Trazodone for Insomnia: Dosage and Recommendations
Primary Recommendation
The American Academy of Sleep Medicine explicitly recommends against using trazodone for insomnia treatment, whether for sleep onset or sleep maintenance difficulties. 1 However, if trazodone must be used despite this recommendation, the evidence-based dose is 50 mg at bedtime, though this showed minimal clinical benefit. 1, 2
Evidence Against Trazodone Use
The 2017 American Academy of Sleep Medicine guideline provides a WEAK recommendation against trazodone based on rigorous analysis: 1
- Sleep latency reduced by only 10.2 minutes (below clinical significance threshold) 1, 2
- Total sleep time increased by only 21.8 minutes (below clinical significance threshold) 1, 2
- Wake after sleep onset reduced by only 7.7 minutes (below clinical significance threshold) 1, 2
- Sleep quality showed no significant improvement versus placebo (−0.13 points on 4-point scale) 1, 2
The harms potentially outweigh benefits: 75% of trazodone subjects experienced adverse events versus 65.4% on placebo, with headache (30% vs 19%) and somnolence (23% vs 8%) being most common. 1, 2
Dosing Information (If Used Despite Recommendations)
For Insomnia (Off-Label)
- Start with 25-50 mg at bedtime 1
- Maximum studied dose: 100 mg at bedtime 1, 3
- Lower doses (25-75 mg) show higher response rates than higher doses (100-150 mg) in long-term studies 4
Important Caveat
The FDA-approved dosing for depression (150-600 mg/day in divided doses) 5 is not applicable to insomnia treatment, where much lower single bedtime doses are used off-label. 1, 4
Preferred Alternatives
The American Academy of Sleep Medicine recommends these evidence-based options instead: 2
For Sleep Onset Insomnia:
For Sleep Maintenance Insomnia:
When Trazodone Might Be Considered
Trazodone may be appropriate as a third-line agent when comorbid depression is present, though the low doses used for insomnia (25-100 mg) do not constitute adequate treatment for major depression. 2 In palliative care settings with limited life expectancy, trazodone 25-100 mg at bedtime is listed among acceptable options. 1
Critical Safety Warnings
Particular caution is warranted in elderly patients due to increased risk of: 2
- Orthostatic hypotension
- Falls
- Daytime drowsiness
Documented daytime impairments include: 6
- Short-term memory deficits
- Verbal learning impairments
- Equilibrium problems (increased body sway)
- Reduced muscle endurance
Administration requirements: 5
- Take shortly after a meal or light snack
- Screen for bipolar disorder before initiating
- Allow 14 days between discontinuing MAOIs and starting trazodone
- Gradually taper rather than abruptly discontinue