“Companies want to sell drugs, doctors prescribe the drugs most heavily marketed, nursing homes need doctors to legitimize their actions, and nurses are probably overworked and want doctors to medicate people so they’re more malleable,” says Robert Rosenheck, a Yale University professor of psychiatry and epidemiology and director of the Division of Mental Health Services and Outcomes Research.

“The participants start to gain, but the general public and the patients may not be better off. There’s evidence the drugs aren’t always effective, may be harmful, and can cost a good deal of money, but there’s nothing we can do about it, because we’re committed to the principal that doctors should be able to choose whatever treatments are best for their patients,” he continues. “About 60 percent are prescribed off label for non-psychiatric conditions for which there’s no FDA approval.”

Off-label marketing has led to huge fines. Last year, Pfizer paid a $2.3 billion fine to settle civil and criminal investigations into fraudulent marketing of several drugs, including Geodon. Eli Lilly, which markets Zyprexa, paid a $1.4 billion fine and pled guilty to a misdemeanor for promoting its drug to the elderly with dementia, even though the pill was never approved for that use. And AstraZeneca reached a tentative $520 million deal to settle probes into off-label marketing, among other charges.

But drugmakers weren’t the only ones tagged. Omnicare, a big pharmacy that specializes in providing drugs to nursing homes, agreed to pay $98 million to settle charges of soliciting or paying kickbacks. One example—payments were made in exchange for recommending Johnson & Johnson’s Risperdal antipsychotic to nursing homes. “Illegal conduct like this can undermine the medical judgments of health care professionals, lead to patients being prescribed medications they do not need, and drive up the costs of health care,” Tony West, Assistant Attorney General for the Justice Department’s Civil Division, said in announcing the settlement.

Whether the fines will alter marketing practices—and by extension, prescribing habits—remains to be seen. But Sube Banerjee, a professor of mental health and aging at the Institute of Psychiatry at King’s College London, says changes must be made immediately and recommends that the use of antipsychotics be cut by two thirds over the next three years in order to minimize deaths.

But as Yale’s Rosenheck notes, billions of dollars are at stake, and changing habits can be difficult. “It’s a major problem, and it goes well beyond these drugs. It’s really the system in which they all participate and has determined the culture in which we live and think about these medications,” he says. “Once you persuade doctors to use these drugs for every mental illness, well, you can sue the company, but litigation won’t make a company go back to doctors and tell them not to use the drugs as they have been doing. The horse is out of the barn.”