SGAs would be indicated as a first line therapy for Schizophrenia and for the positive symptoms of psychotic disorders in general. SGAs treat active psychosis as well as decrease relapses if remission from active symptoms is achieved.

SGAs would not be prescribed for depression unless a psychotic depression was present. For a depression without psychotic symptoms, first line treatment would be an SSRI antidepressant. The potential side effects of SGAs and lack of clinical evidence supporting efficacy of SGAs in depression without psychotics symptoms are both reasons SGAs would not be prescribed for this condition.

Bipolar Mood D/O:
SGAs are often prescribed for Bipolar Disorder. They stabilize mood as well as treat psychotic symptoms associated with mania. Often they are used in combination with mood stabilizers especially to stabilize mania in its initial phase as the mood stabilizers are titrated up. SGAs can be used alone or in combination with mood stabilizers to treat bipolar disorder.

Tourette Syndrome
SGAs would not be prescribed for the treatment of Tourette syndrome. Guidelines for Tourette’s note that antipsychotics may be prescribed only when the potential benefits of treatment outweigh the risks, ie if the symptoms are significantly functionally impairing. For tics, if medication required, alpha adrenergic agonists are “strongly” recommended with clonidine associated with more reduction than guanfacine XR. For tics and Tourette’s, there is a “weak” recommendation made for FGAs and SGAs, and other treatments.

SGAs would not be prescribed to treat ADHD. They are sometimes used in conjunction with expert consultation for off-label, preferably third line use, for short-term treatment for significant irritability and explosive emotions/behaviours while stabilizing on first line and/or second line treatment. First line treatment for ADHD includes monotherapy with long acting stimulants; second line treatment includes combination of first line treatments with guanfacine XR, or atomoxetine, or short-acting stimulants. Third line treatments include NDRIs (bupropion) and clonidine (monotherapy or in combination with stimulants). Comorbidities should be treated with first line treatments specific to the individual condition.

Eating Disorders (AN, BN, ARFID)
SGAs are, in children and adolescents, primarily prescribed for symptom management in severe eating disorders. There are mixed results for enduring effects on weight restoration and any potential benefits are balanced with the well-established risks. For treatment of anorexia nervosa, there are limited positive studies with the use of olanzapine, with quetiapine and aripiprazole having even fewer studies with mild benefit noted at times. Risperidone does not have evidence for AN. ARFID has limited positive reports for olanzapine. Use of SSRIs, specifically fluoxetine, has the most evidence for bulimia nervosa, in which high doses are demonstrated to reduce purging behaviour. There are risks for increased binging with SGAs in BN. SGAs are used off label to help with emotional and behavioral regulation, with some benefit at times for depression and anxiety symptoms, but experts should be consulted prior to initiating. Comorbidities should be treated with first line agents (NOTE: Wellbutrin is contraindicated in eating disorders secondary to seizure risk).