Trazodone 150mg for Insomnia: Not Recommended
The American Academy of Sleep Medicine explicitly recommends against using trazodone for insomnia treatment, and 150mg exceeds the doses studied (50mg) that were already found insufficient—you should use FDA-approved benzodiazepine receptor agonists or ramelteon instead. 1
Why Trazodone 150mg Is Problematic
Guideline Position Against Trazodone
- The American Academy of Sleep Medicine issued a "WEAK" recommendation against trazodone use for both sleep onset and sleep maintenance insomnia, concluding that potential harms outweigh benefits 1
- The VA/DOD guidelines similarly advise against trazodone for chronic insomnia disorder 1
- Clinical trials at 50mg showed only modest improvements in sleep parameters with no improvement in subjective sleep quality compared to placebo 1
- Systematic reviews found no differences in sleep efficiency between trazodone (50-150mg) and placebo in chronic insomnia patients 1
The 150mg Dose Is Particularly Concerning
- The FDA label indicates 150mg/day is the starting dose for depression, not insomnia 2
- Studies evaluating trazodone for insomnia used 50mg doses—your proposed 150mg is three times higher than what was studied and found inadequate 1
- Side effects are dose-dependent, meaning 150mg carries substantially higher risk than the already problematic 50mg dose 3
- The adverse effect profile includes daytime drowsiness, dizziness, psychomotor impairment, and priapism (reported in 12% of one PTSD cohort) 1, 4
What You Should Use Instead
First-Line: Cognitive Behavioral Therapy for Insomnia (CBT-I)
- CBT-I is the gold standard first-line treatment and includes stimulus control therapy, sleep restriction therapy, and relaxation techniques 5, 1
- This should be offered before any pharmacotherapy 1
Second-Line: FDA-Approved Medications
When pharmacotherapy is necessary, use these agents at the lowest effective dose for the shortest duration 1:
For sleep onset difficulty:
- Zaleplon (very short half-life, minimal residual sedation) 5, 1
- Ramelteon (melatonin receptor agonist, not DEA-scheduled, appropriate for substance use history) 5, 1
- Zolpidem 1
For sleep maintenance difficulty:
Third-Line Only: When Would Trazodone Be Considered?
- Trazodone is relegated to third-line status only after benzodiazepine receptor agonists and ramelteon have failed 1
- It becomes more appropriate when comorbid depression or anxiety is present, as it may address both conditions 1
- Even then, use the lowest effective dose (typically 25-50mg for insomnia, not 150mg) 1, 6
Critical Pitfalls to Avoid
Tolerance and Long-Term Issues
- Evidence suggests tolerance development with trazodone use 7
- High discontinuation rates occur due to side effects, particularly concerning in elderly patients 1, 7
Cognitive and Motor Impairment
- Trazodone 50mg produces significant impairments in short-term memory, verbal learning, equilibrium, and muscle endurance the following day 8
- These effects persist even after 7 days of use, indicating no adaptation 8
Serious Adverse Events
- Priapism risk is real and requires direct questioning about this side effect 4
- Cardiac concerns exist, particularly in vulnerable populations 7
- Additive sedation occurs with concurrent use of other sedating medications 1
Practical Algorithm
Step 1: Refer for CBT-I (stimulus control, sleep restriction, relaxation therapy) 1
Step 2: If pharmacotherapy needed, select based on symptom pattern:
- Sleep onset only → Zaleplon, ramelteon, or zolpidem 5, 1
- Sleep maintenance → Eszopiclone, temazepam, doxepin 3-6mg, or suvorexant 5, 1
Step 3: If first agent fails, try alternative within same class 5
Step 4: Only if Steps 1-3 fail AND comorbid depression/anxiety present → Consider low-dose trazodone 25-50mg (not 150mg) 1, 6
Step 5: Regular follow-up to assess effectiveness, side effects, and taper when possible 1