What is the recommended dose of trazodone (antidepressant) for treating insomnia?

Recommended Dose of Trazodone for Insomnia

Trazodone is not recommended for the treatment of insomnia at any dose, as clinical evidence does not support its efficacy for sleep onset or sleep maintenance insomnia in adults. 1

Evidence Against Trazodone for Insomnia

The American Academy of Sleep Medicine (AASM) explicitly recommends against using trazodone for insomnia in their clinical practice guideline:

• A single study of trazodone 50mg showed no clinically significant improvements in:

  • Sleep latency (reduced by only 10.2 minutes)
  • Total sleep time (increased by only 21.8 minutes)
  • Wake after sleep onset (reduced by only 7.7 minutes)
  • Quality of sleep (non-significant improvement)
  • Number of awakenings (reduced by only 0.4 awakenings) 1

• The AASM concluded that none of these improvements reached the threshold for clinical significance, while 75% of trazodone subjects reported adverse events (compared to 65.4% with placebo) 1

• Common side effects included headache (30% vs 19% with placebo) and somnolence (23% vs 8% with placebo) 1

Alternative Recommended Medications for Insomnia

The AASM and other guidelines recommend several FDA-approved alternatives for insomnia:

• For sleep onset insomnia:

  • Zolpidem (10mg adults, 5mg elderly)
  • Zaleplon (10mg)
  • Ramelteon (8mg) 2

• For sleep maintenance insomnia:

  • Doxepin (3-6mg)
  • Eszopiclone (2-3mg)
  • Suvorexant (10-20mg) 2

Important Clinical Context

Despite the lack of recommendation in guidelines, trazodone is frequently prescribed off-label for insomnia. If a clinician still decides to use trazodone for this purpose (against guideline recommendations):

• Low doses of 25-50mg are typically used for insomnia, much lower than the antidepressant dosing range (150-600mg) 3, 4

• Trazodone should be administered 30-60 minutes before bedtime 2

• Trazodone may be more effective for sleep maintenance than sleep onset insomnia 5

• Elderly patients should receive lower doses (25mg) due to increased sensitivity to side effects 2

First-Line Treatment Recommendation

It's important to note that non-pharmacological interventions, specifically Cognitive Behavioral Therapy for Insomnia (CBT-I), are recommended as first-line treatment for chronic insomnia by both the American College of Physicians and the American Academy of Sleep Medicine 2.

Caution and Monitoring

If trazodone is used despite guideline recommendations against it:

• Monitor for common side effects including drowsiness, dizziness, and headache
• Be aware of rare but serious side effects including priapism in men
• Follow up within 2-4 weeks to assess effectiveness and side effects 2
• Consider gradual tapering when discontinuing to avoid withdrawal symptoms 2