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

Trazodone Dosing for Insomnia

For insomnia treatment, trazodone should be used at low doses of 25-50 mg taken before bedtime, which is significantly lower than the antidepressant dosing range, although the American Academy of Sleep Medicine recommends against using trazodone for insomnia due to limited efficacy. 1

Recommended Dosing

• Trazodone is commonly used off-label for insomnia at doses much lower than those used for depression 1, 2
• When used for insomnia, doses typically range from 25-50 mg taken at bedtime 1, 2
• The FDA-approved dosing for depression starts at 150 mg/day in divided doses, which is much higher than the doses used for insomnia 3
• Clinical studies have specifically evaluated the 50 mg dose for insomnia, showing only modest improvements in sleep parameters compared to placebo 1, 4

Efficacy and Evidence

• The American Academy of Sleep Medicine explicitly recommends against using trazodone for sleep onset or sleep maintenance insomnia in adults 1
• Clinical trials showed that trazodone 50 mg produced only modest improvements in sleep parameters and no improvement in subjective sleep quality 1
• A systematic review found that low-dose trazodone may have some efficacy for treating primary insomnia as well as secondary insomnia 2
• One study found that trazodone at 50-100 mg/day improved sleep disorders, with better results at the 100 mg dose 4

Administration Recommendations

• Trazodone should be taken shortly after a meal or light snack according to the FDA label 3
• For insomnia treatment, the medication should be administered at bedtime to maximize sleep benefits and minimize daytime drowsiness 5
• The half-life of trazodone (3-9 hours) supports a bedtime dosing strategy 5

Side Effects and Precautions

• The most common side effect of trazodone is drowsiness, which is dose-dependent 2
• Other potential side effects include dizziness and psychomotor impairment, which are particularly concerning for elderly patients 1
• More serious side effects can include priapism, which has led to treatment discontinuation in clinical studies 1
• Elderly patients may require lower doses due to increased sensitivity to side effects 6

Preferred Alternatives for Insomnia

• The American Academy of Sleep Medicine recommends cognitive behavioral therapy for insomnia (CBT-I) as first-line treatment 1
• FDA-approved medications recommended over trazodone include 1, 6:
  • Eszopiclone (2-3 mg) for both sleep onset and maintenance insomnia
  • Zolpidem (10 mg) for both sleep onset and maintenance insomnia
  • Zaleplon (10 mg) for sleep onset insomnia
  • Ramelteon (8 mg) for sleep onset insomnia
  • Doxepin (3-6 mg) for sleep maintenance insomnia
  • Suvorexant (10-20 mg) for sleep maintenance insomnia

Important Clinical Considerations

• Trazodone should be considered a third-line agent for insomnia treatment, after CBT-I and FDA-approved sleep medications 1
• Trazodone may be more appropriate when comorbid depression is present 1
• If used, trazodone should be prescribed at the lowest effective dose and for the shortest possible duration 1
• Regular follow-up is essential to assess medication effectiveness, side effects, and the ongoing need for treatment 1

Discontinuation

• Trazodone should be gradually reduced rather than stopped abruptly to minimize discontinuation symptoms 3
• Unlike benzodiazepines, trazodone does not appear to cause rebound insomnia or tolerance when discontinued 5