To Psychiatrists: Which off-label medications do you use the most?

[Psycho Bunny]

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As the title says. For drugs not directly made for psychiatric illnesses, what are some of the top medications that you prescribe off-label for patients?

 

[littlefred]

Is this forum turning into BuzzFeed now?

 

[shoomer]

I use a lot of caffeine personally. But I build up tolerance quite quickly so I need to take breaks often.

 

[Psycho Bunny]

Is this forum turning into BuzzFeed now?

😅 reworded the question. I realized I framed it in a bad way

 

[lobstar]

I use a lot of sertraline in GAD. Yes, I know, not FDA approved. I'm quite the edgy risk taker.

Are you trying to diversify what you use since things don't work? I think it's better to just stop looking as it is in fact true that meds don't help lots of people. If you want them to say they feel better, even though there's no actual evidence they are doing better, just send a benzo or stimmy. I'm only partially kidding.

 

[calvnandhobbs68]

Why?

I use a lot of sertraline in GAD. Yes, I know, not FDA approved. I'm quite the edgy risk taker.

Are you trying to diversify what you use since things don't work? I think it's better to just stop looking as it is in fact true that meds don't help lots of people. If you want them to say they feel better, even though there's no actual evidence they are doing better, just send a benzo or stimmy. I'm only partially kidding.

OP is an undergrad.

 

[Psycho Bunny]

Why?



OP is an undergrad.

Yeah, I was just curious because I know a lot of drugs in other specialties are used off label and/or are medically approved for a use in other countries but maybe not in the US. Like for example I know some people use naltrexone for binge eating disorder even though its not technically approved for that. I was just curious if there were any medications that helped for anything like depression, bipolar disorder, schizophrenia, etc that might not necessarily be officially approved for those uses but are used anyway due to some data supporting their efficacy.

I get that I didn't word the question in a clear way.

 

[clausewitz2]

Topamax for binge eating/neuroleptic associated weight gain

tadalafil for SSRI-related sexual dysfunction (male and female)

desipramine for ADHD for people for whom stimulants are not a great idea (e.g. AA folks very leery of substances)

Dopamine agonists (especially pramipexole) for depression that is particularly anhedonic and anergic

I know a lot of people seem to like pregabalin for anxiety, not something I routinely do and have not been impressed

Very rarely, compounded intranasal ketamine for depression. Not a great success rate to date.

naltrexone for compulsive gambling

naltrexone for dissociation (driven by specific request of the patients in question, online community seems to have converged on this as a notion, not less effective than any other alternatives)

low doses of depakote in biological males with problematic aggression and irritability but in situations where getting reliable collateral/symptom reporting is impossible to the extent you'd need to actually pin down a clear affective diagnosis


The big one coming down the pike (haven't done it myself yet) is GLP-1 agonists for substance use d/o of various kinds, especially alcohol and cocaine.

 

[Merovinge]

Topamax for binge eating/neuroleptic associated weight gain

tadalafil for SSRI-related sexual dysfunction (male and female)

desipramine for ADHD for people for whom stimulants are not a great idea (e.g. AA folks very leery of substances)

Dopamine agonists (especially pramipexole) for depression that is particularly anhedonic and anergic

I know a lot of people seem to like pregabalin for anxiety, not something I routinely do and have not been impressed

Very rarely, compounded intranasal ketamine for depression. Not a great success rate to date.

naltrexone for compulsive gambling

naltrexone for dissociation (driven by specific request of the patients in question, online community seems to have converged on this as a notion, not less effective than any other alternatives)

low doses of depakote in biological males with problematic aggression and irritability but in situations where getting reliable collateral/symptom reporting is impossible to the extent you'd need to actually pin down a clear affective diagnosis


The big one coming down the pike (haven't done it myself yet) is GLP-1 agonists for substance use d/o of various kinds, especially alcohol and cocaine.

Clinical trials starting this year for that, weill have a good idea fairly soon, doesn't have to be some off-label mystery.

I'm more impressed with gabapentin for anxiety than I was in training, but it's also far from some amazing/miracle drug. Honestly the BID/TID dosing of this and Buspar likely account for a significant portion of the benefit. I do find people like to take it at a fairly high clip and can be a nice alternative to BZDs.

