What is the role of trazodone in treating middle insomnia?

Trazodone for Middle Insomnia

Trazodone is not recommended for treating middle insomnia (sleep maintenance insomnia) as the American Academy of Sleep Medicine explicitly advises against its use for both sleep onset and sleep maintenance insomnia. 1, 2

Efficacy for Middle Insomnia

• Clinical trials of trazodone 50mg showed only modest improvements in sleep parameters compared to placebo, with no significant improvement in subjective sleep quality despite its widespread off-label use 1, 2
• The American Academy of Sleep Medicine gave a "WEAK" recommendation against trazodone use for insomnia, indicating that its benefits do not outweigh potential harms 1
• Studies specifically examining trazodone for middle insomnia are limited, with most research focusing on general insomnia rather than specifically addressing middle-of-the-night awakenings 3

Preferred Alternatives for Sleep Maintenance Insomnia

For patients with middle insomnia (sleep maintenance), the following medications are recommended instead:

• Suvorexant is specifically recommended for sleep maintenance insomnia 1, 2
• Doxepin (3-6 mg) is recommended for sleep maintenance insomnia 1, 2
• Eszopiclone (2-3 mg) is recommended for both sleep onset and maintenance insomnia 2
• Zolpidem (10 mg) can be used for both sleep onset and maintenance insomnia 2

Side Effects and Safety Concerns

• Trazodone's adverse effect profile includes daytime drowsiness, dizziness, and psychomotor impairment, which are particularly concerning for elderly patients 1
• More serious side effects including priapism have been reported, which led to treatment discontinuation in some clinical studies 1
• The risk-benefit ratio for trazodone use in non-depressed patients with insomnia is questionable given the relative absence of strong efficacy data and the presence of adverse events 4

Special Considerations

• Low-dose trazodone (25-75 mg) may be more effective and better tolerated than higher doses (100-150 mg) when used for insomnia 5
• Unlike benzodiazepine receptor agonists, trazodone may increase the duration of deep sleep, which some patients associate with better subjective sleep quality 6
• The main mechanism through which trazodone promotes sleep is its antagonistic effect on 5-HT2 serotonin receptors, different from hypnotics which are GABAA receptor agonists 6

First-Line Approach

• Cognitive behavioral therapy for insomnia (CBT-I) should be the first-line treatment for all types of chronic insomnia, including middle insomnia 1, 2
• CBT-I components include cognitive therapy, stimulus control therapy, and sleep restriction therapy 1, 2
• If pharmacotherapy is necessary, the medications specifically recommended for sleep maintenance (middle insomnia) should be used at the lowest effective dose and for the shortest possible duration 1, 2

Important Clinical Pitfalls

• Trazodone is commonly prescribed off-label for insomnia despite limited evidence supporting its efficacy 4, 3
• Using trazodone at higher doses increases side effect risk without necessarily improving efficacy for insomnia 5
• Regular follow-up is essential to assess medication effectiveness, side effects, and the ongoing need for pharmacotherapy 2
• Over-the-counter sleep aids and herbal supplements are not recommended for chronic insomnia due to lack of efficacy and safety data 1, 2