Trazodone for Insomnia: Evidence-Based Recommendations

The American Academy of Sleep Medicine explicitly recommends against using trazodone for insomnia treatment, citing that its modest benefits do not outweigh potential harms. 1

Why Trazodone Should Not Be First-Line for Insomnia

The evidence against trazodone is compelling:

Clinical trials using trazodone 50 mg demonstrated only a ~10-minute reduction in sleep-onset latency and ~8-minute reduction in wake after sleep onset—improvements that are clinically insignificant. 1
Subjective sleep quality did not improve compared to placebo in guideline-reviewed trials, meaning patients don't actually feel they sleep better. 1
Adverse events occurred in approximately 75% of older adults taking trazodone, with headache affecting ~30% and somnolence ~23%. 2
The drug causes cognitive impairment, psychomotor deficits, and equilibrium problems that persist into the next day, affecting memory, verbal learning, and balance. 3
Despite widespread off-label use, trazodone has never been FDA-approved for insomnia—it is indicated only for depression at doses of 150–600 mg/day. 4

What You Should Use Instead: Evidence-Based Algorithm

Step 1: Cognitive Behavioral Therapy for Insomnia (CBT-I) – MANDATORY FIRST-LINE

The American Academy of Sleep Medicine and American College of Physicians issue a strong recommendation that all adults with chronic insomnia receive CBT-I before or alongside any medication. 1, 5
CBT-I provides superior long-term efficacy with sustained benefits after treatment ends, whereas medication effects cease when stopped. 1, 5
Core components include stimulus control (use bed only for sleep; leave bed if awake >20 minutes), sleep restriction (limit time in bed to actual sleep time + 30 minutes), relaxation techniques, and cognitive restructuring. 1, 5
CBT-I can be delivered via individual therapy, group sessions, telephone, web-based modules, or self-help books—all formats show comparable effectiveness. 1, 5

Step 2: Pharmacotherapy Selection (Only After CBT-I Initiated)

Match the medication to the specific insomnia phenotype:

For Sleep-Onset Insomnia:

Ramelteon 8 mg at bedtime – preferred when substance-use history exists; no abuse potential, not DEA-scheduled, no withdrawal symptoms. 1, 5
Zaleplon 10 mg (5 mg if age ≥65) – ultrashort half-life (~1 hour), minimal next-day sedation. 1, 5
Zolpidem 10 mg (5 mg if age ≥65) – reduces sleep latency by ~25 minutes, adds ~29 minutes to total sleep time. 1, 5

For Sleep-Maintenance Insomnia:

Low-dose doxepin 3–6 mg at bedtime – preferred first-line option for older adults; reduces wake after sleep onset by 22–23 minutes, minimal anticholinergic effects, no abuse potential. 1, 5, 2
Suvorexant 10 mg – orexin-receptor antagonist; reduces wake after sleep onset by 16–28 minutes, lower risk of cognitive impairment than benzodiazepine-type agents. 1, 5

For Combined Sleep-Onset and Maintenance Insomnia:

Eszopiclone 2–3 mg (1 mg if age ≥65 or hepatic impairment) – increases total sleep time by 28–57 minutes, moderate-to-large improvement in subjective sleep quality. 1, 5
Zolpidem extended-release 10 mg (5 mg if age ≥65) – maintains therapeutic levels throughout the night. 1

If Trazodone Is Already Prescribed: What to Do

If a patient is currently taking trazodone 25–50 mg for insomnia:

Recognize the dose is subtherapeutic: The FDA-approved antidepressant dose starts at 150 mg/day, with therapeutic range 150–600 mg/day. 4 Low doses (25–100 mg) used for insomnia are not supported by clinical trial data. 1
Do NOT escalate trazodone dose to 150–200 mg hoping for better sleep—this increases side effects (daytime sedation, dizziness, orthostatic hypotension, priapism risk) without proportional sleep benefit. 2, 4
Initiate CBT-I immediately while planning medication transition. 1, 5
Switch to a guideline-recommended hypnotic based on the patient's specific insomnia pattern (see algorithm above). 1, 5
Taper trazodone gradually (reduce by ~25% every 1–2 weeks) to avoid discontinuation syndrome (nausea, sweating, dysphoric mood, irritability, dizziness, sensory disturbances). 4

