What is the appropriate dosage and usage of trazodone (antidepressant) for treating insomnia?

Trazodone Should Not Be Used for Insomnia Treatment

The American Academy of Sleep Medicine explicitly recommends against using trazodone for sleep onset or sleep maintenance insomnia in adults, as the modest benefits do not outweigh the potential harms. 1

Why Trazodone Is Not Recommended

Lack of Efficacy

• Clinical trials of trazodone 50 mg showed only modest improvements in objective sleep parameters compared to placebo, with no improvement in subjective sleep quality 1
• The VA/DOD guidelines found no differences in sleep efficiency between trazodone (50-150 mg) and placebo in patients with chronic insomnia 1
• Trazodone reduces sleep latency by only 10 minutes compared to placebo 2
• While trazodone showed fewer nighttime awakenings and reduced Stage 1 sleep, these benefits are minimal 3

Significant Adverse Effects

• Daytime drowsiness, dizziness, and psychomotor impairment are particularly concerning, especially in elderly patients 1
• Trazodone causes small but significant impairments in short-term memory, verbal learning, equilibrium, and arm muscle endurance 3
• Priapism is a serious concern, with rates as high as 12% reported in some studies, leading to treatment discontinuation 1, 4
• High discontinuation rates due to sedation and psychomotor impairment raise particular concerns for elderly patients 5

Dosing Considerations

• Lower doses (25 mg) have not been systematically studied and would likely provide even less benefit than the already insufficient effects at 50 mg 1
• The FDA-approved dosing for depression starts at 150 mg/day in divided doses, far exceeding the 25-50 mg typically used off-label for insomnia 6
• When used for insomnia, doses are below the therapeutic antidepressant range 1

Recommended Treatment Algorithm

First-Line Treatment

• Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the initial treatment for chronic insomnia, including stimulus control therapy, sleep restriction therapy, and relaxation therapy 1

Second-Line Pharmacological Options (If CBT-I Fails)

For sleep onset insomnia:

• Zolpidem 10 mg 1, 2
• Zaleplon 10 mg 1, 2
• Triazolam 0.25 mg 2
• Temazepam 15 mg 2
• Ramelteon 8 mg 1, 7

For sleep maintenance insomnia:

• Zolpidem 10 mg 1, 2
• Eszopiclone 2-3 mg 1, 7
• Suvorexant 10-20 mg 1, 7
• Doxepin 3-6 mg 1, 7

Third-Line Options (Only When First and Second-Line Fail)

• Trazodone is considered only as a third-line agent, after benzodiazepine receptor agonists and ramelteon have failed 1
• Trazodone may be appropriate when comorbid depression or anxiety is present, as it addresses both conditions simultaneously 1

Critical Administration Guidelines

If trazodone must be used despite recommendations against it:

• Administer on an empty stomach to maximize effectiveness 1, 2
• Use the lowest effective dose (typically 50-200 mg for insomnia) 4
• Ensure adequate sleep time and avoid combination with alcohol or other sedatives 2
• Directly ask patients about priapism given the higher-than-expected occurrence 4
• Reduce doses in elderly patients 2
• Provide regular follow-up to assess effectiveness, side effects, and ongoing need 1
• Gradually taper when discontinuing rather than stopping abruptly 6

Common Pitfalls to Avoid

• Do not use trazodone as first-line therapy for primary insomnia—it lacks sufficient evidence and has unfavorable risk-benefit ratio 1
• Do not assume lower doses (25 mg) are safer or more effective—they have not been studied and likely provide even less benefit 1
• Do not overlook screening for bipolar disorder before initiating any antidepressant, including trazodone 6
• Do not continue trazodone indefinitely—attempt to taper when conditions allow and employ the lowest effective dose 1