Trazodone is NOT a first-line medication for primary anxiety disorders
Trazodone lacks robust evidence as a primary treatment for anxiety and should not be your go-to anxiolytic. While it has some anxiolytic properties and limited supporting data, it is primarily an antidepressant with better-established roles in treating insomnia and depression with comorbid anxiety—not standalone anxiety disorders.
Evidence for Anxiety Treatment
Limited Support for Anxiety as Primary Indication
Trazodone has demonstrated some efficacy in anxiety associated with major depressive disorder (MDD), but the American College of Physicians guidelines show no difference between trazodone and other antidepressants for treating anxiety symptoms in depressed patients 1.
One small, single-blind trial (N=11) showed improvement in panic disorder and agoraphobia with panic attacks at 300 mg/day over 8 weeks, suggesting possible antipanic and antiphobic actions 2. However, this is a very small study without placebo control, making it insufficient to recommend trazodone for panic disorder.
A naturalistic study in adjustment disorders showed trazodone reduced anxiety symptoms significantly by day 7 of treatment 3, but adjustment disorders are not the same as primary anxiety disorders like Generalized Anxiety Disorder.
Historical Context with Weak Evidence
Older literature from 1981 suggests trazodone was "comparable with diazepam and chlordiazepoxide in anxiety neurosis" in limited studies 4, but these studies are outdated, poorly described, and lack the rigor of modern trials.
Trazodone is commonly used off-label for various anxiety disorders including Generalized Anxiety Disorder, Panic Disorder, PTSD, and OCD 5, but this widespread use is not supported by strong randomized controlled trial evidence.
Where Trazodone Actually Fits
Better Evidence for Other Indications
Insomnia: Trazodone showed improvement in sleep scores over fluoxetine and venlafaxine in patients with depression 1. The 2008 insomnia guidelines list trazodone as a sedating low-dose antidepressant option when other treatments fail or when comorbid depression exists 1.
Depression with comorbid anxiety: When anxiety occurs alongside depression, trazodone performs equivalently to other antidepressants 1.
Clinical Bottom Line
For primary anxiety disorders, choose evidence-based first-line agents instead:
SSRIs (sertraline, paroxetine, escitalopram) or SNRIs (venlafaxine) have far stronger evidence for anxiety disorders and are guideline-recommended first-line treatments.
Consider trazodone only in specific scenarios:
Important Caveats
Dosing matters: The anxiety studies used 300 mg/day 2, which is higher than typical low-dose use for insomnia (25-100 mg).
Side effects to monitor: Orthostatic hypotension (especially in elderly), drowsiness, and rare but serious priapism 6.
Lack of controlled data: Most off-label anxiety uses lack large randomized controlled trials 5, meaning you're prescribing based on clinical experience rather than robust evidence.
The evidence simply does not support trazodone as a good first-choice medication for anxiety. Reserve it for the specific scenarios outlined above where its sedating properties provide additional benefit or when standard anxiolytics have failed.