Is quetiapine (Seroquel) a suitable first-line treatment for insomnia in a 57-year-old patient with sleep maintenance issues?

Quetiapine Should NOT Be Used for Insomnia in a 57-Year-Old

Do not prescribe quetiapine (Seroquel) for insomnia in this patient—major clinical guidelines explicitly advise against using antipsychotics for primary insomnia disorder due to sparse evidence, significant harms, and availability of superior alternatives. 1

Why Quetiapine Is Contraindicated

• The 2019 VA/DoD guidelines explicitly state that antipsychotics, most commonly quetiapine, should not be used for chronic insomnia disorder because the evidence supporting their use is "sparse and unclear, with small sample sizes and short treatment durations, thus making any determination of efficacy inconclusive" 1

• All antipsychotics, including low-dose quetiapine, are known to cause serious harms including increased risk for death in elderly populations with dementia-related psychosis and increased suicidal tendencies in children, adolescents, and young adults 1

• A 2025 retrospective cohort study of 375 older adults (≥65 years) found that low-dose quetiapine for insomnia was associated with significantly increased mortality (HR 3.1), dementia (HR 8.1), and falls (HR 2.8) compared to trazodone 2

• A 2016 systematic review concluded that "atypical antipsychotics should be avoided in the first-line treatment of primary insomnia until further evidence is available" based on very low quality evidence showing no significant improvement over placebo 3

Evidence-Based Treatment Algorithm for This 57-Year-Old

Step 1: First-Line Treatment - Cognitive Behavioral Therapy for Insomnia (CBT-I)

• CBT-I must be offered as initial treatment before any pharmacotherapy, demonstrating superior long-term efficacy with sustained benefits after discontinuation 4

• CBT-I includes stimulus control therapy, sleep restriction therapy, relaxation techniques, and cognitive restructuring—all showing effectiveness through individual therapy, group sessions, telephone-based programs, or web-based modules 4

Step 2: First-Line Pharmacotherapy (if CBT-I insufficient after 4-8 weeks)

For sleep maintenance insomnia specifically:

• Eszopiclone 2-3 mg is recommended for both sleep onset and sleep maintenance insomnia 4

• Zolpidem 10 mg is recommended for both sleep onset and sleep maintenance insomnia 4

• Low-dose doxepin 3-6 mg is specifically recommended for sleep maintenance insomnia with moderate-quality evidence showing it reduces wake after sleep onset by 22-23 minutes 4

• Suvorexant (orexin receptor antagonist) is suggested for sleep maintenance insomnia 4

Step 3: Second-Line Options (if first-line agents fail)

• Temazepam 15 mg for both sleep onset and sleep maintenance insomnia 4

• Consider sedating antidepressants only if comorbid depression/anxiety is present 4

Critical Safety Considerations for Age 57

• At age 57, this patient does not yet require the reduced dosing recommended for elderly patients (≥65 years), but should still receive the lowest effective dose for the shortest duration 4

• All patients offered benzodiazepine receptor agonists should be counseled on potential risks including complex sleep behaviors (sleepwalking, sleep driving), falls, and cognitive impairment 1

• Regular follow-up every few weeks initially is essential to assess effectiveness on sleep latency, sleep maintenance, daytime functioning, and monitor for adverse effects 4

Why NOT Trazodone Either

• The VA/DoD guidelines explicitly advise against trazodone for chronic insomnia disorder because systematic reviews showed no differences in sleep efficiency compared to placebo, and the low-quality evidence supporting efficacy was outweighed by its adverse effect profile 1

• The American Academy of Sleep Medicine recommends against trazodone for sleep onset or sleep maintenance insomnia 5

Common Pitfalls to Avoid

• Never use quetiapine as first-line treatment for primary insomnia—it bypasses evidence-based treatments with superior efficacy and safety profiles 4

• Avoid combining multiple sedating medications—this significantly increases risks of complex sleep behaviors, cognitive impairment, falls, and fractures 4

• Do not prescribe hypnotics without implementing CBT-I—behavioral interventions provide more sustained effects than medication alone 4

• Never continue pharmacotherapy long-term without periodic reassessment—medications should be tapered when conditions allow 4