What is the maximum recommended dose of trazodone (antidepressant) for insomnia (sleep disorder)?

Maximum Trazodone Dosage for Insomnia

The maximum recommended dose of trazodone for insomnia is 200 mg per day, with most patients responding to 50-100 mg taken as a single dose at bedtime. While the FDA-approved maximum dose for depression is 400 mg/day for outpatients and 600 mg/day for inpatients 1, lower doses are typically effective and safer for insomnia treatment.

Evidence-Based Dosing Recommendations

Initial Dosing

• Start with 25-50 mg taken 30 minutes before bedtime
• Titrate gradually based on response and tolerability
• Most patients with insomnia respond to 50-100 mg 2

Maximum Dosing

• For insomnia treatment: Maximum 200 mg daily 3
• Higher doses (>200 mg) are generally reserved for depression treatment rather than insomnia

Efficacy and Safety Considerations

Efficacy

• Trazodone at 50-100 mg has been shown to improve sleep disorders, particularly at the 100 mg/day dosage 2
• However, the American Academy of Sleep Medicine suggests that clinicians not use trazodone for sleep onset or maintenance insomnia (based on trials of 50 mg doses) 3

Safety Concerns

• Dose-dependent side effects include:
  • Daytime sedation and drowsiness
  • Dizziness
  • Cognitive and psychomotor impairments 4
  • Orthostatic hypotension
  • Priapism (rare but serious)

Clinical Decision Algorithm

1. First-line approach: Consider non-trazodone options

   • The American Academy of Sleep Medicine recommends cognitive behavioral therapy for insomnia (CBT-I) as first-line treatment 5
   • If medication is needed, consider FDA-approved sleep medications before trazodone

2. If using trazodone for insomnia:

   • Start at 25-50 mg taken 30 minutes before bedtime
   • Assess response after 3-7 days
   • If needed, increase by 25-50 mg increments every 3-4 days
   • Do not exceed 200 mg for insomnia treatment
   • Take shortly after a meal or light snack to improve absorption 1

3. Monitoring:

   • Assess for morning drowsiness, cognitive impairment, and dizziness
   • Evaluate sleep quality improvement
   • Consider discontinuation if side effects outweigh benefits

Important Considerations

Advantages of Trazodone

• Single nighttime dosing improves sleep with less daytime drowsiness compared to multiple daily dosing 6, 7
• No tolerance development or rebound insomnia upon discontinuation 6
• Lower abuse potential compared to benzodiazepines

Cautions and Contraindications

• Use with caution in elderly patients (consider lower starting doses)
• Avoid abrupt discontinuation; gradually taper to prevent withdrawal symptoms 1
• Screen for bipolar disorder before initiating treatment 1
• Allow 14-day washout period when switching to/from MAOIs 1

Drug Interactions

• Reduce dose when used with strong CYP3A4 inhibitors
• Consider dose increase when used with strong CYP3A4 inducers 1

Despite its common off-label use for insomnia, evidence suggests trazodone may impair cognitive and motor function 4 and the American Academy of Sleep Medicine does not recommend its use for primary insomnia 3. When prescribed for sleep, the maximum dose should not exceed 200 mg daily, with most patients responding to 50-100 mg.