the 2025 COaST trial (ACTRN12621001539820), published in The Lancet Psychiatry, semaglutide resulted in a 13.46% placebo-subtracted weight reduction, alongside improvements in metabolic parameters, in patients with schizophrenia and clozapine-induced obesity.¹ Randomized controlled trials (RCTs) in JAMA Psychiatry corroborate these findings, demonstrating semaglutide’s efficacy in mitigating antipsychotic-induced metabolic dysfunction.^2,3 As clinicians encounter more patients using or inquiring about these medications, it is important to distinguish established applications from emerging possibilities, while also considering broader psychological and cultural implications of their use. This review examines these details and discusses the wider social impact of a medication class that is reshaping conversations about appetite, body image, obesity, and mental health.

The Growing Market of GLP-1 RAs

GLP-1 is a hormonal peptide that regulates glucose homeostasis by controlling insulin and glucagon secretion. Chemical compounds that are agonists of GLP-1 receptors have been widely used to treat type 2 diabetes mellitus (T2DM) and/or obesity by reducing food intake and resulting in weight loss.⁴ GLP-1’s journey from its initial identification as a potent incretin to the current era of dual agonists spans the past couple of decades of rapid scientific advancement (Figure 1). With exenatide becoming the first GLP-1 RA approved for diabetes in 2005 and liraglutide being approved for weight management in the obese population in 2014,⁵ multiple products are being developed for the market, with ongoing trials aiming to demonstrate the role of GLP-1 RAs in neurodegenerative disorders and addiction disorders. Newer agents such as tirzepatide,⁶ the first dual GLP-1 and glucose-dependent insulinotropic polypeptide agonist, were approved for T2DM in 2022 and obesity in 2023. Despite these milestones (Figure 2), the pace of development and investment in this space remains frantic. These agents are now being trialed for a range of psychiatric applications, extending their reach well beyond metabolic medicine.

Early Evidence and Future Directions

In preclinical models, GLP-1 RAs modulate mesolimbic dopamine signaling, attenuating the reinforcing effects of addictive substances within the brain’s reward pathways. GLP-1 RAs have shown promising results in preclinical models of alcohol addiction, and early clinical evidence is now emerging. In a 2025 phase 2 RCT, low-dose semaglutide significantly reduced alcohol craving and drinks per drinking day in adults with alcohol use disorder (AUD).⁷ Data from a large Swedish observational study similarly demonstrated that semaglutide and liraglutide use were associated with a substantially lower risk of AUD-related hospitalization.⁸ While early RCTs with exenatide and dulaglutide have shown mixed but promising signals, particularly for alcohol (in patients with a body mass index [BMI] > 30) and nicotine (improved smoking abstinence with exenatide), definitive treatment guidelines await results from ongoing trials.^9,10 For cocaine and amphetamines, evidence remains limited to preclinical models, with no completed human RCTs to date.¹¹

GLP-1 RAs are also generating interest for their neuroprotective potential. Early research findings suggest that these agents may reduce neuroinflammation and protect brain cell integrity. Data from a large observational study showed a significant reduction in rates of Alzheimer disease and related dementias among patients with T2DM who were using GLP-1 RAs.¹² This epidemiologic signal, however, has not been borne out in randomized trials: Findings from the phase 3 EVOKE (NCT04777396) and EVOKE Plus (NCT04777409) studies showed that oral semaglutide did not slow progression of early Alzheimer disease on the Clinical Dementia Rating–Sum of Boxes scale, despite favorable movement in disease biomarkers.¹³ The divergence underscores the gap between epidemiologic association and trial-confirmed efficacy and should temper enthusiasm about neuroprotective claims.

Eating disorders present a particularly complex landscape for GLP-1 RA use. Emerging evidence suggests that GLP-1 RAs may reduce binge-eating episodes, food cravings, and emotional eating in individuals with binge eating disorder.¹⁴ Case reports of extreme appetite suppression and pathological dietary restriction with GLP-1 RA therapy have been documented, sometimes necessitating discontinuation.¹⁵ For anorexia nervosa, no clinical trials exist, and pharmacovigilance surveillance has flagged potential risk.¹⁶ GLP-1 RA–induced appetite suppression can reduce caloric intake, raising concerns about nutritional deficiencies. While many patients describe “reduced food noise” as a profound relief, its normalization raises a broader question: Could hunger itself come to be viewed not as a universal human experience, but as an undesirable state to be medically managed?

Suicidality Concerns

Significant public attention has been drawn to concerns about suicidal ideation with GLP-1 RAs. Findings from regulatory evaluations and meta-analyses revealed no significant increase in suicide or self-harm with GLP-1 RAs compared with placebo. On the strength of data from a comprehensive meta-analysis of 91 placebo-controlled trials, the FDA in January 2026 requested the removal of the suicidal ideation and behavior warning from GLP-1 RA labeling.¹⁷ However, pharmacovigilance data paint a more nuanced picture. Observational and reporting systems have found elevated reporting of depressed mood and suicidal ideation with semaglutide, with these signals emerging more prominently after the semaglutide agent Wegovy’s approval for obesity in June 2021, likely reflecting its expansion into populations with higher baseline rates of depression.¹⁸ Nevertheless, clinicians should remain attentive to mood changes, particularly in patients with preexisting psychiatric illness.

