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

Trazodone Dosage for Insomnia

For insomnia, trazodone should be used at a dose of 25-100 mg taken at bedtime, with 50 mg being the most commonly studied and recommended starting dose. 1

Evidence-Based Dosing Recommendations

• The American Academy of Sleep Medicine (AASM) clinical practice guidelines evaluated trazodone at 50 mg for insomnia, finding modest but clinically insignificant improvements in sleep parameters 1
• In palliative care settings, trazodone is recommended at 25-100 mg at bedtime for insomnia 1
• Low-dose trazodone (50-100 mg) has been shown to improve sleep disorders, with 100 mg providing better efficacy than 50 mg in some studies 2
• For elderly or debilitated patients, starting at a lower dose (25 mg) is recommended due to increased sensitivity to side effects 1

Efficacy Considerations

• The AASM does not recommend trazodone as a first-line treatment for either sleep onset or sleep maintenance insomnia, as clinical trials showed only modest improvements that did not reach clinical significance thresholds 1
• In the single study that met inclusion criteria for AASM guidelines, trazodone 50 mg reduced sleep latency by only 10 minutes and wake after sleep onset by only 8 minutes compared to placebo 1
• The VA/DoD clinical practice guidelines also advise against trazodone for chronic insomnia disorder, noting that its limited efficacy is outweighed by its adverse effect profile 1
• Despite these recommendations, trazodone remains one of the most commonly prescribed off-label medications for insomnia 3

Safety and Side Effects

• The most common side effect of trazodone is drowsiness, which can be beneficial for sleep but may cause daytime sedation 4, 5
• Other potential side effects include:
  • Cognitive and psychomotor impairments (short-term memory, verbal learning, equilibrium) 5
  • Dry mouth, headache, and dizziness 6
  • Priapism (rare but serious) 1
• Side effects are dose-dependent, with higher doses associated with more adverse effects 3
• Single nighttime dosing may result in fewer side effects compared to divided daily dosing 6

Administration Recommendations

• Administer trazodone shortly after a meal or light snack to reduce gastrointestinal side effects 7
• For insomnia, the entire dose should be given 30 minutes before bedtime 5
• The tablet can be swallowed whole or broken along the score line if needed 7
• Allow for adequate sleep time (7-8 hours) after taking trazodone to minimize morning drowsiness 5

Clinical Pearls and Caveats

• While trazodone is FDA-approved for depression (at doses of 150-600 mg/day), its use for insomnia is off-label at the lower doses of 25-100 mg 7, 3
• Tolerance to the sedative effects does not appear to develop with continued use, unlike with benzodiazepines or antihistamines 4
• When discontinuing trazodone, gradual dose reduction is recommended to minimize withdrawal symptoms 7
• Trazodone may be particularly useful when insomnia is accompanied by depression, though low doses used for insomnia are not adequate for treating major depression 1
• Screen for bipolar disorder before initiating trazodone, as it may trigger mania in susceptible individuals 7