What is the role of trazodone (an antidepressant) in treating an adult patient with chronic insomnia and a history of depression or anxiety?

Trazodone Should NOT Be Used for Insomnia

The American Academy of Sleep Medicine explicitly recommends AGAINST trazodone for both sleep onset and sleep maintenance insomnia, based on evidence showing that harms outweigh benefits. 1, 2, 3

Why Trazodone Fails as a Sleep Aid

Clinical trials demonstrate that trazodone 50mg produces only modest improvements in objective sleep parameters compared to placebo, with no improvement in subjective sleep quality—the outcome that actually matters to patients. 2, 3 The evidence quality is weak, and the adverse effect profile is concerning. 3

Specific Harms That Outweigh Benefits

• Daytime drowsiness, dizziness, and psychomotor impairment occur frequently, creating particular safety concerns in elderly patients who face increased fall risk. 3, 4
• High discontinuation rates due to side effects in clinical trials suggest poor real-world tolerability. 4
• Priapism, though rare, represents a serious adverse effect that has led to treatment discontinuation. 3
• Evidence suggests tolerance development with continued use, diminishing any initial benefit. 4

What You Should Use Instead

First-Line: Cognitive Behavioral Therapy for Insomnia (CBT-I)

CBT-I must be initiated before or alongside any pharmacotherapy, as it provides superior long-term outcomes with sustained benefits after discontinuation. 5, 1, 2 This includes stimulus control therapy, sleep restriction therapy, cognitive restructuring, and sleep hygiene education, deliverable via individual therapy, group sessions, telephone, web-based modules, or self-help books. 5, 1

Second-Line: FDA-Approved Hypnotics (When CBT-I Insufficient)

For sleep onset AND maintenance insomnia:

• Eszopiclone 2-3mg (moderate-quality evidence for efficacy) 5, 1
• Zolpidem 10mg (5mg in elderly—this dose reduction is mandatory due to increased sensitivity and fall risk) 5, 1
• Temazepam 15mg 1

For sleep onset ONLY:

• Zaleplon 10mg 1
• Ramelteon 8mg 1

For sleep maintenance ONLY:

• Doxepin 3-6mg (moderate-quality evidence showing 22-23 minute reduction in wake after sleep onset) 5, 1
• Suvorexant (orexin antagonist with moderate-quality evidence) 5, 1

When Trazodone Might Be Considered (Third-Line Only)

Trazodone occupies a third-line position in the treatment algorithm, appropriate ONLY when: 1, 3

• First-line BzRAs (benzodiazepine receptor agonists) or ramelteon have failed
• Second-line alternatives in the same class have failed
• Comorbid depression or anxiety is present requiring antidepressant treatment

Critical caveat: The low doses used for insomnia (25-50mg) are inadequate for treating major depression, which requires 150-300mg daily. 3 If depression is present, use a full-dose antidepressant for the mood disorder and add a proper hypnotic for sleep, rather than relying on subtherapeutic trazodone doses. 3

Implementation Algorithm for Comorbid Depression/Anxiety

1. Start CBT-I immediately (non-negotiable first step) 1, 2
2. Initiate full-dose antidepressant for mood disorder (e.g., SSRI, mirtazapine) 1
3. Add FDA-approved hypnotic from list above if insomnia persists despite antidepressant 1
4. Consider trazodone only if steps 1-3 fail and patient cannot tolerate other options 1, 3

Common Pitfalls to Avoid

• Using trazodone as first-line therapy for primary insomnia—this contradicts guideline recommendations and exposes patients to unnecessary risks. 1, 2, 3
• Prescribing trazodone without attempting CBT-I first—behavioral interventions provide more sustained effects than any medication. 1, 2
• Combining two sedating antidepressants (e.g., trazodone + mirtazapine)—this significantly increases risks of serotonin syndrome, excessive sedation, and QTc prolongation without established efficacy. 2
• Using over-the-counter antihistamines (diphenhydramine) as alternatives—these lack efficacy data and carry safety concerns including delirium risk in elderly patients. 5, 1
• Failing to use lowest effective doses and shortest duration for any hypnotic—all sleep medications should be prescribed conservatively with regular reassessment. 1, 3

Medication Selection Based on Sleep Pattern

Sleep onset difficulty: Zaleplon, ramelteon, zolpidem, or triazolam 1

Sleep maintenance difficulty: Eszopiclone, zolpidem, temazepam, doxepin, or suvorexant 1

Both onset and maintenance: Eszopiclone, zolpidem, or temazepam 1

Special Considerations for Elderly Patients

• Mandatory dose reductions: Zolpidem maximum 5mg (not 10mg) due to increased sensitivity 5, 1
• Higher risk profile: Falls, cognitive impairment, complex sleep behaviors (sleep-driving, sleep-walking) occur more frequently 5, 1
• Avoid long-acting benzodiazepines due to drug accumulation and prolonged daytime sedation 1

Monitoring Requirements

• Reassess after 1-2 weeks to evaluate efficacy on sleep latency, maintenance, and daytime functioning 1
• Monitor for adverse effects: Morning sedation, cognitive impairment, complex sleep behaviors 1
• Taper when conditions allow to prevent discontinuation symptoms 1
• Periodic reassessment of ongoing need for pharmacotherapy—do not continue indefinitely without justification 5, 1