Will trazodone help with anxiety and insomnia?

Trazodone for Anxiety and Insomnia

Trazodone is not recommended for the treatment of insomnia, and has limited evidence for anxiety, despite its common off-label use for these conditions. 1

Efficacy for Insomnia

The 2017 American Academy of Sleep Medicine clinical practice guideline explicitly recommends against using trazodone for sleep onset or sleep maintenance insomnia 1. This recommendation is based on trials of 50 mg doses of trazodone which showed:

• No differences in sleep efficiency compared to placebo
• No differences in sleep onset latency or wake after sleep onset
• Only subjective sleep quality showed improvement 1

A systematic review reported that while trazodone was more effective at improving subjective sleep quality, there were significant limitations:

• Very short durations of therapy (mean 1.7 weeks)
• Short follow-up periods (1-4 weeks)
• Low-quality evidence that was outweighed by its adverse effect profile 1

Efficacy for Anxiety

There is limited evidence regarding trazodone's efficacy specifically for anxiety:

• Trazodone is not FDA-approved for anxiety disorders 1
• When used for depression with accompanying anxiety, studies show no difference in efficacy compared to other antidepressants 1

Better Alternatives for Insomnia

For insomnia, the guidelines recommend:

1. First-line: Cognitive Behavioral Therapy for Insomnia (CBT-I) 1

   • Includes cognitive therapy, stimulus control, sleep restriction, and relaxation techniques

2. Pharmacological options (if needed):

   • Non-benzodiazepine BZRAs (eszopiclone, zaleplon, zolpidem) 1
   • Low-dose doxepin (3-6 mg) 1
   • Suvorexant or ramelteon 1

Side Effects and Risks of Trazodone

Trazodone's adverse effects include:

• Daytime drowsiness (most common) 2
• Cognitive and psychomotor impairments 3
• Impairments in short-term memory, verbal learning, equilibrium, and muscle endurance 3
• Potential for orthostatic hypotension
• Priapism (rare but serious)

Clinical Decision Algorithm

1. For insomnia:

   • Start with CBT-I as first-line treatment
   • If pharmacotherapy is needed, use non-benzodiazepine BZRAs (zolpidem, eszopiclone, zaleplon) or low-dose doxepin
   • Avoid trazodone due to limited efficacy evidence and potential side effects

2. For anxiety:

   • Use FDA-approved medications (SSRIs, SNRIs, buspirone)
   • Consider benzodiazepines for short-term use only
   • Do not use trazodone as primary treatment for anxiety

Special Considerations

• While some research suggests trazodone may help with insomnia in depressed patients 4, 5, its use should be limited to cases where the primary diagnosis is depression with secondary insomnia
• Low doses (50mg) are typically used for insomnia, but even at these doses, cognitive and psychomotor impairments have been documented 3
• Despite its widespread off-label use, the scientific evidence does not support trazodone as a first-line agent for either insomnia or anxiety 1, 2

Common Pitfalls

• Prescribing trazodone for insomnia based on clinical tradition rather than evidence
• Overlooking the cognitive and psychomotor impairments associated with trazodone
• Failing to try evidence-based first-line treatments before resorting to off-label medications
• Using trazodone long-term without reassessing its efficacy and side effects