Cultural Impact and Potential Pitfalls

Between 2018 and 2023, the relative search volume for “Ozempic” grew exponentially. GLP-1 RAs are essentially functioning not just as medications but as a cultural phenomenon associated with attractiveness and fitness. The widespread visibility that these medications have achieved online and in association with celebrity culture has accelerated their adoption beyond medically indicated populations with obesity or diabetes. Consequently, psychiatrists may encounter patients whose body image and self-worth are impacted by this growing normalization of pharmacological weight loss. Most existing evidence, including pharmacovigilance data, derives from medically indicated populations with diabetes or obesity. It therefore does not capture the growing number of individuals obtaining these drugs online for cosmetic or aspirational weight loss, often with minimal clinical oversight and no psychiatric screening. This group likely carries a higher baseline risk for body image disturbance and disordered eating.

There have always been societal expectations regarding body size and appetite. Thinness has often been culturally associated with discipline and beauty. GLP-1 RAs can contribute to shifting societal expectations surrounding bodies. Especially among adolescents and young adults exposed to idealized body standards online, failure to achieve thinness (which is increasingly pharmacologically achievable) may become further pathologized or moralized. This may lead to the intensification of shame regarding larger bodies and increase pressure on people to medically modify themselves in pursuit of a socially idealized version of themselves.

As the GLP-1 RA market expands rapidly, so does the drugs’ off-label and nonindicated use, and multinational pharmaceutical companies anticipate major revenue growth. Excessive weight loss in individuals with normal BMI can cause malnourishment, electrolyte imbalance, and an unhealthy relationship with food. While illicit misuse of GLP-1 RAs is not yet well documented, a 2025 case report describes an adolescent girl with atypical anorexia nervosa misusing semaglutide, highlighting early signals of abuse potential in vulnerable populations.¹⁹ The novelty of this weight loss drug, coupled with the heterogeneity of data from published reports and ongoing trials, marks the uncertainty surrounding the effects of long-term use of GLP-1 RAs and raises a concern about prescribers’ limited knowledge of the dosage guidelines and the potential for GLP-1 RA abuse. In clinical practice, sparsity of research should not preclude a prescriber from using a novel treatment, particularly when many positive clinically significant outcomes have been reported. However, prescribing practices should be individualized to the patient’s presenting symptoms.

Are GLP-1 RAs saving lives daily by generating improved cardiovascular health? Absolutely. However, critical questions remain unanswered: Are GLP-1 RAs consistently addressing the patient’s symptomatology, or are they reinforcing maladaptive patterns and potential misuse? Are we optimizing patient outcomes, or feeding into the expansion of an oversaturated culture and pharmacological dependence?

Concluding Thoughts

The public discourse surrounding GLP-1 RAs reveals a compelling narrative: For many patients who have long struggled with their weight, these medications represent the first accessible intervention that addresses biological drivers of obesity rather than framing weight as a matter of willpower and moral discipline. The intense reactions to GLP-1 RAs may reflect, at least in part, discomfort with shifting obesity from a moralized condition to a medically treatable one. This shift may reduce self-blame for some patients, though it continues to raise concerns about disparities in access and the stigmatization of pharmacological assistance as “cheating.” Most clinical trials have enrolled individuals with diabetes or obesity and excluded those with preexisting psychiatric conditions, leaving the safety profile in psychiatrically vulnerable populations largely unknown. Psychiatrists and mental health clinicians should remain attentive not only to the pharmacological effects of these medications but also to their broader cultural impact on patients’ relationships with food, body image, and self-worth. As the evidence base matures, dedicated trials that include psychiatric populations will be essential to clarify both the therapeutic potential and the risks of GLP-1 RAs in the patients we treat.

Dr Suri is a psychiatry resident year 2 at BronxCare Health System in New York, New York, with interests in lifestyle psychiatry, preventive mental health, and evidence-based wellness interventions.

Dr Javaid is the current chief resident at BronxCare Health System in New York, New York, with interests in psycho-oncology, consultation-liaison psychiatry, systems of care, and resident education.

Dr Ali is a psychiatry resident year 1 at BronxCare Health System in New York, New York, with interests spanning toward a research field in psychiatry.

Dr Pathania is an outpatient psychiatrist at BronxCare Health System in New York, New York, actively involved in supervision and education of psychiatry residents.

Dr Mirhom is an assistant professor of psychiatry at Columbia University in New York, New York, a Forbes contributor, and chief well-being officer at Athletes for Hope.

Dr Gunturu is the vice chairman of education, research, and faculty development and the psychiatry residency director at BronxCare Health System in New York, New York. He is also an assistant professor of psychiatry at Icahn School of Medicine at Mount Sinai in New York, New York, and clinical associate professor at St. George’s University School of Medicine in St. George’s, Grenada.

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