Trazodone: Common sleep drug is little-known antidepressant

Consumer Reports (August 2015)
http://www.consumerreports.org/cro/2012/04/trazodone-common-sleep-drug-is-little-known-antidepressant/index.htm

What are the top prescribed drugs for insomnia—Ambien? Lunesta? Yes, but there's another: a three-decade-old generic antidepressant called trazodone, which causes drowsiness as a potentially useful side effect. A recent U.S. study in the journal Sleep found it to be one of most commonly used medications to treat sleeplessness.

Trazodone was first approved by the Food and Drug Administration in 1981 as an antidepressant. Though doctors can legally prescribe trazodone (and all drugs, for that matter), for any treatment, the drug is actually not approved to treat insomnia. Today, there's no branded form of trazodone—you can only get it as a generic—but there is a long-acting version available called Oleptro.

In a few studies, trazodone is reported to improve sleep during the first two weeks of treatment. But the drug has not been studied for longer than six weeks, so little is known about how well it works or its safety past that point. Also, an effective dose range has not been studied.

There's very little clinical trial evidence on whether it's effective as a sleep aid when a person does not have depression, and only modest evidence when there is. Treatment guidelines from the American Academy of Sleep Medicine recommend trazodone for chronic insomnia without depression only when drugs like Ambien and Lunesta have failed.

But numerous doctors are convinced, based mainly on their own experience, that trazodone is an appropriate sleep medication for many people, even when there's no depression. Here's why trazodone has become so popular—and what to do if your doctor suggests you try it.

Trazodone: Risks and benefits

While trazodone is rarely used to treat depression alone any more, it's widely prescribed, off-label, at lower doses for treating insomnia, for several likely reasons.

First, trazodone has one distinct advantage—and possibly a few others. It's generic, so it's considerably cheaper than many of the other widely prescribed sleep medications—about $3 for a week's supply. That's compared to other sleep drugs like generic zolpidem (Ambien), generic eszopiclone (Lunesta) or generic Sonata (zalepon) that run about $15 for a week's supply. And while some of the insomnia drugs are classified by the FDA as controlled substances that require doctors and pharmacists to take additional steps before they're prescribed or dispensed; trazodone is not a controlled substance, so doctors can prescribe it without those constraints.

In addition, many physicians apparently believe that trazodone is safer than other frequently prescribed sleep medications. But because there are not studies that actually show it is safer, whether or not that is true remains unknown.

It's true that the 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 still essentially unconscious. We could find no evidence to date of those problems having been reported with trazodone. Moreover, many doctors seem to believe that trazodone is less likely than even the newer sleep drugs to cause dependency and, when discontinued, renewed insomnia. Yet there's little evidence to prove or disprove those ideas.

And, trazodone has certain risks of its own. In particular, it's more likely than the newer sleep drugs, particularly the short-acting ones, to leave you feeling drowsy the next day, which increases the chance of accidents. It can also cause abnormally low blood pressure and, in turn, dizziness or even fainting, particularly in seniors.

Trazodone can also cause heart-rhythm disorders. It might possibly weaken the immune system. And some evidence suggests it can cause priapism, or persistent erection, a medical emergency that may require surgery and can lead to impotence if not treated promptly. Moreover, a black-box warning in the package insert notes that trazodone, like other antidepressants, can increase the risk of suicidal thoughts and behavior in children and adolescents.

Trazodone: Should you take it?

For the average person who has occasional brief bouts of insomnia, making certain changes to your lifestyle may help, including: avoiding big meals, alcohol, smoking and exercising late at night or working or watching TV in bed. (See sidebar for a full list.) If those don't work, our medical advisors recommend first trying an inexpensive over-the-counter drug containing an antihistamine such as diphenhydramine (Benadryl, Nytol, Sominex, and generic) or doxylamine (Unisom Nighttime Sleep-Aid and generic)—but only use those for a few nights.

