Maximum Dose of Trazodone for Sleep
The American Academy of Sleep Medicine explicitly recommends against using trazodone for insomnia treatment, but if it must be used despite this recommendation, the studied dose is 50 mg at bedtime—though this dose showed minimal clinical benefit and should not be exceeded for sleep purposes. 1, 2
Why Trazodone Is Not Recommended for Insomnia
The 2017 American Academy of Sleep Medicine clinical practice guideline gives trazodone a "WEAK" recommendation against use for either sleep onset or sleep maintenance insomnia. 1 This recommendation is based on evidence showing:
- 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 a 4-point scale) 1, 2
- Harms potentially outweigh benefits, with 75% of subjects experiencing adverse events versus 65.4% on placebo 2
Dosing Information When Trazodone Must Be Used
If trazodone is prescribed for insomnia despite guideline recommendations:
- Start at 50 mg at bedtime 1, 3, 4
- Maximum dose for insomnia should remain at 50-100 mg 3, 4
- Doses of 100 mg showed improved efficacy over 50 mg in one dose-finding study, but this still falls below clinical significance thresholds 4
Important distinction: The FDA-approved dosing for depression (150-600 mg/day in divided doses) 5 is completely different from off-label insomnia use and should not be confused with sleep dosing.
When Trazodone Might Be Considered (Third-Line)
Trazodone may be appropriate as a third-line agent only when: 1, 2
- Comorbid depression is present (though low doses used for insomnia do not constitute adequate treatment for major depression) 1, 2
- Other treatments have failed (after benzodiazepine receptor agonists and other first-line agents) 1
- Patient has contraindications to preferred agents 3
Preferred First-Line Alternatives
For sleep onset insomnia: 2
- Zolpidem 10 mg at bedtime
- Zaleplon 10 mg at bedtime
- Ramelteon 8 mg at bedtime
For sleep maintenance insomnia: 2
- Eszopiclone 2-3 mg at bedtime
- Doxepin 3-6 mg at bedtime
- Temazepam 15-30 mg at bedtime
Critical Safety Considerations
Particular caution in elderly patients due to increased risk of: 2
- Orthostatic hypotension
- Falls
- Daytime drowsiness
Common adverse events include: 2, 6
- Drowsiness (dose-dependent)
- Headache
- Somnolence
Administration: Should be taken shortly after a meal or light snack to optimize absorption. 5