Is Seroquel (quetiapine) effective for anxiety and panic attacks?

Quetiapine (Seroquel) for Anxiety and Panic Attacks

Quetiapine is not recommended as a first-line treatment for anxiety or panic attacks due to limited evidence of efficacy and significant side effect concerns. While it may have some anxiolytic properties, particularly in generalized anxiety disorder, the risks often outweigh the benefits for most patients 1.

Evidence on Efficacy

Generalized Anxiety Disorder

• Quetiapine has shown some efficacy specifically for generalized anxiety disorder (GAD), representing the only anxiety condition where there is moderate evidence supporting its use 1
• In doses ranging from 50-300 mg/day (mean effective dose around 186 mg/day), quetiapine XR has demonstrated improvement in anxiety symptoms in patients with bipolar disorder who also have comorbid panic disorder or GAD 2

Panic Disorder

• For panic disorder specifically, quetiapine has not demonstrated superior efficacy compared to placebo when used as augmentation therapy 3
• A comprehensive review of clinical trials from 2010-2018 found that quetiapine augmentation was not superior to placebo for panic disorder 3

Other Anxiety Conditions

• Evidence for quetiapine in other anxiety disorders is limited and inconsistent 1
• The strongest evidence for off-label quetiapine use exists for anxiety broadly and delirium, with only moderate evidence for other conditions 4

Safety Concerns and Side Effects

• Significant side effects include:

  • Weight gain (higher than with some alternatives) 2
  • Metabolic abnormalities
  • Sedation/somnolence
  • Potential for abuse and dependence 5

• There are documented cases of quetiapine abuse and dependence, particularly among individuals with substance use disorders and in correctional facilities 5

• Some individuals misuse quetiapine through non-prescribed routes (intranasal, intravenous) or combine it with other substances to enhance sedation 5

Alternative Treatment Options

For anxiety and panic disorders, evidence-based first-line treatments include:

1. SSRIs/SNRIs:

   • Sertraline, escitalopram, paroxetine have demonstrated efficacy 3
   • Better established safety profiles for anxiety disorders

2. Benzodiazepines:

   • Clonazepam and alprazolam have confirmed efficacy for panic disorder 3
   • Should be used cautiously due to dependence potential

3. Psychotherapy:

   • Cognitive-behavioral therapy (CBT) is highly effective for anxiety disorders
   • Can be combined with appropriate pharmacotherapy for optimal outcomes

Clinical Recommendation

Given the available evidence:

1. First-line options should include SSRIs/SNRIs (sertraline, paroxetine, escitalopram) and/or CBT for both anxiety and panic disorders 3

2. Second-line options may include benzodiazepines (with caution regarding dependence) or other antidepressants like vortioxetine 3

3. Consider quetiapine only when:

   • First and second-line treatments have failed
   • Patient has comorbid conditions that might benefit from quetiapine (e.g., bipolar disorder with anxiety)
   • Benefits clearly outweigh risks
   • Lower doses (50-300 mg/day) are used
   • Close monitoring for metabolic and other side effects is implemented

Important Caveats

• Most studies examining quetiapine for anxiety are of low quality with small sample sizes 1
• Long-term efficacy and safety data for quetiapine in anxiety disorders are lacking 1
• The potential for abuse and dependence with quetiapine should not be overlooked 5
• Risk-benefit assessment should be carefully considered before prescribing quetiapine off-label for anxiety or panic