Quetiapine (Seroquel) Is Not Recommended for Insomnia Treatment
Quetiapine should not be used for the treatment of insomnia due to significant safety concerns and lack of supporting evidence, regardless of dosage. 1, 2
Evidence Against Quetiapine for Insomnia
The 2019 U.S. Department of Veterans Affairs and Department of Defense clinical practice guidelines strongly advise against using antipsychotics, including quetiapine, for insomnia treatment 1. Despite its sedating effects, the evidence supporting quetiapine for insomnia is sparse, with studies showing:
- Small sample sizes and short treatment durations
- Inconclusive efficacy data
- Significant safety concerns, even at low doses
Recent evidence from 2025 shows that low-dose quetiapine is associated with significantly higher rates of:
- Mortality (HR 3.1) compared to trazodone
- Dementia (HR 8.1) compared to trazodone
- Falls (HR 2.8) compared to trazodone
- Higher dementia rates compared to mirtazapine 3
Recommended First-Line Approaches
Non-Pharmacological Options (First-Line)
- Cognitive Behavioral Therapy for Insomnia (CBT-I) is the recommended first-line treatment 2
- Sleep hygiene practices including consistent sleep/wake schedule
- Stimulus control therapy
- Regular physical activity and morning bright light exposure
Preferred Pharmacological Options (If Needed)
When medication is necessary, the following are preferred over quetiapine:
- Trazodone 25-50 mg at bedtime (first-line pharmacological option) 2
- Low-dose Doxepin (3-6 mg) for sleep maintenance insomnia 2
- Mirtazapine (7.5-15mg) when insomnia co-occurs with depression or anxiety 2
Safety Concerns with Quetiapine
Even at low doses (25-200 mg/day), quetiapine presents significant risks:
- Weight gain and metabolic adverse effects 4
- Increased mortality in older adults 3
- Cognitive decline and dementia risk 3
- Falls and potential for traumatic injuries 3
- Potential for hepatotoxicity, restless legs syndrome, and akathisia 4
Clinical Considerations
- The 2025 Praxis Medical Insights explicitly states that trazodone is preferred over quetiapine for insomnia due to better evidence and fewer metabolic risks 2
- While some studies have examined quetiapine at 25-50 mg for insomnia 5, the safety profile does not justify its use when safer alternatives exist
- Older adults are particularly vulnerable to adverse effects of quetiapine, even at low doses 3
Common Pitfalls to Avoid
- Using quetiapine as a "quick fix" for insomnia due to its sedating properties
- Assuming that low doses (25-50 mg) are safe simply because they're below therapeutic doses for psychotic disorders
- Overlooking the significant mortality and dementia risks, particularly in older adults
- Failing to try evidence-based non-pharmacological approaches first
While some small studies have shown trends toward improved sleep with quetiapine 6, 5, the safety concerns and availability of better alternatives make quetiapine an inappropriate choice for insomnia treatment.