Trending: trazodone for insomnia. Is that OK? Are women more at risk for side effects?

Get into happy hour conversations in a 55+ community (Gen X, Boomer, and Builder generations) and you’re likely to find there’s more trazodone in the bathroom than white sugar in the kitchen.

[A longer piece, but important not only if you’re taking trazodone, but for women to understand why we know so little about women’s medication reactions and health in general.]

Trazodone prescriptions for insomnia are increasing, as a systematic review¹ noted even back in 2017: “While trazodone is approved for the treatment of depression, the off-label use of this medication for insomnia has surpassed its usage as an antidepressant.” That study and others indicate trazodone is safe in low doses for treatment of insomnia and believed to be safer than drugs like Ambien (zolpidem). Trazodone prescriptions picked up substantially after 2017 following reports on zolpidem dangers. [Click for a comparison of zolpidem and trazodone.]

Middle age and older adults—45% of the population—are 50% more likely to say poor sleep quality is interfering with daily function, so a safe medication can literally sound life- or career-saving. And for risk-adverse² clinicians looking for safe ways to improve the sleep and lives of patients, findings like that are reassuring. Trazodone is generic, so inexpensive—often a $0 co-pay. Compare that to monthly copays ranging from $75 for branded drugs to more than $200 for drugs like the wildly popular obesity meds.

And trazodone can be a medical double or triple homer. It’s an antidepressant originally developed to treat depression—common with aging—and to treat anxiety. An American Psychiatric Association poll found 43% of adults say they’re more anxious in 2024 than 2023, citing the economy, the election, and gun violence. Trazodone dosage can start at 25 mg but happy hour chatter suggests 100 mg is frequently in play for insomnia, and one large study says dosages up to 150 mg are common for insomnia.³

At Women Untamed, science is our north star. But drugs can ‘trend’ like anything else, with more people suddenly saying they’re on it. And research says women are generally likely to have 50% to 70% more adverse drug reactions (ADR) than men; see more below.

Should we worry that trazodone is ‘trending?’

Baby aspirin is a great example of ‘prescription trending.’ Not long ago, it was an “everyone should take it” recommendation. Now it’s recommended only for specific individuals. Statin enthusiasm to treat ever-lower cholesterol levels has also become more cautious. Right now we’re in the ‘enthusiasm phase’ about the GLP-1 drugs, which had a 40-fold increase in use just between 2017 and 2021, back before most of us ever heard the word “Ozempic.” It’s likely that will be tempered by finding more side effects as well. It’s a predictable cycle, although it can take years or decades for the entire cycle. As always, it’s a matter of balance: do the good effects outweigh the bad?

And once a medication has been started, it’s often harder to get it discontinued. [Here’s a good guide on when and how to do that.]

Providers don’t glibly recommend drugs. They depend on current science and best practices. But when any medication enters widespread use, we find out more about side effects than preliminary studies—even big ones—can uncover. Then, science and recommendations should reflect new information, and change; it’s not that the original studies were wrong. We know more in the fifth grade than we did in the first, but that knowledge built on what we learned in the first grade.

It’s important to remember that using trazodone for sleep is “off-label,” meaning the FDA originally approved it for a different use, not sleep; approval is a lengthy process. The original approved use was for treatment of depression, and the studies leading to approval were based on that use, done predominantly with psychiatric patients, including hospitalized dementia patients, where the positive benefits may have been more important than side effects that may more to someone who is not significantly depressed or doesn’t have dementia.

What do we know about side effects? Why might it be riskier for women? Or men?

No medication is without side effects, and effects can get multiplied when combined with other drugs or medical problems or just aging. Since most of the research was based on use for depression, it’s likely we do not yet have enough data on trazodone in healthy older populations to completely understand the potential for problems when used primarily for sleep.

And the risk particularly to women is likely both unknown and greater. It wasn’t until 2001 that the Institute of Medicine “validated” the science of sex differences”⁴ in medical research, and then they only recommended changes in research. It took about a decade before medical research did a good job including and identifying female findings separately from men’s. By 2020, research identified that, generally, “women experience ADRs [adverse drug reactions] nearly twice as often as men” and that “most drugs currently in use were approved based on clinical trials conducted on men, so women may be overmedicated.” That applies to trazodone: most of the (predominantly psych) research on trazodone safety was done before 2010. Add that onto the information below plus as our general knowledge that medications are always riskier in older populations (health problems and on other medications). All that adds up to a even greater potential for side effects in 55+ women. Here’s more:

• Even without trazodone, about half of women (and 20% of men) over 65 experience urinary incontinence at some point to the point of frequent memes. In the psych studies, a side effect of incontinence was found so rarely (<1%) it isn’t even in this side effect list. But if you talk to women on trazodone, some say they’re getting up as often as every 90 minutes at night to urinate, actually getting worse sleep. Bottom line: they may be more likely to report continence issues than a dementia patient.

• Trazodone is broken down in the liver, and everything from aging to disease, alcohol, and even grapefruit juice or St. John’s Wort can interfere with liver metabolism, leaving unmetabolized trazodone in your body longer than the clinical average 5 to 13 hour half-life of trazodone.⁵

  • Women metabolize drugs through the liver as much as 40% differently than men, meaning we may experience side effects more often or at lower dosages. If you feel groggy, for instance, don’t discount it. Be cautious. It wasn’t until several deadly car accidents involving people on zolpidem generated studies of that side effect, more than 20 years after zolpidem went on the market for insomnia. That was the start of the switch from zolpidem to trazodone, only about seven years ago. There is some promise that AI could shorten discovery phase like that.

