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

Trazodone for Insomnia: Not Recommended as First-Line Treatment

The American Academy of Sleep Medicine recommends against using trazodone for both sleep onset and sleep maintenance insomnia in adults, as the benefits do not outweigh the potential harms. 1, 2

Evidence Against Trazodone for Insomnia

• Clinical trials of trazodone 50 mg showed only modest improvements in sleep parameters compared to placebo, with no significant improvement in subjective sleep quality 1, 2
• The American Academy of Sleep Medicine has issued a "WEAK" recommendation against trazodone use for insomnia, indicating low evidence quality but clear concerns about benefit-risk ratio 1
• The Department of Veterans Affairs/Department of Defense (VA/DOD) guidelines explicitly advise against using trazodone for chronic insomnia disorder 1

Safety Concerns with Trazodone

• Trazodone carries significant side effect risks including:

  • Orthostatic hypotension and syncope 3
  • Increased risk of bleeding, especially when combined with antiplatelet or anticoagulant medications 3
  • Priapism (painful erections lasting >6 hours) that may cause permanent damage to erectile tissue 3
  • Cognitive and psychomotor impairment affecting driving ability and other tasks 3, 4
  • Daytime drowsiness, dizziness, and impaired equilibrium 5, 4
  • Short-term memory and verbal learning deficits 4

• These side effects are particularly concerning for elderly patients who may be more vulnerable to falls and cognitive impairment 1

Recommended First-Line Treatments for Insomnia

• 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, 2

Recommended Pharmacological Alternatives

If medication is needed, the following are recommended over trazodone:

• For both sleep onset and maintenance insomnia:

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

• For sleep onset insomnia only:

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

• For sleep maintenance insomnia only:

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

Special Considerations

• While some studies suggest trazodone may be effective for sleep maintenance issues, particularly in patients with comorbid depression 6, the most recent guidelines still recommend against its use for primary insomnia 1, 2
• When trazodone is used off-label for insomnia, lower doses (25-50 mg) are typically employed, which are below the therapeutic antidepressant range 1
• If trazodone must be used, it should be administered at least 1 hour before bedtime to maximize effectiveness for sleep onset issues 6

Important Clinical Pitfalls to Avoid

• Avoid abrupt discontinuation of trazodone as it may cause withdrawal symptoms including nausea, sweating, dysphoric mood, irritability, agitation, and sensory disturbances 3
• Do not use trazodone in patients with untreated narrow-angle glaucoma due to risk of triggering an angle closure attack 3
• Monitor for hyponatremia, especially in elderly patients and those taking diuretics 3
• Be cautious about potential drug interactions, particularly with antihypertensives, which may require dose adjustments 3