Trazodone for Insomnia: Not Recommended as First-Line Treatment

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

Current Guideline Recommendations

The American Academy of Sleep Medicine explicitly recommends against using trazodone for both sleep onset and sleep maintenance insomnia, with a "WEAK" rating indicating low evidence quality 1
The Department of Veterans Affairs/Department of Defense (VA/DOD) guidelines similarly advise against trazodone for chronic insomnia disorder 2
Clinical trials showed only modest improvements in sleep parameters with trazodone 50 mg compared to placebo, with no significant improvement in subjective sleep quality 2

Evidence for trazodone's efficacy in treating insomnia is very limited, with most studies being small, conducted primarily in depressed populations, and often lacking objective efficacy measures 3
A systematic review found no differences in sleep efficiency between trazodone (50-150 mg) and placebo in patients with chronic insomnia 2
While trazodone has been widely prescribed off-label for insomnia, the benefits do not outweigh the potential harms according to current guidelines 2

Trazodone's adverse effect profile includes daytime drowsiness, dizziness, and psychomotor impairment, which are particularly concerning for elderly patients 2
Studies have demonstrated significant impairments in short-term memory, verbal learning, equilibrium, and muscle endurance the morning after trazodone use 4
More serious side effects can include priapism, which has led to treatment discontinuation in clinical studies 2
There is evidence of tolerance developing with continued trazodone use 3

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 2

For both sleep onset and maintenance insomnia: eszopiclone (2-3 mg) or zolpidem (10 mg) 1, 2
For sleep onset insomnia only: zaleplon (10 mg), ramelteon (8 mg), or triazolam (0.25 mg) 1
For sleep maintenance insomnia only: suvorexant or doxepin (3-6 mg) 1, 2

All hypnotic medications should be used at the lowest effective dose and for the shortest possible duration 1, 2
Patients should be cautioned about potential side effects and the importance of allowing appropriate sleep time 5
Administration on an empty stomach is advised to maximize effectiveness of sleep medications 5
Caution is advised if signs/symptoms of depression, compromised respiratory function, or hepatic heart failure are present 5
Over-the-counter sleep aids and herbal supplements are not recommended for chronic insomnia due to lack of efficacy and safety data 1, 2

Trazodone may have a role in specific clinical scenarios not addressed by insomnia guidelines, such as when comorbid depression is present 2
A 2020 preliminary study suggested trazodone might be more effective than CBT-I for the insomnia with objective short sleep duration phenotype, showing increased total sleep time and decreased cortisol levels 6
When used for insomnia, lower doses (25-50 mg) are typically employed, which are below the therapeutic antidepressant range 5, 7