If your insomnia last longer than a few nights and this continues for several weeks, you should see your doctor to determine if other conditions or drug side effects could be disturbing your sleep. If those are ruled out—or if your insomnia persists despite treatment of the underlying problem—nondrug sleep treatments such as cognitive behavioral therapy appear to yield better, more lasting results than medication. If possible, try that before resorting to medication, which can undermine your motivation to make the behavioral changes.

If your doctor recommends sleeping pills for more than a temporary bout of insomnia without mentioning nondrug therapy, you should mention it yourself. For more on such treatment, see our Best Buy Drug report on drugs to treat insomnia.

Of course, medication is sometimes needed for persistent insomnia—when nondrug treatment is refused, 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 drug trazodone to treat insomnia:

• Insomnia without depression. Because there's so little supporting evidence, sleep experts generally recommend trazodone for insomnia only after the newer sleep drugs have failed. Trazodone may improve sleep initially, as found in one small study, but that effect could fade after several weeks. Researchers theorize that this could be due to residual sleepiness in the daytime, so a person is less physically active , which may contribute to the ability to sleep well at night.
• Insomnia with depression. Some conditions, such as depression, have a complex and intertwined relationship with insomnia, and the best treatment for these two issues together has not been determined. If you have both, discuss the options with your doctor, based on 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 the 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.

Although trazodone may improve sleep at first, the effect may not continue past several weeks. Taking trazodone may also worsen sleepiness during the daytime, and morning grogginess. Plus, the side effect of sedation may not actually improve depression or insomnia.

Precautions to take

• Because trazodone may not work well to treat insomnia after a few weeks, check in with your doctor periodically to discuss how or if 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 over age 55 or so since they're more susceptible to falls caused by dizziness or drowsiness and to abnormal heart rhythms. 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.

Poor sleep habits and how to correct them

 

Watching TV in bed	Don't. TV viewing is not conducive to calming down.
Computer work in bed	Don't work on a computer at all for at least an hour before going to bed.
Drinking alcoholic or caffeinated drinks at night	Don't drink either for at least 3 hours before going to bed.
Taking medicines late at night	Many prescription and nonprescription medicines can delay or disrupt sleep. If you take any on a regular basis, check with your doctor about this.
Big meals late at night	Not ideal especially if you are prone to indigestion or heartburn. Allow at least 3 hours between dinner and going to bed.
Smoking at night	Don't smoke for at least 3 hours before going to bed. (Better yet: quit!)
Lack of exercise	Just do it! Regular exercise promotes healthy sleep.
Exercise late at night	A no-no. Allow at least 4 hours between exercise and going to bed. It revs up your metabolism, making falling asleep harder.
Busy or stressful activities late at night	Another no-no. Stop working or doing strenuous house work at least 2 hours before going to bed. The best preparation for a good night's rest is unwinding and relaxing.
Varying bedtimes	Going to sleep at widely varying bed times -- 10:00 p.m. one night and 1:00 a.m. the next -- disrupts optimal sleep. The best practice is to go to sleep at around the same time every night, even on the weekends
Varying wake-up times	Likewise, the best practice is to wake up around the same time every day (with not more than an hour's difference on the weekends).
Spending too much time in bed, tossing and turning	Solving insomnia by spending too much time in bed is usually counter-productive; you'll become only more frustrated. Don't stay in bed if you are awake, tossing and turning. Get up and do something else until you are ready to go to sleep.
Late day napping	Naps can be wonderful but should not be taken after 3:00 pm. This can disrupt your ability to get to sleep at night.
Poor sleep environment	Noisy, too hot, uncomfortable bed, not dark enough, not the right covers or pillow -- all these can prevent a good night's sleep. Solve these problems if you have them.

Editor's Note: 

This article and related materials are made possible by a grant from the state Attorney General Consumer and Prescriber Education Grant Program, which is funded by the multistate settlement of consumer-fraud claims regarding the marketing of the prescription drug Neurontin (gabapentin).