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Trazodone For Insomnia: A Popular Off-Label Option

Trazodone (Desyrel) is classified as an atypical antidepressant, functioning specifically as an SARI (serotonin antagonist and reuptake inhibitor).  It is considered a second generation antidepressant, and is still utilized primarily for the treatment of depression in patients that don’t respond well to newer medications (e.g. SSRIs).  The drug also is used on an off-label basis for the treatment of many conditions including: diabetic neuropathy, fibromyalgia, OCD, and alcohol withdrawal.

Of all the off-label uses, arguably the most common is using Trazodone for insomnia or to help individuals facing an inability to fall asleep.  Newer anecdotal evidence has even suggested that Trazodone’s off-label usage as a sleeping pill has surpassed its usage as an antidepressant.  It is considered considerably cheaper than most sleeping pills, plus it may be slightly safer than other traditional tranquilizing agents like benzodiazepines that are linked to dementia.

The precise mechanism of action for Trazodone hasn’t been confirmed, but it is believed to affect a variety of receptor sites including: 5-HT1D, 5-HT1A, Alpha-1A, Alpha-2C, and H1.  This means that it primarily is thought to affect serotonin, with secondary effects on norepinephrine and histamine.  It is also believed that there is a relationship between the dose and the drug’s effect.

Trazodone For Insomnia: A Popular Off-Label Option

When administered at low doses, Trazodone is considered an effective treatment for insomnia.  A lower dose has a different mechanism of action than a higher one.  Specifically lower dosages of Trazodone tend to elicit effects of 5-HT2A antagonism, H1 receptor antagonism, and Alpha-1 adrenergic antagonism.  At higher doses, Trazodone also would significantly inhibit serotonin by targeting both 5-HT2A and 5-HT2C (serotonin receptors) and may not be as effective.

Potential Benefits of Trazodone for Insomnia

There are several advantages associated with using Trazodone for the treatment of insomnia, despite the fact that it remains “off-label.”  These advantages include things like: cost, efficacy, long-term effects, weight neutrality, and the fact that it can target multiple psychiatric conditions simultaneously.

  • Cost: The fact that this drug is generic means that its overall cost will be relatively low by comparison to name-brand sleeping pills (Z-drugs) like Lunesta, Rozerem, and Ambien.  A full week supply of Trazodone should only cost a few dollars, compared to between $30 and $50 for other name brand sleeping agents.
  • Drug withdrawal: Many people have successfully utilized Trazodone to help cope with insomnia and agitation associated with opiate withdrawal, antidepressant withdrawal, and even withdrawal from alcohol.  Trazodone helps take the edge off of some wicked withdrawal symptoms that are often reported such as inability to fall asleep, or broken sleep throughout the night.
  • Effective: It’s no secret that Trazodone is effective for treating insomnia, which is why it has gained popularity as a sleep-inducing agent.  Although the efficacy of this drug is subject to significant individual variation, most people find that one low dose before bedtime either helps them transition from wakefulness to sleep or knocks them out cold.  Some would argue that this drug is just as effective (or in certain cases more effective) than traditional sleeping pills.
  • Long-term effects: While the long-term effects associated with using Trazodone for insomnia aren’t well documented, it is thought to be relatively safe.  Meaning, there likely aren’t any permanent neural effects such as brain damage from repetitive long-term administration.  The fact that the drug acts on histamine may be a cause for concern, but the low dose administered may be preferred over an agent like a sleeping pill or benzodiazepine.
  • Low dose: Some have noted that there’s a relationship between the dosage of Trazodone as well as its mechanism of action.  When administered at a low (or lower) dose, it tends to work remarkably well for eradicating insomnia.  Some speculate that this is due to its ability to target the H1 histaminergic receptor as an antagonist, reducing the effects of histamine, which leads to drowsiness.
  • Non-controlled substance: Due to the fact that most sleeping pills and other sleep-inducers are considered “controlled substances” is a cause for concern.  This means that they have the potential for abuse, dependence, tolerance, and/or addiction.  Trazodone is primarily an antidepressant and an entirely different mechanism of action, lessening its potential for dependence and making it easier to obtain.
  • Sleep enhancement: There are a vast number of anecdotal claims suggesting that when taking Trazodone, a person’s quality of sleep improves.  Even some of the most hardcore insomniacs have discovered that using Trazodone completely eliminates their insomnia and allows them to sleep without waking throughout the night.  They may wake up feeling rested, which then has a carryover on their mood and cognitive function.
  • Treat multiple conditions: The ideal usage of Trazodone is for the treatment of depression among individuals with comorbid insomnia.  Since the drug has a short half-life, it is typically administered in 3 separate doses throughout the day.  It is clinically effective as an antidepressant, and generally works well for insomnia.  Those that complain of both depression and insomnia may benefit significantly from this drug.

