Considerations Before Taking Trazodone for Insomnia

The pharmaceutical drug trazodone is a commonly prescribed antidepressant that is also used off-label as a hypnotic to initiate sleep. It has been used for decades as a sleep aid, but how does trazodone work? How well does it work on average to improve falling asleep or sleeping more at night? What are the common side effects?

Learn whether trazodone is right for you and what alternatives may be helpful to consider, including the need for a sleep test if chronic insomnia persists.

Trazodone is an older drug that has been used to treat depression and severe anxiety for many years. Since it has sedative or hypnotic effects, meaning that it causes drowsiness, it is also helpful for treating insomnia or acute insomnia.

It is not known precisely how trazodone works. What is known is that it acts on neurotransmitters, which are chemical messengers within the brain. It allows a specific neurotransmitter called serotonin to build up in the spaces between nerve cells by blocking its uptake into the nearby cells. It also seems to interact with histamine (and antihistamines like diphenhydramine are well known as sleep aids). These effects seem to collectively enhance slow-wave (or N3) sleep.

The American Academy of Sleep Medicine does not currently recommend the use of trazodone to treat insomnia, suggesting that the potential risks and harms outweigh the benefits. This is based on research that suggests the time it takes to fall asleep is only reduced by an average of 10 minutes with the use of trazodone compared to placebo. In addition, the amount of time spent awake at night is only reduced by 8 minutes on average with trazodone.

If you decide to use trazodone, there are certain people who should further reconsider its use. Trazodone should not be used in people who are recovering from a heart attack. It should also not be used by people under 25 years old, and the elderly should use the drug with caution. Trazodone should be avoided if you are pregnant or breastfeeding.

Trazodone may also not be appropriate for people who have psychiatric illnesses, including bipolar disease and schizophrenia, as well as in those at risk for suicide. Use trazodone with caution if you have heart or cerebrovascular disease, seizures, or kidney or liver problems.

Trazodone has the potential to interact with many other drugs, so your medications should be carefully reviewed by your health care provider before you start to take trazodone. No deaths or heart complications have been reported in people who are taking trazodone alone. Stopping the medication abruptly should be avoided; instead, it may need to be tapered under doctor's supervision.

There are many potential side effects of any drug. Although an individual would not be expected to experience most side effects (and may indeed not have any of them), some that may commonly occur with trazodone include:

• Sleepiness
• Dizziness
• Lightheadedness
• Dry mouth
• Headache
• Blurred vision
• Nausea or vomiting
• Nervousness
• Fatigue
• Constipation
• Palpitations
• Rapid heart rate
• Low blood pressure
• Skin reactions, such as a rash
• Confusion
• Muscle pain
• Weight changes
• Diarrhea
• Tremor (shakiness)
• Difficulties with walking or coordination

With the use of any drug, there are also risks of serious side effects. These occur more rarely. When using trazodone, these may include:

• Priapism (persistent painful erection)
• Orthostatic hypotension (low blood pressure when standing)
• Abnormal heart rhythms
• Hypertension (high blood pressure)
• Fainting
• Stroke
• Heart attack
• Extrapyramidal symptoms
• Tardive dyskinesia
• Hypomania/mania
• Psychosis exacerbation
• Worsening depression
• Suicidal thoughts
• Hallucinations
• Seizures
• Neutropenia (low white blood cell count)
• Anemia
• Hepatitis (liver inflammation)
• SIADH (Syndrome of Inappropriate Anti-Diuretic Hormone secretion)

As noted above, certain people should use the medication with caution or not at all. It is important that you are monitored by your doctor as the medication is started or changes in the dose are made. In particular, symptoms of suicidality or unusual behavior changes should be watched for.

If you experience any difficulties, you should be in close contact with your primary health provider. If insomnia persists, consider treating it with the use of cognitive behavioral therapy for insomnia (CBTI). You can use our Doctor Discussion Guide below to start that conversation with your doctor.

If you find that insomnia has taken hold, prompting the consideration of sleep aids including prescription medications like trazodone, consider the need for an evaluation by a board-certified sleep specialist. Sleep disorders, including sleep apnea, may commonly contribute to difficulty sleeping through the night.

Treatment of this condition may allow insomnia to resolve. Moreover, conditions like sleep apnea may undermine the efficacy of medications and lead to long-term consequences if left untreated or masked by drugs. Fortunately, effective treatments may allow improvement while avoiding the ongoing need for potentially harmful medications.