Special Clinical Scenarios Where Trazodone May Be Considered (Third-Line Only)

Trazodone may have a role in these specific contexts—but only after first- and second-line options have failed:

Comorbid depression requiring full antidepressant dosing (150–300 mg/day) – the sedating effect at therapeutic doses may help insomnia, but 50 mg is inadequate for treating major depression. 1, 2
Patient already on a full-dose antidepressant with residual insomnia – adding low-dose trazodone (50–100 mg) may augment sleep, though low-dose doxepin 3–6 mg is safer and more effective. 1, 2
Insomnia in patients with substance-use history who cannot tolerate or refuse benzodiazepine-receptor agonists – though ramelteon or suvorexant are better choices. 1, 5

Critical Safety Warnings for Trazodone

If trazodone is used despite guideline recommendations, monitor for:

Priapism – painful erections >4 hours require immediate emergency care; discontinue trazodone permanently if this occurs. 4
Orthostatic hypotension and syncope – measure orthostatic vital signs at baseline and after dose changes, especially in older adults. 2, 4
Serotonin syndrome – when combined with SSRIs (sertraline, escitalopram) or other serotonergic agents, monitor for agitation, tremor, hypertension, hyperthermia during first 24–48 hours. 2
Cognitive and psychomotor impairment – trazodone causes measurable deficits in short-term memory, verbal learning, equilibrium, and muscle endurance that persist into the next day. 3
Increased bleeding risk – when combined with NSAIDs, aspirin, antiplatelet drugs, or anticoagulants. 4
Hyponatremia – especially in elderly patients, those on diuretics, or volume-depleted individuals; can cause confusion, falls, seizures. 4

Medications to Explicitly Avoid for Insomnia

The following are NOT recommended by guidelines:

Trazodone – harms outweigh modest benefits. 1, 2
Over-the-counter antihistamines (diphenhydramine, doxylamine) – lack efficacy data, strong anticholinergic effects (confusion, urinary retention, falls, delirium), tolerance develops within 3–4 days. 1, 5
Antipsychotics (quetiapine, olanzapine) – weak evidence for insomnia, significant risks (weight gain, metabolic syndrome, extrapyramidal symptoms, increased mortality in elderly). 1, 5
Traditional benzodiazepines (lorazepam, clonazepam, diazepam) – high risk of dependence, falls, cognitive impairment, respiratory depression, associations with dementia and fractures. 1, 5
Melatonin supplements – only ~9-minute reduction in sleep latency, insufficient evidence. 1, 5
Herbal supplements (valerian, L-tryptophan) – insufficient evidence. 1, 5

Dosing and Administration (If Trazodone Is Used Despite Recommendations)

Per FDA labeling for depression (not insomnia):

Initial dose: 150 mg/day in divided doses. 4
May increase by 50 mg/day every 3–4 days. 4
Maximum outpatient dose: 400 mg/day; inpatient dose: 600 mg/day. 4
Take shortly after a meal or light snack to maximize absorption and minimize side effects. 4

For off-label insomnia use (not FDA-approved):

Typical dosing: 25–100 mg at bedtime, though this is below the therapeutic antidepressant range and not supported by robust clinical trial data. 1, 2
Take at least 1 hour before bedtime on an empty stomach to maximize sedative effect. 1

Common Pitfalls to Avoid

Prescribing trazodone as first-line therapy for primary insomnia contradicts explicit guideline recommendations. 1, 2
Failing to initiate CBT-I before or alongside medication—behavioral therapy provides more durable benefits than medication alone. 1, 5
Using adult dosing in older adults—age-adjusted dosing is mandatory (e.g., zolpidem ≤5 mg, eszopiclone ≤2 mg for age ≥65). 1, 5
Combining multiple sedating agents (e.g., adding trazodone to a benzodiazepine or Z-drug)—markedly increases risk of respiratory depression, falls, cognitive impairment. 1, 5
Continuing pharmacotherapy long-term without reassessment—FDA labeling indicates hypnotics are for short-term use (≤4 weeks); reassess every 1–2 weeks initially, then every 4 weeks. 1, 5
Assuming trazodone is "safer" than FDA-approved hypnotics—guideline evidence does not support a superior safety profile. 1

Is trazodone appropriate for treating insomnia, and what is the recommended starting dose and safety precautions?

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