I am taking trazodone 150 mg at bedtime for insomnia, anxiety, and depression but still have poor sleep; should I increase the dose or consider other treatments?

Trazodone 150mg Insufficient for Insomnia, Anxiety, and Depression

You should not increase trazodone for this indication—the American Academy of Sleep Medicine and VA/DOD explicitly recommend against using trazodone for chronic insomnia because the evidence shows no meaningful benefit over placebo, and the adverse effects outweigh any modest subjective improvement. 1

Why Trazodone is Failing at 150mg

Trazodone at 50-150mg produces no significant improvement in objective sleep parameters (sleep efficiency, sleep onset latency, total sleep time, or wake after sleep onset) compared to placebo in chronic insomnia trials. 1 While patients report modest subjective sleep quality improvement, this does not translate to measurable sleep architecture changes. 1

For depression treatment, 150mg is subtherapeutic—the FDA-approved antidepressant dose starts at 150mg/day in divided doses and typically requires 200-400mg/day for outpatients to achieve adequate antidepressant response. 2 Your single bedtime dose of 150mg is insufficient to treat the underlying depression driving both the insomnia and anxiety. 1

Immediate Next Steps: Evidence-Based Treatment Algorithm

Step 1: Initiate Cognitive Behavioral Therapy for Insomnia (CBT-I) FIRST

• CBT-I is the mandatory first-line treatment for chronic insomnia and demonstrates superior long-term efficacy with sustained benefits after discontinuation. 1
• Core components include sleep restriction therapy, stimulus control (leave bed if not asleep within 20 minutes, use bed only for sleep), and relaxation training. 3

Step 2: Address Depression with Adequate Antidepressant Dosing

• If continuing trazodone for depression, increase to 200-300mg/day in divided doses (not all at bedtime) to reach therapeutic antidepressant range. 4
• Screen for bipolar disorder before escalating any antidepressant—personal or family history of mania/hypomania is a contraindication to monotherapy antidepressant escalation. 2
• Alternative: Switch to a first-line antidepressant (SSRI/SNRI) at therapeutic doses, as trazodone is not a preferred agent for major depression.

Step 3: Add FDA-Approved Hypnotic for Insomnia (Only After CBT-I)

For sleep onset AND maintenance insomnia:

• Eszopiclone 2-3mg (reduce to 1mg in elderly/hepatic impairment) 1
• Zolpidem 10mg (reduce to 5mg in elderly) 1
• Temazepam 15-30mg (reduce to 7.5mg in elderly) 1

For sleep onset insomnia only:

• Zaleplon 10mg (short-acting, no morning sedation) 1
• Ramelteon 8mg (preferred if substance use history—zero addiction potential) 1

For sleep maintenance insomnia only:

• Low-dose doxepin 3-6mg (most effective for maintenance, minimal side effects, no abuse potential) 1

Critical Safety Considerations with Current Trazodone Regimen

Daytime cognitive impairment: Trazodone 50mg causes measurable impairments in short-term memory, verbal learning, equilibrium, and muscle endurance even after 7 days of use. 5 At 150mg, these effects are likely more pronounced.

Orthostatic hypotension and falls risk: Dizziness and orthostatic hypotension are common, especially in older adults—patients must rise slowly from seated/supine positions. 1

Priapism risk: Any prolonged painful erection >4 hours requires immediate emergency care. 1

What NOT to Do (Common Pitfalls)

• Do not increase trazodone above 150mg for insomnia alone—higher doses do not improve sleep outcomes and increase side effects. 1
• Do not combine trazodone with another sedating antidepressant (e.g., mirtazapine)—additive sedation without proven benefit. 1
• Do not use antihistamines (diphenhydramine) or herbal supplements (valerian, melatonin)—lack efficacy data and carry anticholinergic burden. 1
• Do not prescribe benzodiazepines (lorazepam, clonazepam)—higher dependency risk, falls, and cognitive impairment compared to FDA-approved hypnotics. 1

Monitoring and Follow-Up Requirements

• Reassess every 2-4 weeks initially for effectiveness, adverse effects, and ongoing need for pharmacotherapy. 1
• Use lowest effective dose for shortest duration—taper medications when conditions allow. 1
• Counsel about complex sleep behaviors (sleepwalking, sleep-driving) with any sedative medication. 1
• Allow 7-8 hour sleep window to reduce residual morning sedation. 1

Special Scenario: If Trazodone Must Be Continued

If you elect to continue trazodone despite guideline recommendations:

• Take at least 1 hour before bedtime on an empty stomach to maximize effectiveness. 1
• Avoid alcohol and other CNS depressants due to additive sedative effects. 1
• Use caution with compromised respiratory function (asthma, COPD, sleep apnea), hepatic impairment, or heart failure. 1
• Consider dose reduction in hepatic impairment to minimize risks. 1

Bottom line: The evidence strongly supports discontinuing trazodone for insomnia, initiating CBT-I, optimizing depression treatment with adequate antidepressant dosing (if depression is present), and adding an FDA-approved hypnotic only if CBT-I is insufficient. 1