What is the recommended dosing for trazodone (antidepressant) for depression and insomnia?

Trazodone Dosing for Depression and Insomnia

For depression, trazodone should be initiated at 150 mg/day in divided doses and gradually increased to 300 mg/day, while for insomnia as a primary indication, a lower dose of 25-100 mg at bedtime is recommended. 1, 2

Dosing for Depression

Initial Dosing and Titration

• Start with 150 mg/day in divided doses 1
• Increase gradually by 50 mg/day every 3-4 days based on clinical response and tolerance 1
• Maximum outpatient dose is typically 400 mg/day in divided doses 1
• For more severely depressed inpatients, doses up to 600 mg/day may be used 1

Administration Recommendations

• Take shortly after a meal or light snack to improve absorption 1
• Can be swallowed whole or administered as a half tablet by breaking along the score line 1
• Consider administering a major portion of the daily dose at bedtime if drowsiness occurs 1, 3
• Single nighttime dosing (150-300 mg) has shown equal efficacy to multiple daily dosing for depression with improved sleep and less daytime drowsiness 3

Dosing for Insomnia

When Used Primarily for Insomnia

• Initial dosage: 25 mg per day at bedtime 2
• Effective dose range: 25-100 mg at bedtime 4, 5
• Maximum: 200-400 mg per day in divided doses if needed 2

Important Considerations

• Lower doses (50-100 mg) have been confirmed effective for sleep disorders, with 100 mg showing particular efficacy 5
• The American Academy of Sleep Medicine suggests against using trazodone for primary insomnia based on trials of 50 mg doses 2
• However, when insomnia is secondary to depression, trazodone can effectively address both conditions 6

Special Populations

Elderly Patients

• Lower starting doses are recommended due to increased risk of side effects 2
• Careful monitoring for orthostatic hypotension is advised, especially in those with cardiovascular disease 7

Patients with Hepatic Impairment

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

Safety Considerations

Common Side Effects

• Drowsiness (most common) 3, 4
• Headache, dizziness, and dry mouth 7
• Side effects are dose-dependent 4

Precautions

• Use with caution in patients with premature ventricular contractions 2
• Screen for bipolar disorder before initiating treatment 1
• Minimal anticholinergic activity but may cause orthostatic hypotension, QT interval prolongation, and rarely priapism 7
• Allow at least 14 days between discontinuation of MAOIs and initiation of trazodone 1

Discontinuation

• Gradually reduce the dosage rather than stopping abruptly to minimize withdrawal symptoms 1
• Tapering over 10-14 days limits withdrawal symptoms 2

Advantages of Trazodone

• Low risk of anticholinergic side effects, weight gain, and sexual dysfunction compared to other antidepressants 6
• Particularly helpful for patients with depression and comorbid insomnia 6
• Safe in overdose compared to many other antidepressants 3
• No tolerance development or REM rebound on discontinuation 3