What to do if taking trazodone (antidepressant) 100mg and able to fall asleep but can't stay asleep?

Management of Sleep Maintenance Insomnia with Trazodone 100mg

For patients taking trazodone 100mg who can fall asleep but cannot stay asleep, the most effective approach is to implement Cognitive Behavioral Therapy for Insomnia (CBT-I) techniques while considering a dosage adjustment to 150mg given predominantly at bedtime. 1, 2

Immediate Interventions for Sleep Maintenance Issues

1. Dosing Adjustment Options:

   • Consider increasing to 150mg given predominantly at bedtime 2
   • Alternatively, split the current 100mg dose with 50mg taken earlier (1 hour before bedtime) and 50mg at bedtime 3
   • Trazodone is particularly effective for sleep maintenance insomnia at dosages of 100mg/day 4, 3

2. Implement CBT-I Techniques:

   • Sleep Restriction Therapy: Limit time in bed to match actual sleep time based on 2-week sleep logs 1
   • Stimulus Control: Leave the bedroom if you wake up and can't fall back asleep within 15-20 minutes; return only when sleepy 1
   • Sleep Hygiene:
     • Maintain consistent sleep-wake schedule
     • Limit daytime naps to 30 minutes before 2 PM
     • Avoid caffeine, alcohol, and nicotine, especially in evening 1

Why This Approach Works

Trazodone works differently than traditional hypnotics:

• It increases deep sleep duration through its antagonistic effect on 5-HT2 serotonin receptors 3
• It's particularly effective for sleep maintenance insomnia compared to sleep onset issues 3
• Studies show trazodone at 100mg/day specifically improves sleep maintenance problems 4, 5

Important Considerations

• Timing matters: For sleep maintenance issues, ensure proper timing of medication; trazodone should be taken at least 1 hour before bedtime for optimal effect 3
• Side effects are dose-dependent: Most common is drowsiness, which may actually be beneficial for sleep maintenance 5
• Monitor for tolerance: Some evidence suggests tolerance may develop with prolonged use 6
• Elderly patients: Use lower doses and monitor closely for side effects like dizziness and psychomotor impairment 6

Follow-Up Plan

• Track sleep improvements using the Insomnia Severity Index (ISI) 1
• Schedule follow-up within 7-10 days after making any medication adjustments 1
• If sleep maintenance issues persist after 4-6 weeks despite adjustments, consider:
  • Referral to sleep specialist
  • Evaluation for other sleep disorders
  • Alternative medications like low-dose doxepin (3-6mg) or eszopiclone (1-2mg) for sleep maintenance 1

Common Pitfalls to Avoid

• Don't focus only on medication: CBT-I techniques are essential components of effective insomnia treatment 1
• Don't ignore timing: Trazodone needs proper timing for sleep maintenance issues 3
• Don't overlook potential side effects: Monitor for daytime sedation, dizziness, and psychomotor impairment 6
• Don't miss underlying causes: Consider whether depression or other conditions may be contributing to sleep maintenance problems 1, 5