 

[Sushirolls]

I seldom know the FDA indications of drugs.
The bulk of medications are prescribed off label, its more the exception to be on label.
If person has Unspecified Anxiety, Unspecified Depressive Disorder, or Unspecified Psychosis; I'm not aware of any medications that are FDA approved for any of those.

In training the angle that FDA is the authority - the bible - the know all of pharmacotherapy is not taught. Training in residency is evidence based what helps XYZ condition whether its meds or other. The FDA is merely an organization that sets the guiding doses, risks, and safety parameters of a medicine. After that, academic medicine takes over to find where the real clinical benefits are, the real clinical dosing, AND the post release side effects that become apparent, and reported back to FDA for more labeling (or revocation).

Now I do know FDA max doses for most psych meds and discuss with patients when blowing past the FDA max.

 

[comp1]

Yeah I have to second that I don't really track what something is FDA approved for so this is a very hard question to answer. FDA approval is much more relevant to advertising (particularly direct to consumer) than it is for what a physician does with a given medication.

 

[thelastpsych]

Low dose atypical antipsychotics for mood disregulation in PD (especially BPD), mostly associated with insomnia/agitation. Have mixed results, mostly with quetiapine (25-100mg) or Aripiprazol (2.5-5mg). Olanzapine and Risperidone are good options, but usually have some intolerable side effects even at low doses.

Of course I advise patients of side effects (metabolic mostly), and only use it as adjunctive

 

[brosa]

I am also not aware of most list of FDA approval meds. I don't think I even trust the FDA, lol. If something is recommended for bipolar disorder in the CANMAT guidelines and other guidelines, I much rather trust that than the FDA.

FDA usually causes more harm than good with black label warnings too btw, always good to read about the SSRI fiasco on teenagers. On a side note, has anyone ever seen pancreatitis with depakote? It has a black label warning but I've never seen it, not even close to it.

 

[Sushirolls]

FDA gripes:

SSRI teenagers...
QTc Celexa
clozaril REMS
nasal esketamine REMS
suboxone REMS
ECT and new warnings...

 

[mistafab]

I am also not aware of most list of FDA approval meds. I don't think I even trust the FDA, lol. If something is recommended for bipolar disorder in the CANMAT guidelines and other guidelines, I much rather trust that than the FDA.

FDA usually causes more harm than good with black label warnings too btw, always good to read about the SSRI fiasco on teenagers. On a side note, has anyone ever seen pancreatitis with depakote? It has a black label warning but I've never seen it, not even close to it.

Seen 1 case for depakote pancreatitis. Interestingly, seen more agranulocytosis and pancytopenia from depakote (n=3). Overall, a great medication but terrible for women of childbearing age.

 

[calvnandhobbs68]

Almost everything is technically off label for kids (besides the ADHD meds which all usually run their initial clinical trials in pediatrics) so yeah if you look at the technical labeling for a lot of meds, things go "off label" quickly.

Zoloft for instance is actually only on-label for OCD in kids. Cymbalta and Lexapro are the actual only "on label" options for GAD in kids.

 

[FatherPsychiatry]

I seldom know the FDA indications of drugs.
The bulk of medications are prescribed off label, its more the exception to be on label.
If person has Unspecified Anxiety, Unspecified Depressive Disorder, or Unspecified Psychosis; I'm not aware of any medications that are FDA approved for any of those.

Same.

Although if a company gets a medication approved for UNSPECIFIED SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDER, that would be a game changer.

 

[annoyedpsychiatrist]

metformin for antipsychotic induced weight gain/metabolic effects

 

[ObsequiousAplomb]

Haloperidol and/or Benadryl for agitation or aggression

 

[vanfanal]

Gabapentin and Topiramate for alcohol, cannabis and stimulants.

 

[2025DandW]

Seen 1 case for depakote pancreatitis. Interestingly, seen more agranulocytosis and pancytopenia from depakote (n=3). Overall, a great medication but terrible for women of childbearing age.

I have seen a number of cases of Depakote induced pancreatitis. I actually transferred a patient
to a higher level of care due to poor response to medications, and I was later told the patient died from Depakote induced pancreatitis. So, it is definitely something I will continue to monitor for in my patients.