Controversies in the use of second generation antipsychotics as sleep agent

A growing number of patients present in clinics with complaints of insomnia. Over the past century, great advances have been made in our knowledge of mechanisms of sleep and wakefulness. Understanding sleep neurochemistry has led to better management of different types of insomnias with a variety of non-pharmacological and pharmacological treatments. Unfortunately, the increasing development and availability of second generation antipsychotics (SGA) have prompted their frequent use exclusively for insomnia. However, to date, no large randomized-controlled or placebo-controlled studies have shown the utility of SGAs in the realm of treating insomnia. Many clinicians use SGAs as “off-label” for sleep induction and maintenance, but this practice needs to be readdressed given their potential risks and the current lack of evidence base. This review will highlight the neurochemistry related to sleep, the mechanisms of action by which SGA may have some benefit in treating insomnia, and the risks associated with their utilization.