Is trazodone HCl (trazodone hydrochloride) 150 MG orally once daily at bedtime for 30 days, with counseling, an effective treatment for insomnia?

Trazodone for Insomnia: Not Recommended as First-Line Treatment

Trazodone 150 mg is not recommended as a first-line treatment for insomnia and should be reconsidered in favor of more effective and better-studied alternatives. 1

Current Recommendation Status

• The American Academy of Sleep Medicine explicitly recommends against using trazodone for sleep onset or sleep maintenance insomnia in adults 1
• The Department of Veterans Affairs/Department of Defense (VA/DOD) guidelines also advise against trazodone for chronic insomnia disorder 1
• Trazodone is considered a third-line agent in the treatment algorithm for insomnia, after benzodiazepine receptor agonists and ramelteon 2

Efficacy Concerns

• Clinical trials showed that trazodone produced only modest improvements in sleep parameters compared to placebo 1
• No significant improvement in subjective sleep quality has been demonstrated at the commonly used doses 1
• The benefits of trazodone for sleep do not outweigh the potential harms according to current guidelines 1

Preferred Treatment Algorithm for Insomnia

1. First-line: Cognitive Behavioral Therapy for Insomnia (CBT-I) 2, 1

   • Should be offered as the initial treatment for chronic insomnia
   • Components include cognitive therapy, stimulus control, and sleep restriction therapy

2. Second-line: Short-intermediate acting benzodiazepine receptor agonists or ramelteon 2, 1

   • Examples include zolpidem, eszopiclone, zaleplon, and temazepam
   • Should be used at the lowest effective dose for the shortest duration

3. Third-line: Sedating antidepressants (including trazodone) 2

   • Only recommended when first and second-line treatments have failed
   • More appropriate when comorbid depression/anxiety is present

Safety Concerns with Trazodone

• Side effects include daytime drowsiness, dizziness, and psychomotor impairment 1, 3
• Particular concern for elderly patients due to increased risk of falls 3
• Priapism has been reported in approximately 12% of patients in some studies 4
• Orthostatic hypotension and cardiac arrhythmias are potential concerns 5

Appropriate Use of Trazodone (If Deemed Necessary)

• When used for insomnia, lower doses (25-50 mg) are typically employed, which are below the therapeutic antidepressant range 1
• The prescribed dose of 150 mg is within the antidepressant range and may increase side effect risk 6, 5
• Should be accompanied by patient education regarding treatment goals, safety concerns, and potential side effects 2
• Regular follow-up is essential to assess effectiveness, side effects, and ongoing need 2

Special Considerations

• Trazodone may be more appropriate if the patient has comorbid depression 1, 7
• Counseling referral is appropriate and aligns with guidelines recommending CBT-I as first-line therapy 2, 1
• If trazodone is continued, efforts should be made to employ the lowest effective dose and to taper when conditions allow 2

Alternative Recommendations

• Consider switching to a second-line agent such as zolpidem, eszopiclone, zaleplon, or ramelteon 2, 1
• Ensure the patient receives adequate cognitive behavioral therapy for insomnia 2, 1
• If continuing trazodone, consider reducing the dose to minimize side effects 1, 6