• For men, there are concerns about priapism, a painful, long-lasting erection that can be an emergency. This new study notes trazodone has the “highest associated risk with ischaemic priapism of all drugs.” Read here about prescreening for priapism for men, and see more on sexual side effects of trazodone here.

• Drug interactions are already the most common reason older populations are seven times more likely to be admitted to the hospital after an ED visit. That leads to a real issue in older populations—casual use with alcohol. Side effects of combining antidepressants like trazodone with alcohol are well-known and dangerous. That’s important because we know drinking is more common in older adults, particularly among 75 to 85 year-olds identified in studies as drinking significantly more than younger populations. The 150,000+ population of The Villages in Florida, a 55+ community, is so well-known for partying that they’ve been the subject of several studies. In one study, 15.4% of The Village residents reported what is categorized as “hazardous drinking.” That’s 50% higher than the general population of older adults, and alcohol addiction there is a recognized serious problem.

Are there specific research warnings about using trazodone for sleep?

There are some warnings about using trazodone as the first-line approach for insomnia. One publication reviewed existing research and included opinions of experts in the field; they were hesitant to recommend trazodone as a primary treatment for insomnia. A scientific sleep journal published guidelines saying the argument for using trazodone for sleep is weak; unfortunately, they didn’t recommend anything else, either. Another, a meta-analysis⁶ of multiple studies, firmly states “Trazodone should not be used to treat insomnia,” finding that people feel it improves sleep but an actual review of sleep data says it doesn’t. More research studies on use in normal, daily life will come; we just don’t have many yet on the use of trazodone for sleep.

So, what do we do in the meantime?

None of the above means you should not take it if you need it. But until more data comes in, if you’re taking trazodone, pay attention to how it affects you. Are you groggier during the day? Feeling spacey while driving? Be really careful if you are; that’s what finally tipped off researchers on the dangers of zolpidem, 20+ years after it came into use. We couldn’t find any studies yet on driving safety after trazodone use.

If you’re on meds to lower your blood pressure, trazodone can lower it too much. Blurred vision? New headaches? Irregular heartbeat? Are you getting up more often at night to urinate and dribbling on the way to the bathroom? Is low sex drive or priapism a new issue? Talk about it with your provider. Just as with any treatment, you’ll need to evaluate whether the benefits of trazodone outweigh the side effects. Minor side effects may not matter if you’re getting better sleep. Major ones should be addressed quickly with your provider.

Also take a look at this recent post with tips and tech to improve sleep. While Boomers have long embraced a motto of “BLTC”—better living through chemistry—new information and innovative tech devices are showing up now that sleep issues are better recognized and occurring more frequently in our aging population. Figuring out the extent of the problem is no longer relegated only to an awkward sleep study or a life sentence to bulky CPAP machines.

Even if you’re told a side effect is rare—“so it’s probably not trazodone”—keep alert. If you’re a woman, keep all of the above about higher adverse effects in mind. Busy, understaffed providers can’t begin to keep up with the daily flood of new studies on multiple diseases and medications. It’s easy for us in healthcare to refer to other specialists for problems like incontinence or an irregular heartbeat. Consider talking with your provider about decreasing or stopping trazodone first to see if the side effect goes away, before you start seeing other specialists for something that might be related to trazodone. Trazodone is believed to be non-addictive, but there could be withdrawal symptoms, so don’t decrease or stop it without talking to your provider first.

On the use of trazodone for sleep, there aren’t many large studies yet on everyday life, and history says we won’t know all the side effects until a lot more people are using it for sleep and researchers spot data trends. We’re all contributing to medical science every day, like it or not; nothing in life is guaranteed to be 100% safe. In the meantime, current research indicates it’s safer for sleep than other meds like zolpidem.

This webpage is for informational purposes only and does not constitute medical advice or diagnosis. Consult a licensed clinician for medical advice applicable to your specific needs.

1. A systematic review in medical literature is a comprehensive analysis of all available research studies on a specific medical topic. Read more here.

2. Click here for a good overview of how the threat of malpractice influences healthcare decision-making and adds to our high overall healthcare costs. “In the U.S., total legal costs in the medical liability system are estimated to be roughly $10 billion annually. Approximately 57 percent of this spending goes to administration and overhead rather than patients.”

3. Most studies on Trazodone dosage are for psychiatric use; so far, we have less information on optimal doses for sleep, particularly in older populations and with the concomitant use of other drugs like alcohol. In psychiatry, doses range from 75 mg to 300 mg and sometimes higher. For more on dosages for sleep, click here.

4. Really. Don’t get us started. Short version: before 2001, most research had been done only on men, and if women were included (usually in smaller numbers than men), findings were not identified by sex. It’s the “women are just smaller men” theory prevalent in everything from office furniture and car designs to healthcare. (You may have noticed that is not real life.) Even after the Institutes of Medicine finally flagged the issue in 2001 and recommended a different approach, it took a while for already funded and approved studies to incorporate that recommended. Bottom line: most of the medical research done before ~2010 was on men, but the findings were applied to everyone. For the full, sorry story, see “Why we know so little about women’s health” from the Association of American Medical Colleges.

5. Half-life of a drug is the time it takes for the amount of the drug’s active substance in your body to reduce by half. Trazodone’s average half-life is 5 to 13 hours, which is why some talk about sleeping less deeply 5 to 6 hours after taking it.

6. Meta-analysis goes further than systematic reviews by including statistical analysis of objective data.