Nocturnal Eating Episodes After Eszopiclone Discontinuation
The most likely culprit for your persistent nocturnal eating is quetiapine (Seroquel), which is well-documented to cause sleep-related eating disorder, and this should be discontinued or replaced with a safer alternative for sleep. 1
Primary Cause: Quetiapine (Seroquel)
Quetiapine is explicitly not recommended for insomnia treatment by the American Academy of Sleep Medicine due to weak evidence for efficacy and significant risks including neurological complications, weight gain, metabolic dysregulation, and abnormal eating behaviors. 1
Antipsychotics like quetiapine have problematic metabolic side-effects that can manifest as nocturnal eating behaviors, and these effects may persist even after the initial trigger (eszopiclone) is removed. 2, 1
The combination of quetiapine with your other CNS depressants (tizanidine, clonazepam) creates dangerous polypharmacy that increases risks of complex sleep behaviors, including sleep-eating, cognitive impairment, and falls. 1
Why Eszopiclone May Have Triggered This
Complex sleep behaviors such as sleep-eating have been reported with eszopiclone, particularly when combined with other CNS depressants or at doses exceeding recommendations. 3
The FDA warns that eszopiclone can cause patients to perform activities while not fully awake, including preparing and eating food, with amnesia for the event—and these behaviors may persist as a learned pattern even after drug discontinuation. 3
Your regimen included multiple sedating agents simultaneously (eszopiclone, clonazepam, tizanidine, quetiapine), which markedly increases the risk of complex sleep behaviors. 1
Immediate Management Steps
1. Discontinue Quetiapine
Stop quetiapine immediately as it is the most likely ongoing cause of nocturnal eating and is not an appropriate treatment for insomnia. 1
Quetiapine should be tapered gradually (reduce by 25% every 1-2 weeks) to avoid withdrawal symptoms, though at your low dose (25 mg) the risk is minimal. 1
2. Address Your Dangerous Polypharmacy
You are currently taking three CNS depressants (tizanidine 12 mg total, clonazepam 2 mg, quetiapine 25 mg) which creates additive psychomotor impairment, respiratory depression risk, and increased fall risk. 1
Clonazepam 2 mg is a high dose and long-acting benzodiazepines are explicitly not recommended for insomnia due to drug accumulation, prolonged daytime sedation, cognitive impairment, and increased fall/fracture risk. 1
The American Academy of Sleep Medicine recommends against using traditional benzodiazepines like clonazepam as first-line treatment for insomnia. 1
3. Implement Cognitive Behavioral Therapy for Insomnia (CBT-I)
CBT-I must be initiated immediately as it is the first-line treatment for chronic insomnia and provides superior long-term outcomes compared to medications alone, with sustained benefits after drug discontinuation. 1, 4
CBT-I includes stimulus control, sleep restriction, relaxation techniques, and cognitive restructuring, and can be delivered via individual therapy, group sessions, telephone, web-based modules, or self-help books—all showing effectiveness. 1
4. Replace Quetiapine with Evidence-Based Sleep Medication (If Needed)
For sleep maintenance insomnia (your primary complaint):
Low-dose doxepin 3-6 mg at bedtime is the preferred first-line option, with moderate-quality evidence showing a 22-23 minute reduction in wake after sleep onset, minimal anticholinergic effects at hypnotic doses, and no abuse potential. 1, 4
Suvorexant 10 mg is an alternative orexin-receptor antagonist that reduces wake after sleep onset by 16-28 minutes with lower risk of cognitive and psychomotor effects compared to benzodiazepines. 1, 4
If you need both sleep onset and maintenance help:
Eszopiclone 2-3 mg can be restarted (despite your previous experience) at a lower dose (2 mg) and without the dangerous combination of other sedatives, as it improves both sleep onset and maintenance with 28-57 minutes increase in total sleep time. 1, 4
However, eszopiclone should only be used short-term (≤4 weeks) according to FDA labeling, and always in combination with CBT-I. 1
Critical Safety Considerations
Taper clonazepam gradually (reduce by 25% every 1-2 weeks) while implementing CBT-I, as benzodiazepine withdrawal carries risks including rebound anxiety, seizures, and delirium tremens. 1
Monitor for complex sleep behaviors at every visit; if sleep-eating or other complex behaviors persist after quetiapine discontinuation, stop all hypnotics immediately. 1, 3
Your stimulant use (Adderall 60 mg total daily) may be contributing to insomnia—ensure the last dose is taken no later than early afternoon to minimize sleep interference. 1
Semaglutide can cause nausea and gastrointestinal effects that may disrupt sleep, but is unlikely to cause nocturnal eating behaviors. 1
Specific Treatment Algorithm
Week 1-2: Stop quetiapine immediately (or taper if concerned about withdrawal). Start CBT-I. Continue current sleep medications temporarily.
Week 2-4: Begin tapering clonazepam by 0.5 mg every 1-2 weeks. Add low-dose doxepin 3 mg at bedtime if sleep worsens during taper.
Week 4-8: Continue clonazepam taper. Increase doxepin to 6 mg if 3 mg insufficient after 1-2 weeks. Intensify CBT-I components.
Week 8-12: Complete clonazepam taper. Reassess need for doxepin—attempt to reduce or discontinue as CBT-I effects consolidate.
Ongoing: Maintain CBT-I techniques. Use lowest effective dose of hypnotic for shortest duration. Reassess every 4-6 weeks.
Common Pitfalls to Avoid
Do not continue quetiapine "because it helps with sleep"—it is not an appropriate sleep medication and is causing your nocturnal eating. 1
Do not abruptly stop clonazepam—taper gradually to avoid withdrawal seizures. 1
Do not add another sedative without removing existing ones first—you already have dangerous polypharmacy. 1
Do not skip CBT-I—it is the only intervention with durable benefits after medication discontinuation. 1, 4
Do not use eszopiclone long-term without periodic reassessment—FDA labeling recommends short-term use only. 1, 3