Do Not Increase the Trazodone Dose
You should discontinue trazodone and switch to an evidence-based treatment for insomnia, as the American Academy of Sleep Medicine explicitly recommends against using trazodone for either sleep onset or sleep maintenance insomnia. 1
Why Increasing Trazodone is Not Recommended
Trazodone at 50 mg shows no clinically significant benefit for insomnia, with sleep latency reduction of only 10.2 minutes and total sleep time increase of only 21.8 minutes—both below clinical significance thresholds 1, 2
Higher doses lack guideline support for insomnia treatment and would only increase the risk of adverse events without established efficacy for sleep disorders 2
The FDA labeling for trazodone indicates it is approved for depression at doses starting at 150 mg/day in divided doses, not for insomnia at 50 mg 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 2
Evidence-Based Alternatives to Consider
First-line treatment:
- Cognitive behavioral therapy for insomnia (CBT-I) should be the initial treatment as it is recommended by major guidelines for chronic insomnia disorder 2
Pharmacologic options if CBT-I is unavailable or insufficient:
For sleep onset insomnia:
- Consider eszopiclone, zolpidem, or zaleplon at the lowest effective dose and shortest possible duration 2
For sleep maintenance insomnia:
- Consider suvorexant or doxepin (3-6 mg) 1, 2
- Doxepin at 3-6 mg shows clinically significant improvement in sleep efficiency (+6.78% to +7.06%) and is specifically effective for sleep maintenance 1
Critical Safety Considerations
Avoid these common pitfalls:
Do not prescribe benzodiazepines—VA/DoD guidelines explicitly recommend against them due to risks of dependency, falls, cognitive impairment in elderly patients, and respiratory depression 2
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 2
Do not use antipsychotics like quetiapine—evidence is sparse and they carry serious harms including increased mortality risk in elderly patients with dementia 2
Non-benzodiazepine hypnotics carry FDA warnings about serious injuries from sleep behaviors (sleepwalking, sleep driving) while not fully awake 2
Discontinuation Strategy
Gradually reduce the trazodone dosage rather than stopping abruptly to minimize withdrawal symptoms 3
If the patient has cardiovascular conditions, this is an additional reason to discontinue trazodone, as it requires careful monitoring during use 2, 4
In elderly patients, switching medications rather than adding them reduces fall risk and drug interactions 2