What is the recommended dose of Trazodone (antidepressant medication) for adults?

Trazodone Dosing for Adults

For Depression (FDA-Approved Indication)

The FDA-approved starting dose of trazodone for depression is 150 mg/day in divided doses, which can be increased by 50 mg/day every 3-4 days, with outpatient maximum doses typically not exceeding 400 mg/day and inpatient doses up to 600 mg/day. 1

Initial Dosing Strategy

• Start at 150 mg/day in divided doses, taken shortly after a meal or light snack 1
• Increase by 50 mg/day every 3-4 days based on clinical response and tolerability 1
• If drowsiness occurs, administer the major portion of the daily dose at bedtime or reduce the total dose 1

Maximum Doses

• Outpatients: Usually should not exceed 400 mg/day in divided doses 1
• Inpatients (more severely depressed): May receive up to 600 mg/day in divided doses 1
• Elderly patients: Maximum tolerated doses are 300-400 mg/day 2

Single Bedtime Dosing Option

• For antidepressant efficacy, trazodone is best dosed at 150 mg given predominantly at bedtime and increased as needed to 200-300 mg for full antidepressant effect 3
• Single nighttime dosing shows equal efficacy to multiple daily dosing for depression, with the advantage of improved sleep and less daytime drowsiness at treatment onset 3
• The 3-9 hour half-life of trazodone supports bedtime-weighted dosing 3

For Insomnia (Off-Label Use - NOT Recommended)

The American Academy of Sleep Medicine explicitly recommends AGAINST using trazodone for either sleep onset or sleep maintenance insomnia, as the studied dose of 50 mg showed no clinically significant benefit. 4, 5

Why Trazodone Is Not Recommended for Insomnia

• At 50 mg, trazodone reduced sleep latency by only 10.2 minutes (below clinical significance threshold) 4, 5
• Total sleep time increased by only 21.8 minutes (clinically insignificant) 4, 5
• Wake after sleep onset reduced by only 7.7 minutes (below threshold) 4, 5
• Sleep quality showed no significant improvement versus placebo 4, 5
• Harms potentially outweigh benefits: 75% of subjects experienced adverse events versus 65.4% on placebo, with headache (30% vs 19%) and somnolence (23% vs 8%) being most common 4

If Used Despite Recommendations

• The only studied dose for insomnia is 50 mg at bedtime 4
• Some studies in depression with comorbid insomnia used 50-100 mg at bedtime, with 100 mg showing better efficacy 6

For Nightmares in PTSD (Off-Label Use)

• A retrospective study found a mean effective dose of 212 mg/day for reducing nightmare frequency in PTSD patients 4
• However, 60% experienced side effects (particularly daytime sedation or dizziness), and 19% discontinued due to intolerable adverse effects including priapism (5 patients) 4

Important Safety Considerations

Drug Interactions

• With strong CYP3A4 inhibitors: Consider reducing trazodone dose based on tolerability 1
• With strong CYP3A4 inducers: Consider increasing trazodone dose based on therapeutic response 1
• MAOIs: At least 14 days must elapse between discontinuing an MAOI and starting trazodone, and vice versa 1

Discontinuation

• Gradually reduce the dosage rather than stopping abruptly to minimize adverse reactions upon discontinuation 1

Special Populations

• Elderly patients: Use caution due to increased risk of orthostatic hypotension, falls, and daytime drowsiness 5
• Maximum tolerated doses in elderly are typically 300-400 mg/day compared to 600 mg/day in younger patients 2

Screening Requirements

• Screen patients for personal or family history of bipolar disorder, mania, or hypomania before initiating treatment 1

Clinical Context

While trazodone is widely prescribed off-label for insomnia at low doses (25-100 mg), this practice lacks strong evidence support and contradicts current American Academy of Sleep Medicine guidelines 4, 5. The medication may be more appropriate as a third-line agent when comorbid depression is present, though low doses used for insomnia do not constitute adequate treatment for major depression 5.