Atypicals: Off-label

The off-label use of psychotropic medications was nicely reviewed by Judith G. Edersheim, MD, in the April 2009 issue of Psychiatric Times. Recently, there has been increasing interest in—some would say “hype” about—the use of atypical antipsychotics (AAPs) to treat a variety of nonpsychotic conditions or symptoms.

Thus, there is intense interest in the use of AAPs for refractory depressive states, bipolar disorder, and anxiety disorders—none of which necessarily involves the presence of psychosis! Is this a justifiable “off-label” practice? Are these drugs being hyped by “Big Pharma” to expand its market base, or is there a sound, evidence-based foundation for the use of AAPs in nonpsychotic conditions? (Both propositions could be true, of course!) Is it even correct to consider these agents as “antipsychotic” medications, or would it be more accurate to consider them “broad-spectrum,” cognition-affect modulators? Does reconsideration of the AAPs in this light remove or mitigate the medico-legal problems associated with their off-label use (eg, the risk of tardive dyskinesia, neuroleptic malignant syndrome, and metabolic syndrome)?

—Ronald Pies, MD (Editor in Chief)

PS: For a good background article on the use of AAPs in anxiety disorders, you might take a look at the excellent review by Gao and colleagues in the Journal of Clinical Psychiatry.