Trazodone Dosing for Sleep: Clinical Guidance
Primary Recommendation
The American Academy of Sleep Medicine explicitly recommends against using trazodone for insomnia treatment, as the studied dose of 50 mg showed no clinically significant benefit and potential harms may outweigh benefits. 1
Evidence-Based Dosing When Used Despite Guidelines
Despite the recommendation against its use, when trazodone is prescribed off-label for sleep, the following doses are commonly employed:
Standard Sleep Dosing
- 50 mg at bedtime is the only dose formally studied in controlled trials for primary insomnia 1
- 25-50 mg at bedtime represents the typical off-label range used in clinical practice, though 25 mg has never been systematically studied 2, 3
- 50-100 mg at bedtime showed efficacy for sleep disorders accompanied by depression, with 100 mg being more effective than 50 mg 4
- 50-200 mg nightly was the effective dose range for 70% of PTSD patients with insomnia and nightmares 5
Important Dosing Context
- These sleep doses (25-100 mg) are substantially below the FDA-approved antidepressant dosing of 150-400 mg/day in divided doses 6
- Lower doses used for sleep do not constitute adequate treatment for major depression 2, 3
Clinical Performance at 50 mg
The evidence demonstrates minimal clinical benefit at the studied dose:
- Sleep latency reduced by only 10.2 minutes (below clinical significance threshold) 1
- Total sleep time increased by only 21.8 minutes (below clinical significance threshold) 1
- Wake after sleep onset reduced by only 7.7 minutes (below clinical significance threshold) 1
- Sleep quality showed no significant improvement versus placebo (−0.13 points on 4-point scale) 1
Adverse Effects Profile
Trazodone carries significant safety concerns that clinicians must monitor:
- 75% of patients experienced adverse events versus 65.4% on placebo 1, 3
- Headache occurred in 30% of patients (versus 19% placebo) 1
- Somnolence occurred in 23% of patients (versus 8% placebo) 1
- Priapism risk is substantial: 12% incidence reported in one PTSD study, requiring direct questioning about this side effect 5
- Orthostatic hypotension, falls, and daytime drowsiness are particularly concerning in elderly patients 2, 7
When Trazodone May Be Considered
Trazodone functions as a third-line agent in the insomnia treatment algorithm, only after benzodiazepine receptor agonists and ramelteon have failed 3:
Specific Clinical Scenarios
- Comorbid depression or anxiety where sedation is desired, though higher antidepressant doses would be needed for depression treatment 2, 3
- PTSD with nightmares and insomnia, where 50-200 mg showed benefit in uncontrolled studies 5
- Sleep disorders with depressive features, where 50-100 mg (particularly 100 mg) demonstrated efficacy 4
Preferred Alternatives
The American Academy of Sleep Medicine recommends these evidence-based options instead:
For Sleep Onset Insomnia
For Sleep Maintenance Insomnia
- Eszopiclone 2-3 mg at bedtime 2
- Doxepin 3-6 mg at bedtime (note: much lower than antidepressant dosing) 2
- Temazepam 15-30 mg at bedtime 2
Critical Administration Details
If trazodone is used despite guideline recommendations:
- Administer shortly after a meal or light snack to optimize absorption 6
- Weight the dose at bedtime to maximize sleep benefit and minimize daytime sedation 8
- Start at the lowest effective dose (typically 25-50 mg) and titrate based on response 2, 3
- Monitor closely for priapism by directly asking patients about this side effect 5
- Exercise particular caution in elderly patients due to fall risk and orthostatic hypotension 2, 7
- Gradually taper when discontinuing rather than stopping abruptly 6
Common Pitfall to Avoid
The most critical error is assuming trazodone is "safer" than FDA-approved hypnotics simply because it's an antidepressant. This perception drives widespread prescribing despite weak evidence and a concerning adverse effect profile, particularly the risk of priapism, orthostatic hypotension, and falls 1, 3.