Drawbacks of Using Trazodone for Insomnia

Despite numerous anecdotal claims of Trazodone working well for insomnia, it is important to consider the fact that this is an “off-label” option, meaning it was never approved by the FDA specifically for insomnia.  In other words, it was never found to be effective in clinical trials to improve ability to sleep.

  • Drowsiness: While drowsiness may be ideal for inducing a transition from a state of wakefulness to sleepiness, this same drowsiness may be present upon waking.  Despite the short half-life of Trazodone, the drowsiness may persist throughout the following morning, afternoon, or entire day after taking it the previous night.  This drowsiness may make it dangerous to operate heavy machinery (e.g. drive a vehicle) and may impair cognitive function for work-related tasks.
  • Lack of scientific evidence: Some studies suggest that there remains insufficient scientific evidence to support the usage of Trazodone for insomnia.  Critics argue that since it was never approved specifically for insomnia, that other sleep-inducing agents (i.e. Z-drugs) should be used as a first-line treatment.  A 2005 review of evidence of Trazodone for insomnia suggested that there was an “absence of efficacy” to support this usage.
  • Memory impairment: The fact that Trazodone affects histamine as an antagonist means that it has potential to cause memory impairment when taken over the long-term.  Although the risk of memory impairment is likely considerably lower than that associated with benzodiazepines and sleeping pills, antihistamines may carry similar risks.  Despite no scientific publications suggesting memory problems from Trazodone, it is a possibility to consider.
  • Side effects: All medications that affect a person’s neurochemistry are going to carry side effects.  Some people won’t experience any major problems taking low doses of Trazodone, while others may feel overwhelmingly drowsy, experience muscle aches, diarrhea, nausea, or vomiting.  It is important for those taking Trazodone to weigh unwanted side effects with the drug’s efficacy.
  • Weight gain: There is some evidence that Trazodone causes weight gain.  Due to the sedating nature of the drug as well as action on serotonergic receptors, it may lead to a decreased metabolism, laziness, and increased cravings for carbohydrates.  Those that took a low dose of the drug for 6 weeks tend to gain an average of 1.2 lbs.  This little amount may not seem like much weight, but as dosing increases and/or a person keeps using the drug,
  • Withdrawal: It is known that there are an array of unpleasant effects associated with discontinuation of this drug.  Many people have reported significant Trazodone withdrawal symptoms, including a worsening of insomnia than they’ve ever experienced prior to taking the drug.  This means that during the withdrawal period, the symptoms that were being treated by the drug become even more debilitating than they were prior to initial administration.

Does the research justify using Trazodone for insomnia?

The scientific evidence is relatively mixed regarding Trazodone’s usage as a sleeping aid.  Early research from the late 1990s suggests that Trazodone is only slightly better than Fluoxetine (Prozac) for relieving insomnia among depressed individuals.  A publication in 2004 suggested that Trazodone had increased greatly in popularity as a hypnotic.

