Can Seroquel (quetiapine) be used to treat insomnia?

From the Guidelines

Quetiapine (Seroquel) is not recommended as a first-line treatment for insomnia. While it may cause sedation as a side effect, it is primarily an antipsychotic medication approved for conditions like schizophrenia, bipolar disorder, and as an adjunct for depression. Using quetiapine for insomnia represents an off-label use that carries significant risks including metabolic effects (weight gain, diabetes risk, lipid abnormalities), potential cardiac issues (QT prolongation), and anticholinergic effects, as noted in the 2020 guidelines from the U.S. Department of Veterans Affairs and U.S. Department of Defense 1.

For insomnia, it's better to start with sleep hygiene improvements and consider medications specifically designed for sleep like short-term use of z-drugs (zolpidem, eszopiclone), low-dose doxepin, or melatonin. If insomnia persists, cognitive behavioral therapy for insomnia (CBT-I) has proven highly effective without medication risks, as supported by the American Academy of Sleep Medicine clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults 1.

Quetiapine's sedating effects come from its antihistamine properties, but this doesn't justify its use for simple insomnia given the risk-benefit ratio. The evidence supporting the use of antipsychotics like quetiapine for insomnia is sparse and unclear, with small sample sizes and short treatment durations, making any determination of efficacy inconclusive 1.

Any consideration of quetiapine for sleep should only occur after safer options have failed and with careful monitoring by a healthcare provider. The American College of Physicians also recommends that all patients with chronic insomnia receive CBT-I as the initial treatment intervention, with pharmacotherapy considered only after CBT-I has been tried, based on a shared decision-making approach between the clinician and patient 1.

Key points to consider:

• Quetiapine is not approved for treating insomnia and carries significant risks.
• First-line treatments for insomnia include sleep hygiene improvements, CBT-I, and medications specifically designed for sleep.
• Pharmacotherapy, including quetiapine, should be considered only after safer options have failed and with careful monitoring.
• The risk-benefit ratio of using quetiapine for insomnia does not justify its use as a first-line treatment.

From the FDA Drug Label

Somnolence was a commonly reported adverse event reported in patients treated with quetiapine especially during the 3 to 5 day period of initial dose-titration. 5. 19 Discontinuation Syndrome Acute withdrawal symptoms, such as insomnia, nausea, and vomiting have been described after abrupt cessation of atypical antipsychotic drugs, including quetiapine

Seroquel (quetiapine) is not approved for the treatment of insomnia. Although somnolence is a common side effect of quetiapine, the FDA drug label does not provide information to support the use of quetiapine as a treatment for insomnia. In fact, insomnia is listed as a potential withdrawal symptom when quetiapine is discontinued 2.

From the Research

Seroquel for Insomnia

• Seroquel (quetiapine) is increasingly being used off-label for treating insomnia in the general population, possibly to avoid standard medications with known addictive qualities and adverse side effects 3.
• However, evidence to support using it in this way is scant, and quetiapine is associated with weight gain and other metabolic effects 3.
• The strongest evidence exists for anxiety and delirium, while moderate evidence exists for quetiapine as a pharmacological intervention for insomnia 4.
• Quetiapine's antagonism of histamine H1- and serotonin type 2A receptors has the added effect of causing sedation, making it widely used off-label as a treatment for insomnia 5.
• Guidelines for the treatment of insomnia have recommended the drug's use only in patients with specific comorbid psychiatric disorders 5.
• Robust studies evaluating the safety and efficacy of quetiapine for the treatment of insomnia are lacking, and its benefit in the treatment of insomnia has not been proven to outweigh potential risks 5.
• A case study found that quetiapine was effective in reducing chronic insomnia in a male patient, but the dose had to be increased over time, highlighting the importance of regular and careful patient monitoring 6.

Risks and Considerations

• Quetiapine is associated with weight gain and other metabolic effects 3.
• The risk of side effects and, possibly, dependence and abuse underlines the importance of regular and careful patient monitoring 6.
• Quetiapine's use for insomnia should be cautious and with appropriate monitoring for adverse effects and abuse 3.
• Further research on the long-term effects and potential adverse events of quetiapine for this indication is of the utmost importance 6.