Second generation antipsychotics (SGAs) appear to be effective for a broad range of psychiatric disorders. When used in doses lower than those to treat psychosis, these agents are effective for anxiety disorders and insomnia. In fact, the utilization of SGAs for indications other than psychosis may exceed 70%. 1 We are concerned about the widespread use of low-dose SGAs as sedative-hypnotic agents. We briefly discuss our concerns with the use of these agents as sedativehypnotics with a special focus on quetiapine. We chose to comment specifically on quetiapine because it is prescribed most frequently for off-label use, but many of the arguments relate to all SGAs.

Quetiapine is a dibenzothiazepine derivative that is frequently prescribed for the management of anxiety and insomnia without regard for its side effect profile. Metabolic syndrome is the most concerning adverse effect of SGAs because it increases the risk of cardiovascular-related morbidity and mortality. Studies have shown that dyslipidemia and insulin resistance are associated with clozapine and olanzapine, while quetiapine and risperidone have shown discrepant results. All of the aforementioned drugs, however, are known to cause weight gain. 2 Future studies should elucidate whether these effects are dose-dependent. A concern that is especially relevant to the chemically dependent patient is the recent reporting of quetiapine abuse. Although the abuse of antihistaminic and anticholinergic agents has been documented in the past, 3 quetiapine may produce a different type of high. Illicit use of quetiapine may be referred to as quell, Susie-Q, baby heroin, and Q-ball (a variant of a speedball with quetiapine substituted for heroin) on the street. It can be gathered from these names that