What is the recommended usage and dosage of Trazodone (an antidepressant medication) for treating depression or insomnia?

Trazodone Usage and Dosage for Depression and Insomnia

Trazodone is not recommended as a first-line treatment for insomnia, but it can be used as a third-line option for depression at doses of 150-300 mg/day, or at lower doses (50 mg) for insomnia when other treatments have failed. 1

For Depression

Dosing and Administration

• Start with 150 mg/day divided into 2-3 doses, taken shortly after meals or light snacks 2
• Gradually increase to effective dose range of 150-300 mg/day for antidepressant effects 3, 4
• Once-daily formulation (Contramid) maintains effective blood levels for 24 hours while avoiding concentration peaks associated with side effects 3
• Take with food to reduce risk of dizziness and lightheadedness 2

Efficacy for Depression

• Comparable efficacy to other antidepressants for treating major depressive disorder 3, 4
• Particularly effective for depression with comorbid insomnia 5, 4
• Low incidence of weight gain and sexual dysfunction compared to other antidepressants 3
• Rapid onset of action for symptoms like insomnia and psychomotor agitation 4

For Insomnia

Position in Treatment Algorithm

1. First-line: Cognitive Behavioral Therapy for Insomnia (CBT-I) 1, 6

   • Most effective long-term treatment with no adverse effects
   • Multiple delivery formats available (individual, group, telehealth, internet-based)

2. Second-line: FDA-approved medications 1, 6

   • For sleep onset: zolpidem 10mg (5mg in elderly), eszopiclone 2-3mg, zaleplon 10mg, or ramelteon 8mg
   • For sleep maintenance: eszopiclone 2-3mg or suvorexant 10-20mg

3. Third-line: Sedating antidepressants 1

   • Trazodone (50mg), doxepin (3-6mg), mirtazapine, or amitriptyline
   • Note: The American Academy of Sleep Medicine specifically recommends against using trazodone for insomnia 1

Trazodone for Insomnia (When Used)

• Low dose of 50mg taken 30 minutes before bedtime 7, 8
• Improves sleep maintenance by reducing night-time awakenings and Stage 1 sleep 8
• Increases slow wave sleep with continued use (by day 7) 8
• May reduce daytime sleepiness with continued use 8

Side Effects and Cautions

Common Side Effects

• Somnolence, headache, dizziness, and dry mouth 3
• Morning-after cognitive and psychomotor impairments:
  • Short-term memory deficits
  • Verbal learning impairment
  • Balance problems (increased body sway)
  • Reduced muscle endurance 8

Serious Adverse Effects

• Orthostatic hypotension (especially in elderly or those with cardiovascular disease) 3
• QT interval prolongation and cardiac arrhythmias (rare) 2, 3
• Priapism (rare but serious) 3
• Risk of serotonin syndrome when combined with other serotonergic medications 2

Contraindications

• Do not use within 14 days of MAOIs 2
• Use with caution in patients with cardiovascular disease 3
• Use with caution in elderly patients (start with lower doses) 2

Monitoring and Follow-up

• Regular follow-up every few weeks during initial treatment 1
• Assess for effectiveness, side effects, and need for continued medication 1
• Use lowest effective maintenance dose and taper when conditions allow 1
• Monitor for emergence of suicidal thoughts, especially early in treatment and with dose changes 2

Important Considerations

• Trazodone at 50mg doses shows minimal efficacy for primary insomnia compared to placebo, with only small improvements in sleep latency (10 min) and wake after sleep onset (8 min) 1
• Despite limited evidence for efficacy, trazodone is commonly prescribed off-label for insomnia 7
• The cognitive and psychomotor impairments associated with trazodone may outweigh its modest benefits for insomnia 8
• For insomnia treatment, CBT-I should always be the first approach before considering any medication 6