What is the recommended dosing for trazodone (antidepressant medication)?

Trazodone Dosing Recommendations

For Depression (Primary Indication)

Start trazodone at 150 mg/day in divided doses, increase by 50 mg every 3-4 days as tolerated, with outpatient maximum of 400 mg/day and inpatient maximum of 600 mg/day for severe depression. 1

Initial Dosing Strategy

• Begin with 150 mg/day in divided doses, taken shortly after meals or a light snack to minimize side effects 1
• Alternative approach: Start at 100 mg and increase by 100 mg increments every 5-7 days until therapeutic benefit or significant side effects appear 2
• Target therapeutic range: 150-300 mg/day for full antidepressant efficacy 2, 3

Dose Titration

• Increase by 50 mg/day every 3-4 days based on clinical response and tolerability 1
• Outpatients: Maximum 400 mg/day in divided doses 1
• Inpatients (severely depressed): Up to 600 mg/day in divided doses 1
• Allow 4-8 weeks at therapeutic dose before concluding treatment failure 2

Dosing Schedule Optimization

• Single nighttime dosing is preferred over multiple daily doses - equally effective for depression with better sleep promotion and less daytime drowsiness at treatment onset 3
• If drowsiness occurs, administer the major portion of daily dose at bedtime or reduce total dosage 1
• Tablets can be swallowed whole or split along score line 1

For Insomnia/Behavioral Agitation (Off-Label)

The American Academy of Sleep Medicine recommends against using trazodone for insomnia 4, though it remains widely used off-label in clinical practice.

When Used Despite Guidelines

• Start at 25-50 mg at bedtime for insomnia 4, 2
• For behavioral agitation in dementia: Initial 25 mg/day, maximum 200-400 mg/day in divided doses 4
• Use with extreme caution in patients with premature ventricular contractions 4, 2

Critical Safety Considerations

Drug Interactions

• Strong CYP3A4 inhibitors: Reduce trazodone dose based on tolerability 1
• Strong CYP3A4 inducers: Consider increasing dose based on therapeutic response 1
• MAOI antidepressants: Allow 14 days washout period before starting or after stopping trazodone 1

Monitoring Requirements

• Screen for personal/family history of bipolar disorder before initiating treatment 1
• Monitor for orthostatic hypotension, particularly during initial titration 2
• Watch for cardiac arrhythmias in patients with pre-existing cardiovascular disease 5
• Be aware of priapism risk (rare but serious adverse effect) 5, 6

Discontinuation

• Gradually taper over 10-14 days rather than abrupt cessation to limit withdrawal symptoms 2, 1
• After 9 months of treatment, consider dosage reduction to reassess need for continued medication 2

Special Populations

Geriatric Patients

• Maximum tolerated doses typically 300-400 mg/day (lower than younger adults who tolerate up to 600 mg/day) 5
• Start at lower end of dosing range and titrate more slowly 2
• Particularly useful when anxiety and insomnia are prominent features 5
• Lower anticholinergic burden compared to tricyclic antidepressants 5, 7

Common Pitfalls to Avoid

• Avoid excessively rapid titration - studies using high starting doses (200 mg/day) and rapid escalation to 600 mg/day showed poorer therapeutic responses than conservative dosing 6
• Don't dismiss food timing - taking trazodone after meals reduces side effects and improves tolerability 6
• Don't overlook cardiovascular monitoring - despite being safer than tricyclics, orthostatic hypotension and arrhythmias can occur 2, 5