Discontinue Trazodone and Switch to Evidence-Based Insomnia Treatment
The next step is to discontinue trazodone, as major clinical guidelines explicitly recommend against its use for insomnia, and instead initiate cognitive behavioral therapy for insomnia (CBT-I) as first-line treatment, or consider FDA-approved hypnotics if pharmacotherapy is necessary. 1, 2, 3
Why Trazodone Should Be Discontinued
The American Academy of Sleep Medicine explicitly recommends against using trazodone for either sleep onset or sleep maintenance insomnia because the 50 mg dose shows no clinically significant benefit 2, 3
At 50 mg, trazodone reduces sleep latency by only 10.2 minutes and increases total sleep time by only 21.8 minutes—both below clinical significance thresholds 3
The 2019 VA/DoD Clinical Practice Guidelines found no differences in sleep efficiency or discontinuation rates between trazodone (50-150 mg) and placebo, and concluded that the low-quality evidence supporting efficacy is outweighed by its adverse effect profile 1
In elderly patients specifically, trazodone carries increased risks of orthostatic hypotension, falls, and daytime drowsiness 3
Adverse events occur in 75% of patients on trazodone versus 65.4% on placebo, with headache (30% vs 19%) and somnolence (23% vs 8%) being most common 3
Evidence-Based Treatment Algorithm
First-Line: Non-Pharmacologic Approach
- Cognitive behavioral therapy for insomnia (CBT-I) should be the initial treatment as it is recommended by major guidelines for chronic insomnia disorder 1
Second-Line: FDA-Approved Pharmacotherapy (If CBT-I Fails or Is Unavailable)
For sleep onset insomnia:
- Consider eszopiclone, zolpidem, or zaleplon 2
- These should be prescribed at the lowest effective dose and shortest possible duration 1
For sleep maintenance insomnia:
- Consider suvorexant or doxepin 2
Important caveat: Non-benzodiazepine hypnotics carry FDA warnings about serious injuries from sleep behaviors (sleepwalking, sleep driving) while not fully awake 1
What NOT to Do
Do not increase the trazodone dose—higher doses do not have guideline support for insomnia and increase adverse event risk 2, 3
Do not prescribe benzodiazepines—the VA/DoD guidelines explicitly recommend against them due to risks of dependency, falls, cognitive impairment in elderly patients, and respiratory depression 1
Do not use antihistamines—the 2019 Beers Criteria carry a strong recommendation to avoid these in older adults due to antimuscarinic effects, and tolerance develops after 3-4 days 1
Do not use antipsychotics (like quetiapine)—evidence is sparse and they carry serious harms including increased mortality risk in elderly patients with dementia 1
Clinical Pitfalls to Avoid
Tolerance development: Evidence suggests tolerance to trazodone's sedative effects can occur, making it even less effective over time 4
Cardiovascular monitoring: If the patient has cardiovascular conditions, this is an additional reason to discontinue trazodone, as it requires careful monitoring during use 2, 5
Polypharmacy risk: In elderly patients, adding medications rather than switching increases fall risk and drug interactions 3