Can Trazodone (an antidepressant) be used to treat insomnia?

Trazodone Should Not Be Used for Insomnia Treatment

Trazodone is not recommended for the treatment of sleep onset or sleep maintenance insomnia in adults, as the benefits do not outweigh the potential harms. 1

Evidence Against Trazodone for Insomnia

• The American Academy of Sleep Medicine (AASM) explicitly recommends against using trazodone for both sleep onset and sleep maintenance insomnia, based on trials of 50 mg doses 1, 2
• This recommendation received a "WEAK" rating in the guidelines, indicating that while the benefits do not outweigh the harms, the evidence quality is low 1, 2
• Despite trazodone's widespread off-label use for insomnia, clinical trials showed only modest improvements in sleep parameters compared to placebo, with no significant improvement in subjective sleep quality 2, 3
• Cognitive and psychomotor testing has shown that trazodone produces impairments in short-term memory, verbal learning, equilibrium, and muscle endurance 3

Side Effects and Safety Concerns

• Trazodone can cause significant side effects including:
  • Orthostatic hypotension and syncope 4
  • Increased risk of bleeding, especially when combined with antiplatelet agents or anticoagulants 4
  • Priapism (painful erections lasting >6 hours) that may require emergency treatment 4
  • Activation of mania or hypomania in patients with bipolar disorder 4
  • Cognitive and motor impairment that may affect driving ability 4, 3
  • Drowsiness, dizziness, and psychomotor impairment, which are particularly concerning for elderly patients 2, 5

Recommended Alternatives for Insomnia

First-Line Treatment:

• Cognitive behavioral therapy for insomnia (CBT-I) should be the first-line treatment for chronic insomnia 1, 2
• CBT-I components include cognitive therapy, stimulus control therapy, and sleep restriction therapy 1

Recommended Pharmacological Options:

The AASM recommends several medications over trazodone for insomnia treatment:

1. For sleep onset and maintenance insomnia:

   • Eszopiclone (2-3 mg) 1, 2
   • Zolpidem (10 mg) 1, 2
   • Temazepam (15 mg) 1

2. For sleep onset insomnia only:

   • Zaleplon (10 mg) 1, 2
   • Ramelteon (8 mg) 1, 2
   • Triazolam (0.25 mg) 1

3. For sleep maintenance insomnia only:

   • Suvorexant 1, 2
   • Doxepin (3-6 mg) 1, 2

Limited Scenarios Where Trazodone Might Be Considered

• Trazodone might be considered in specific clinical scenarios not directly addressed by the insomnia guidelines:
  • When comorbid depression is present alongside insomnia 1, 6
  • When used in combination with activating antidepressants that may worsen insomnia 1, 6, 7
  • In these cases, trazodone would be considered a third-line agent after BzRAs and ramelteon 1

Important Clinical Considerations

• All hypnotic medications should be used at the lowest effective dose and for the shortest possible duration 1, 2
• Regular follow-up is essential to assess medication effectiveness, side effects, and the ongoing need for pharmacotherapy 1
• Over-the-counter sleep aids (antihistamines) and herbal supplements (valerian, melatonin) are also not recommended for chronic insomnia due to lack of efficacy and safety data 1
• If trazodone is used despite recommendations against it, patients should be warned about potential cognitive impairment and advised against driving or operating machinery 4, 3

Conclusion

Based on the most recent and highest quality evidence, trazodone should not be used as a primary treatment for insomnia. The AASM guidelines clearly recommend against its use, and several safer and more effective alternatives are available. While trazodone may have a limited role in treating insomnia secondary to depression or as an adjunct to other antidepressants, it should not be considered a first-line or even second-line agent for primary insomnia.