A person with insomnia lying in bed.

The top prescribed drugs for insomnia are pretty familiar: Ambien and Lunesta. But there’s another drug often used to help people fall asleep that’s actually a decades-old antidepressant. It’s called trazodone, and it's used as a sleep drug because it can cause drowsiness as a side effect.

It’s now one of the most commonly prescribed medications to treat sleeplessness: An October 2018 Consumer Reports nationally representative survey found that 10 percent of Americans have taken a prescription medication to fight off insomnia in the last 12 months, and of those, a third took trazodone.

Here’s why, and what to do if your doctor suggests that you try it.

What Is Trazodone, Anyway?

Trazodone was first approved as an antidepressant by the Food and Drug Administration in 1981. Although doctors can legally prescribe trazodone (and all drugs, for that matter) for any treatment, the drug has never been approved to treat insomnia.

More on Sleep

A handful of studies have shown that trazodone may improve sleep during the first two weeks of treatment. But the drug has not been studied for longer than six weeks. As a result, little is known about how well it works or how safe it is past that point for the treatment of chronic insomnia. Also, an effective dose range has never been established for the drug when it's being used to treat insomnia, although lower doses are typically used.

Updated treatment guidelines from the American Academy of Sleep Medicine published in 2018 don’t recommend trazodone for chronic insomnia because there is so little data to support its use. In addition, a May 2018 Cochrane review found that there's no evidence to support the use of any antidepressant to treat insomnia, including trazodone.

Still, recent prescribing data suggest that doctors remain convinced that trazodone is an appropriate sleep medication for many people, even those without depression.

Why Trazodone Is Prescribed so Often

Though trazodone is rarely used to treat depression alone anymore, it’s widely prescribed, off-label, at lower doses for treating insomnia.

One reason could be because that, unlike other insomnia drugs—including Ambien—trazodone is not classified by the FDA as a controlled substance (PDF) because there’s little risk of the drug causing dependency and abuse. The result is that doctors can prescribe trazodone without a limit on how many pills a patient can receive.

And, perhaps because trazodone is unlikely to cause dependence, the high levels of prescribing suggests that many physicians may believe trazodone is safer than other frequently prescribed sleep medications. But there are no studies that confirm this.

Another reason trazodone may frequently be prescribed is that it’s inexpensive. Available only as a generic, we found it for as little as $4 for a month’s supply at Walmart.

Other drugs approved to treat insomnia can impair your ability to recall new experiences and may even—although rarely—cause you to walk, eat, have sex, or drive a car while essentially unconscious. There’s no evidence that trazodone can cause those serious side effects. Moreover, many doctors believe that trazodone is less likely to cause renewed insomnia once patients stop taking it, although there’s little evidence to support that thinking.  

Trazodone Risks You Should Know About

Trazodone is not without risks, however. It’s more likely than other sleep drugs to leave you feeling drowsy the next day, which increases the chance of having an accident, particularly while driving or using heavy machinery.

It can also cause abnormally low blood pressure and, in turn, trigger dizziness or even fainting, particularly in seniors, which can increase the risk of falling. A recent study in the Canadian Medical Association Journal found that seniors with dementia who were given trazodone as a sleep aid were as likely to fall as were seniors given antipsychotics, another drug that can cause sedation.

Trazodone can also cause heart-rhythm disorders. And some evidence suggests that it can cause priapism, or persistent erection, a medical emergency that may require surgery and can lead to impotence if not treated promptly.

Last, a black-box warning in the package insert (PDF) notes that trazodone, like other antidepressants, can increase the risk of suicidal thoughts and behavior in children and adolescents, even when taken at approved doses for depression.

The Bottom Line on Trazodone

For the average person who suffers occasional bouts of insomnia, making certain changes to your lifestyle may help the most, including avoiding big meals, alcohol, smoking, and exercising late at night or working or watching TV in bed. (See below for a full list.)

If these actions don’t help, our medical experts advise taking an inexpensive over-the-counter drug containing an antihistamine such as diphenhydramine (Benadryl Allergy, Nytol, Sominex, and generic) or doxylamine (Unisom Nighttime Sleep-Aid and generic)—but for a maximum of a few nights. However, it's important to know that an earlier CR report found that drugs like diphenhydramine can cause dependence when taken for longer than directed (usually two weeks). Plus, they have other risks, such as constipation, confusion, dizziness, and next-day drowsiness.

If your insomnia lasts longer than a few nights, see your doctor to determine whether other factors, such as pain, heartburn, hot flashes, or drug side effects, could be disturbing your sleep. If these are ruled out—or if your insomnia persists despite treatment of the underlying problems—nondrug sleep treatments such as cognitive behavioral therapy appear to yield better, more lasting results than any sleep medications. If possible, try CBT before resorting to medication, which can undermine your motivation to make behavioral changes.

If your doctor recommends sleeping pills for more than a temporary bout of insomnia without mentioning nondrug therapy, ask about these options yourself. For more on such treatment, see our latest tips on how to treat insomnia.

Tips for Safe Use

Of course, medication is sometimes needed for persistent insomnia—when nondrug treatment is unavailable or ineffective, or when the sleep disturbance is affecting your ability to carry out your daily activities. Here are the main considerations for using trazodone to treat insomnia:

  • Insomnia without depression. Because there’s so little supporting evidence, treatment guidelines by the American Academy of Sleep Medicine do not recommend trazodone for treatment of chronic insomnia. Still, trazodone may improve insomnia symptoms initially, as found in one small study, but this effect could fade after a few weeks.
  • Insomnia with depression. Some conditions, such as depression, have a complex and intertwined relationship with insomnia, and the best treatment for these two problems together has not been determined. If you have both, discuss the options with your doctor, making sure to mention the severity of the depression, the nature of your sleep problem, your medical history and susceptibility to side effects, any possible drug interactions, and, of course, your personal preferences.
  • Usually, the most important consideration is managing the depression, which should be treated separately with a more effective antidepressant medication, counseling, or both. A separate drug can then be prescribed for insomnia—either a newer sleep medication or low-dose trazodone. Studies have suggested that trazodone plus another antidepressant can improve sleep in these cases. Alternatively, trazodone might be taken alone, at a higher, antidepressant dose, to treat both problems.

Precautions If You Take Trazodone

  • Because trazodone may not work well to treat insomnia after a few weeks, check in with your doctor periodically to discuss how or whether it’s still working.

  • If you have trouble getting to sleep, take it several hours before you go to bed. If you have trouble staying asleep, take it within 30 minutes before bedtime.

  • Avoid trazodone if you’re recovering from a heart attack. Inform your doctor if you have abnormal heart rhythms, weakened immunity, active infection, or liver or kidney disease. Use it cautiously if you have heart disease.

  • Watch for adverse effects. That’s especially important for people older than 55 or so because they’re more susceptible to abnormal heart rhythms and falls caused by dizziness or drowsiness. Close monitoring is also crucial if you’re taking trazodone with another antidepressant.

  • As with any sleep medication, never mix trazodone with alcohol, and use it cautiously if you’re taking other sedating medications or antihypertensive drugs. Ask your doctor or pharmacist about other possible drug interactions.

  • If you develop an erection that is unusually prolonged or occurs without stimulation, discontinue the drug and contact your physician. Also call your doctor if you develop fever, sore throat, or other signs of infection while taking trazodone.

—Additional reporting by Chris Hendel and Ronald Buchheim

 

Editor’s note: Information in this report is partially based on a report commissioned by Consumer Reports from the American Society of Health-System Pharmacists.

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