ATYPICAL ANTIPSYCHOTICS IN THE MANAGEMENT OF INSOMNIA: A TRUE ALTERNATIVE OR A TREND? A NARRATIVE REVIEW

Abstract

Background: Insomnia is a very common sleep disorder worldwide and it is associated with an important impairment in quality of life, daytime functioning, and long-term health outcomes. Although cognitive behavioral therapy for insomnia (CBT-I) remains the recommended first-line treatment, atypical antipsychotics, particularly low-dose quetiapine, are increasingly prescribed off-label for insomnia despite the absence of scientific evidence for this indication.
Objective: To review the available evidence about atypical antipsychotics in the management of insomnia, with particular emphasis on their pharmacological properties, effects on sleep architecture, adverse effect profiles, and potential impact on other sleep disorders.
Methods: A narrative review of the literature was conducted, focusing on the pharmacology of commonly prescribed atypical antipsychotics, their effects on sleep continuity and sleep architecture, current evidence supporting their use in insomnia, and the associated short- and long-term risks.
Results: Atypical antipsychotics may reduce sleep latency and increase total sleep time through antagonism of histaminergic, serotonergic, and adrenergic receptors. However, these effects do not necessarily represent a restoration of physiological sleep architecture. Quetiapine, the most frequently prescribed antipsychotic for insomnia, has limited evidence supporting its effectiveness and may reduce slow-wave and rapid eye movement sleep. Atypical antipsychotics are associated with a number of adverse effects, including excessive daytime sedation, weight gain, metabolic dysfunction, hyperprolactinemia, extrapyramidal symptoms, and increased cardiovascular risk. They may also induce or worsen sleep-related conditions such as restless legs syndrome and obstructive sleep apnea.
Discussion: Current evidence does not support the routine use of atypical antipsychotics for primary insomnia in the absence of a major psychiatric indication. Their potential benefits are outweighed by safety concerns and the lack of long-term effectiveness data. CBT-I should remain the main modality of insomnia management. When pharmacological treatment is required, evidence-based therapies with established efficacy and safety profiles should be prioritized over atypical antipsychotics.