What is the recommended dose of trazodone (antidepressant) for sleep after 100mg?

Trazodone Dosing for Insomnia After 100mg

For insomnia treatment, trazodone doses can be increased from 100mg to 150-200mg at bedtime if the initial 100mg dose is ineffective, with a mean effective dose of approximately 212mg/day reported in clinical studies. 1

Dosing Recommendations

• The American Academy of Sleep Medicine (AASM) generally recommends against using trazodone for insomnia treatment, based on studies showing limited efficacy at 50mg doses 1, 2
• However, when used for insomnia, clinical evidence suggests higher doses may be more effective, with a mean effective dose of 212mg/day reported in patients with PTSD-related sleep disturbances 1
• For sleep disorders with comorbid depression, trazodone at 100mg/day has shown better efficacy than 50mg/day when administered as a single dose before bedtime 3
• Trazodone can be dosed at 150mg given predominantly at bedtime and increased as needed to 200-300mg for full efficacy 4

Side Effect Considerations

• Common side effects at higher doses include:
  • Daytime sedation (most common) 4
  • Dizziness 1, 2
  • Dry mouth 5
  • Headache 1
• More serious but less common side effects include:
  • Priapism (reported in 5 subjects in one study) 1
  • Severe agitation 1
  • More vivid nightmares (paradoxical effect) 1

Administration Guidance

• Single nighttime dosing is preferred over divided doses as it:
  • Produces better sleep with less daytime drowsiness 4, 5
  • Results in fewer overall side effects 5
  • Shows equivalent therapeutic efficacy to divided dosing 5
• The NCCN Palliative Care guidelines list trazodone 25-100mg PO at bedtime as an option for insomnia 1

Important Caveats

• Trazodone's efficacy for insomnia is questionable according to the AASM, which gave it a "WEAK" recommendation against its use 1, 2
• Higher doses may improve efficacy but also increase side effect risk 1
• Tolerance to trazodone for sleep does not typically develop, unlike with benzodiazepines 4
• Abrupt discontinuation after long-term use may lead to increased drinking in patients with alcohol use disorder 6
• The 3-9 hour half-life of trazodone supports nighttime dosing 4

Alternative Options

• If trazodone is ineffective or poorly tolerated, the AASM recommends considering:
  • Doxepin 3-6mg for sleep maintenance insomnia 2
  • Zolpidem for both sleep onset and maintenance insomnia 2
  • Eszopiclone for both sleep onset and maintenance insomnia 2
  • Cognitive behavioral therapy for insomnia (CBT-I) as first-line treatment 2

When increasing from 100mg, a gradual titration (e.g., 25-50mg increments) is advisable to minimize side effects while finding the effective dose, with most patients responding to doses between 150-212mg.