Is Trazodone (an antidepressant) effective for treating insomnia?

Trazodone is Not Recommended for Treating Insomnia

Trazodone is not recommended for the treatment of chronic insomnia disorder due to limited evidence of efficacy and potential adverse effects. 1, 2

Evidence Against Trazodone for Insomnia

• The Department of Veterans Affairs/Department of Defense (VA/DOD) guidelines explicitly advise against the use of trazodone for chronic insomnia disorder 1
• A systematic review found no differences in sleep efficiency between trazodone (50-150 mg) and placebo in patients with chronic insomnia 1
• While trazodone showed modest improvement in subjective sleep quality, there were no significant differences in sleep onset latency, total sleep time, or wake time after sleep onset compared to placebo 1, 2
• The American Academy of Sleep Medicine specifically recommends against using trazodone for both sleep onset and sleep maintenance insomnia in adults 2

Adverse Effects of Trazodone

• Trazodone's adverse effect profile includes daytime drowsiness, dizziness, and psychomotor impairment, which are particularly concerning for elderly patients 1, 3
• Studies have demonstrated small but significant impairments in short-term memory, verbal learning, equilibrium, and muscle endurance the morning after trazodone use 4
• More serious side effects including priapism have been reported, leading to treatment discontinuation in some clinical studies 2
• The low-quality evidence supporting trazodone's efficacy is outweighed by its adverse effect profile 1

Recommended Alternatives for Insomnia Treatment

First-Line Treatment:

• Cognitive behavioral therapy for insomnia (CBT-I) should be the first-line treatment for chronic insomnia 1, 5
• CBT-I components include cognitive therapy, stimulus control therapy, sleep restriction therapy with or without relaxation therapy 1

Pharmacological Options (if needed):

1. First choice: Short-intermediate acting benzodiazepine receptor agonists (BzRAs) or ramelteon 1, 2

   • Examples: zolpidem, eszopiclone, zaleplon, and temazepam 1, 2
   • These should be used at the lowest effective dose and for the shortest possible duration 1

2. Second choice: Low-dose doxepin (3-6 mg) for sleep maintenance insomnia 2

3. Third choice (only if other options fail): Sedating antidepressants may be considered, especially when treating comorbid depression/anxiety 1

Special Considerations

• For patients with insomnia and comorbid depression, the treatment algorithm may differ, as trazodone might address both conditions 5, 6
• A small preliminary study suggested that trazodone may be more effective than CBT-I specifically for the insomnia with objective short sleep duration phenotype, improving total sleep time and reducing cortisol levels 7
• When pharmacotherapy is utilized, the choice should be directed by symptom pattern, treatment goals, past responses, comorbid conditions, and potential drug interactions 1

Important Caveats

• All hypnotic medications should be administered at the lowest effective dose and for the shortest possible duration 1
• Patients should be counseled about potential risks including sleep behaviors (sleepwalking, sleep driving) associated with sedative medications 1
• Over-the-counter sleep aids (antihistamines) and herbal supplements (valerian, melatonin) are not recommended for chronic insomnia due to lack of efficacy and safety data 1
• Regular follow-up is essential to assess medication effectiveness, side effects, and the ongoing need for pharmacotherapy 1