What is the best psych medication for insomnia?

Best Psychiatric Medication for Insomnia

For primary chronic insomnia, avoid trazodone and other psychiatric medications as first-line agents; instead, use FDA-approved hypnotics like eszopiclone, zolpidem, or ramelteon, with cognitive behavioral therapy for insomnia (CBT-I) as the preferred initial treatment. 1, 2

Why Trazodone Should NOT Be Used

• The American Academy of Sleep Medicine explicitly recommends AGAINST using trazodone for both sleep onset and sleep maintenance insomnia based on clinical trial evidence showing no significant differences in sleep efficiency, sleep onset latency, total sleep time, or wake after sleep onset compared to placebo 1, 2
• The VA/DOD guidelines similarly advise against trazodone use, concluding that its low-quality efficacy evidence is outweighed by its adverse effect profile including daytime drowsiness, dizziness, psychomotor impairment, and orthostatic hypotension 1, 3
• Despite being the second most commonly prescribed agent for insomnia due to off-label use, trazodone has very limited evidence supporting its efficacy, with most studies being small, poorly designed, and conducted only in depressed populations 4

Recommended Psychiatric Medications (When Pharmacotherapy Is Indicated)

For Sleep Onset Insomnia:

• Ramelteon 8 mg (melatonin receptor agonist): Take 30 minutes before bedtime; FDA-approved with demonstrated efficacy in reducing sleep latency and no abuse potential 1, 5
• Zaleplon 10 mg (benzodiazepine receptor agonist): Effective for sleep initiation with shorter half-life 1
• Triazolam 0.25 mg (benzodiazepine): Use cautiously due to dependency risk and adverse effects in elderly 1

For Sleep Maintenance Insomnia:

• Doxepin 3-6 mg (low-dose tricyclic): Specifically effective for sleep maintenance with better tolerability profile than trazodone 1, 3
• Suvorexant (orexin receptor antagonist): Recommended specifically for sleep maintenance problems 1, 6

For Both Sleep Onset AND Maintenance:

• Eszopiclone 2-3 mg: Most versatile option with evidence for both sleep initiation and maintenance 1, 6
• Zolpidem 10 mg: Effective for both components of insomnia 1, 6
• Temazepam 15 mg: Benzodiazepine option but carries higher risk of dependency 1

Treatment Algorithm

1. First-line: CBT-I - Cognitive behavioral therapy for insomnia should be offered initially, including stimulus control, sleep restriction, and cognitive therapy components 1, 2

2. Second-line: FDA-approved hypnotics - If pharmacotherapy is needed, choose based on the specific sleep complaint:

   • Sleep onset only → Ramelteon or zaleplon 1, 6
   • Sleep maintenance only → Doxepin or suvorexant 1, 6
   • Both → Eszopiclone or zolpidem 1, 6

3. Use lowest effective dose for shortest duration - All hypnotics should be started at minimum doses with regular follow-up to assess effectiveness, side effects, and ongoing need 1, 2

Medications to Avoid

• Antihistamines (diphenhydramine): Not recommended due to antimuscarinic effects, tolerance after 3-4 days, and high risk in elderly per Beers Criteria 1
• Antipsychotics (quetiapine): Sparse evidence, serious harms including increased mortality in elderly with dementia 1
• Melatonin supplements: No evidence supporting efficacy for chronic insomnia 1
• Herbal supplements (valerian, chamomile, kava): Lack efficacy data and kava carries risk of fatal liver toxicity 1

Critical Caveats

• Benzodiazepines have significant harms: While effective for sleep, they carry substantial risks including dependency, falls and cognitive impairment in elderly, respiratory depression in sleep apnea patients, and should generally be avoided despite their efficacy 1
• Trazodone may have a role in comorbid depression: When insomnia occurs with major depressive disorder, trazodone might be considered as it addresses both conditions, though this is not supported by insomnia-specific guidelines 2, 7
• Monitor for next-day impairment: Counsel patients about allowing adequate sleep time (7-8 hours) and avoiding driving or operating machinery if experiencing residual sedation 2
• Reassess regularly: Follow up after 1-2 weeks to evaluate response, and consider switching agents if inadequate improvement after 2-3 weeks 6