This publication suggested that there was minimal data to support the usage of Trazodone as a hypnotic agent, especially in non-depressed patients suffering from insomnia.  A study published a year later in 2005 stated that there were few studies analyzing Trazodone’s effect for treating insomnia.  Studies that existed were small and often only conducted among those suffering from major depression.

This study concluded that there is limited evidence to support using Trazodone for insomnia.  Furthermore, it suggested that side effects such as dizziness, sedation, and psychomotor impairment may be a cause for concern and may lead to discontinuation.  A newer Polish publication from 2010 suggests that Trazodone is effective for the treatment of insomnia.

The authors elaborated by stating that Trazodone acts quickly, efficiently, and safely with very few adverse reactions.  They considered it a “proven” option for those suffering from insomnia.  It seems as though the evidence remains a mixed bag in terms of treating Trazodone for insomnia; some researchers think it’s effective, while others suggest that it isn’t or lacks clinical evidence to support this usage.

Doctors seem to think it’s a fine medication for insomnia, and clearly has helped many individuals.  Many anecdotal reports indicate that the medication is effective for improving sleep quality, decreasing nightmares, and enhancing ability to fall asleep.  Due to a favorable side effect profile and ability to target depression, it may be a preferred drug for insomnia in some cases over traditional Z-drugs.

  • Source: http://www.ncbi.nlm.nih.gov/pubmed/9334895
  • Source: http://www.ncbi.nlm.nih.gov/pubmed/15291651
  • Source: http://www.ncbi.nlm.nih.gov/pubmed/15816789
  • Source: http://www.ncbi.nlm.nih.gov/pubmed/20642116

Risk-Benefit Ratio of Trazodone for Insomnia

If you are using Trazodone for the treatment of insomnia, it is important to analyze the risk-benefit ratio.  Those that have been taking the drug for awhile, but still aren’t able to fall asleep may want to try a more traditional hypnotic.  Individuals that find Trazodone effective for the treatment of insomnia will want to determine whether the drug is causing unwanted side effects.

Some people complain of psychomotor impairment, increased drowsiness, and weight gain.  These side effects may affect a person’s work performance, compromise their safety while operating heavy machinery, and may affect their self-esteem (should they gain weight).  With any pharmaceutical drug, it’s important to reflect upon whether it is treating the condition for which it was prescribed, and whether the side effects are tolerable.

You should also consider the fact that you may end up dealing with discontinuation symptoms should you ever stop taking the drug.  These symptoms may be pretty severe and difficult to cope with.  Some people report getting through them in several weeks, but others report protracted withdrawals spanning months.

Note: Withdrawal severity is generally influenced by dose as well as time span over which you took the drug; longer spans coupled with high dosages may result in more severe, protracted withdrawals.

Trazodone as a hypnotic: Short-term vs. Long-Term

If you’re using Trazodone to treat insomnia, it is important to consider the duration over which you plan on using it.  In other words, you must think about your potential “endgame” strategy with this drug.  Do you want to be on it for the rest of your life or do you plan on taking it just to get you through a few tough weeks of withdrawal from a different medication?

Those that are taking Trazodone for a long-term are more likely to end up with unwanted effects that make it even more difficult to function without the drug.  Unless a person has a type of insomnia that is idiopathic, the insomnia would be better treated with natural interventions that activate the parasympathetic nervous system and decrease sympathetic activation.  Examples of various natural treatments include: physical exercise early in the day, meditation, brainwave entrainment (to decrease beta waves and increase alpha waves), melatonin supplementation, etc.

Using Trazodone over the short term may be highly effective for insomnia, and minimize risk of long-term effects and tolerance.  Short-term treatment is generally administered with low doses (or the minimal effective dose), due to the fact that lower doses may work even better than higher ones for insomnia.

