Should a 65-year-old woman who has been taking trazodone 100 mg nightly for a year and is now experiencing worsening sleep discontinue the medication?

Do Not Stop Trazodone Abruptly—Reassess and Optimize the Regimen

You should not simply discontinue trazodone without first investigating the cause of worsening sleep and implementing evidence-based alternatives, because abrupt cessation may trigger rebound insomnia and the underlying sleep problem will remain unaddressed. 1

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Why Trazodone Alone Is Insufficient

• The American Academy of Sleep Medicine explicitly recommends against using trazodone for chronic insomnia because clinical trials show only minimal benefit—approximately 10 minutes shorter sleep-onset latency and 8 minutes less wake after sleep onset—with no improvement in subjective sleep quality and adverse events in roughly 75% of older adults. 1, 2
• Your patient's current 100 mg dose falls below the therapeutic range required for any meaningful antidepressant or sleep benefit; studies in PTSD-related insomnia identified a mean effective dose of approximately 212 mg/day, and FDA labeling for depression starts at 150 mg/day in divided doses. 2, 3
• Tolerance to trazodone's sedative effects can develop over time, which may explain why a regimen that worked for a year is now failing. 4

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

• Both the American Academy of Sleep Medicine and the American College of Physicians issue a strong recommendation that all adults with chronic insomnia receive CBT-I as first-line treatment before or alongside any medication, because it provides superior long-term efficacy with sustained benefits after drug discontinuation. 1, 5
• Core CBT-I components include:
  • Stimulus control—use the bed only for sleep; leave the bed if unable to fall asleep within 20 minutes. 5
  • Sleep restriction—limit time in bed to approximate actual sleep time plus 30 minutes. 5
  • Cognitive restructuring—modify negative beliefs about sleep. 5
  • Relaxation techniques—progressive muscle relaxation, guided imagery, or breathing exercises. 5
• CBT-I can be delivered via individual therapy, group sessions, telephone, web-based modules, or self-help books—all formats demonstrate comparable efficacy. 1, 5

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Step 2: Switch to a Guideline-Recommended Hypnotic (Do Not Continue Trazodone)

For Combined Sleep-Onset and Sleep-Maintenance Insomnia (Most Likely in a 65-Year-Old)

• Eszopiclone 1 mg at bedtime (maximum 2 mg for age ≥65 years) is the preferred first-line pharmacologic option after CBT-I initiation; it increases total sleep time by 28–57 minutes and produces moderate-to-large improvements in subjective sleep quality. 1, 5
• Take within 30 minutes of bedtime with at least 7 hours remaining before planned awakening; if 1 mg is tolerated but insufficient after 1–2 weeks, increase to 2 mg (do not exceed 2 mg in older adults). 1, 5
• Reassess after 1–2 weeks for changes in sleep-onset latency, total sleep time, nocturnal awakenings, daytime functioning, and adverse effects (somnolence, bitter taste, headache). 1, 5

Alternative Second-Line Options If Eszopiclone Fails or Is Contraindicated

Agent (Dose)	Primary Indication	Key Efficacy	Safety Profile
Low-dose doxepin 3 mg (increase to 6 mg after 1–2 weeks if needed)	Sleep-maintenance insomnia	Reduces wake after sleep onset by 22–23 minutes	Minimal anticholinergic effects; no abuse potential [1,5]
Suvorexant 10 mg	Sleep-maintenance insomnia	Reduces wake after sleep onset by 16–28 minutes	Lower risk of cognitive/psychomotor impairment than benzodiazepine-type agents [1,5]
Zolpidem 5 mg (maximum for age ≥65 years)	Combined sleep-onset and maintenance	Shortens sleep-onset latency by ~25 minutes; adds ~29 minutes to total sleep time	FDA warns about next-day impairment and complex sleep behaviors [1,5]
Ramelteon 8 mg	Sleep-onset insomnia	Improves sleep onset without abuse risk	No DEA scheduling; no withdrawal symptoms; preferred if substance-use history [1,5]

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Step 3: Taper Trazodone Gradually While Introducing the New Regimen

• Do not stop trazodone abruptly—the FDA advises gradual dose reduction to avoid discontinuation symptoms such as rebound insomnia, anxiety, or agitation. 3
• Suggested taper schedule:
  • Week 1: Reduce trazodone to 50 mg at bedtime while starting eszopiclone 1 mg (or alternative agent) and CBT-I. 3
  • Week 2: Discontinue trazodone entirely if the new hypnotic is effective; continue CBT-I nightly. 3
• Monitor for rebound insomnia on the second withdrawal night—this is the peak time for withdrawal effects with trazodone. 6

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Critical Safety Warnings

• All benzodiazepine-receptor agonists (eszopiclone, zolpidem, zaleplon) carry FDA warnings for complex sleep behaviors (sleep-driving, sleep-walking, sleep-eating); discontinue immediately if these occur. 1, 5
• Avoid alcohol while taking any hypnotic because it markedly increases the risk of complex sleep behaviors and respiratory depression. 1, 5
• Falls, fractures, and cognitive decline are increased with all hypnotics, especially in adults ≥65 years; use the lowest effective dose for the shortest duration. 1, 5
• FDA labeling limits hypnotic use to ≤4 weeks for acute insomnia; evidence beyond 4 weeks is limited, so reassess every 2–4 weeks and taper after 3–6 months if effective. 1, 5

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Common Pitfalls to Avoid

• Stopping trazodone without implementing CBT-I first leads to persistent insomnia because the underlying behavioral factors remain unaddressed. 1, 5
• Continuing trazodone at 100 mg indefinitely is futile—it provides no meaningful benefit at this dose and exposes the patient to unnecessary side effects (orthostatic hypotension, daytime drowsiness, falls). 1, 2, 4
• Adding a second hypnotic to trazodone (e.g., a benzodiazepine or Z-drug) creates dangerous polypharmacy with additive CNS depression, respiratory risk, falls, and cognitive impairment; instead, switch agents. 1, 5
• Using over-the-counter antihistamines (diphenhydramine, doxylamine) as an alternative is explicitly not recommended—they lack efficacy, cause strong anticholinergic effects (confusion, urinary retention, falls), and tolerance develops within 3–4 days. 1, 5

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Practical Implementation Algorithm

1. Tonight: Continue trazodone 100 mg while you arrange CBT-I resources (referral, web-based program, or self-help book). 1, 5
2. Within 1 week: Start CBT-I (stimulus control, sleep restriction, relaxation techniques) and obtain a prescription for eszopiclone 1 mg or an alternative guideline-recommended hypnotic. 1, 5
3. Week 1 of new regimen: Reduce trazodone to 50 mg at bedtime; start eszopiclone 1 mg (or alternative) 30 minutes before bed. 3
4. Week 2: Discontinue trazodone entirely; continue eszopiclone and CBT-I nightly. 3
5. Weeks 2–4: Reassess sleep parameters, daytime functioning, and adverse effects; titrate eszopiclone to 2 mg if 1 mg is insufficient (maximum 2 mg for age ≥65 years). 1, 5
6. Months 3–6: Attempt gradual taper of eszopiclone while maintaining CBT-I techniques to sustain sleep improvements. 1, 5