last updated 3/27/24
In research studies, quetiapine/Seroquel has some of the best results for antidepressant effects of any mood stabilizer. It also helps nearly everyone get to sleep. But that sleep effect can be too strong. And there’s one other big problem with quetiapine: almost everyone gains weight. Sometimes a lot of weight.
Lurasidone is less likely to cause weight gain (note: “less likely”; it can still happen). But it has its own problems.
A quick comparison
Pro’s | Con’s | |
quetiapine | Good evidence for benefit Strongly helps get to sleep | Major weight gain common Slow to get going in a.m. |
lurasidone | Good evidence for benefit Less weight gain | Newest, so less well known Have to time it with meals |
In my experience, the weight gain concern drives most people’s decisions. That’s appropriate, because medication-driven weight gain is likely to cause “metabolic syndrome”: abdominal fat, increased cholesterol and blood pressure, and a resistance to your own insulin that can lead to diabetes. Does that sound disastrous? It is.
You’d think this would tip the balance straight to lurasidone, no? But lurasidone also can cause this kind of weight gain, just not as often.
Why would anyone ever choose quetiapine?
Because:
- it works pretty fast, and pretty often
- It helps with sleep in the meantime
- the provider doesn’t worry enough about metabolic syndrome
What’s the sleep effect?
The very first night, you’re pretty likely to sleep for hours. With an inpatient starting dose of 100 mg, you’ll feel sleepy much of the following day too. With an outpatient starting dose of 25 or 50 mg, the daytime sedation won’t be so bad and should be gone within a few days.
The target for depression is generally 100-300 mg nightly (lowest clearly effective dose is best). Once the dose is no longer increasing, the daytime sleepiness should go away completely. Except for mornings: one of my patients said “after I’ve had a shower and a cup of coffee, I’m fine; until then, I’m not good for much.”
Can I block the weight gain?
Some people will gain less weight, or occasionally not gain at all, if they start an anti-diabetes medication called metformin at the same time they start quetiapine. Of course starting two medications at once is tricky: if there’s a side effect, which one caused it? For this reason, very few doc’s I know start both at once. Actually, not very many start the metformin at all: it commonly causes nausea at first and has to be stepped up 3 times (from 500 to 2000 mg per day) for full benefit.
Okay, lurasidone then?
It’s generic now but when I stopped seeing patients it was still very expensive. So I don’t have much experience with lurasidone. I did use it enough to see some people gain weight rather like I’d expect from quetiapine.
I also saw it cause a shift toward hypomania in several people, whereas I only saw that with quetiapine once or twice over many years.
So I came away from my limited experience with lurasidone not trusting it very much and certainly not trusting it to take over for quetiapine. They’re quite different. Beyond that, I’ll have to defer to your further learning and your providers’ opinions.