Trazodone vs. Other Sleeping Pills

It is important to consider the fact that traditional hypnotics are FDA approved specifically for the treatment of insomnia, and thus are thought to be more effective than Trazodone.  However, among insomnia sufferers that have had the experience of dabbling with both Z-drugs (nonbenzodiazepines) and Trazodone, some of them may prefer Trazodone over the Z-drugs or find them to be of equal efficacy.  The side effects that you experience with either drug may be subject greatly to individual variation.

Additionally even Z-drugs are thought to have discontinuation effects. (Read: Ambien withdrawal symptoms). Both Trazodone and Z-drugs have the potential to increase drowsiness, and result in tolerance.  However, Z-drugs are thought to have greater habit-forming potential, hence being considered “controlled-substances” – meaning it’s more difficult to obtain a prescription.

If you have personal concerns regarding Trazodone or other sleeping pills, be sure to talk to your doctor.  Medical professionals should be able to thoroughly explain the subtle differences between Trazodone and traditional hypnotics.  If you don’t respond well to hypnotics, you may respond well to Trazodone; vice-versa also applies.

Should you take Trazodone for insomnia?

If your insomnia is unbearably bad to the point that it’s affecting your performance, it may be time to consider a pharmaceutical agent like Trazodone.  It is important to understand first and foremost that Trazodone was never officially approved for insomnia by the FDA – its primary use is an antidepressant.  That said, it can be an effective option when used strategically over a short-term.

You should always make sure you’ve tried natural interventions to treat your insomnia before resorting to pharmaceuticals.  Natural strategies include: daily exercise (in the morning), avoiding caffeine after 10 AM, decreasing bright light in the evening, melatonin supplementation, and even relaxation techniques such as meditation or the emWave2.  Various other supplements such as valerian root or L-Tryptophan may also be beneficial.

If these strategies are all ineffective and you’ve given them a reasonable shot, short-term treatment with Trazodone or hypnotic may be prescribed by a doctor.  Ask your doctor about the pros and cons associated with each treatment to get a better understanding of which treatment sounds optimal for your individual circumstances.

Ideal scenario: Trazodone for depression with comorbid insomnia…

An ideal scenario for the usage of Trazodone to treat insomnia is among those who have been diagnosed with depression.  Trazodone is primarily used as an antidepressant, meaning it should help reduce depressive symptoms.  It has been approved by the FDA to treat depression and has substantial evidence proving its efficacy; this is a medically acceptable use.

If you have insomnia without depression, there’s insubstantial evidence to support using Trazodone.  Sleep experts are more likely to recommend a traditional hypnotic such as Ambien or Lunesta.  If you find these drugs to be too expensive, you may want to bring up Trazodone as a possibility and see how the professionals respond.  If they believe Trazodone is a viable option and will save you money, it is a treatment modality that may be considered.

Those that are already taking an antidepressant medication may want to inquire about possibly adding Trazodone as an augmentation strategy.  In some cases it cannot be added due to the potential for serotonin syndrome, but in other cases it may be an acceptable adjunct.  In other scenarios, a doctor or patient may even suggest transitioning from their current medication to Trazodone.

When taken specifically for depression, Trazodone is taken up to 3 times per day at varying doses.  When taken for insomnia, it is usually only taken once before bedtime at a low dose.  A doctor may need to work out some kinks with the dosing to determine how well the drug is working for depression and insomnia.  It should be considered that Trazodone may only effectively treat one condition (depression) and prove ineffective for the other (insomnia).

Have you used Trazodone for insomnia?

If you have personal experience taking Trazodone for insomnia, feel free to share how well it worked in the comments section below.  To help others get a better idea of your scenario, discuss your dosage such as whether you’re taking a low, moderate, or high dose.  Additionally you may want to add how Trazodone compares to other sleeping aids you’ve tried in the past, whether you’ve experienced any unwanted side effects while taking it, and how long you’ve been taking it.

  • Source: http://www.ncbi.nlm.nih.gov/pubmed/21220793
  • Source: http://www.ncbi.nlm.nih.gov/pubmed/15341891

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