Trazodone Dosing for Sleep
The American Academy of Sleep Medicine explicitly recommends against using trazodone for insomnia, but if it must be used despite this recommendation, the studied dose is 50 mg at bedtime, though this provides minimal clinical benefit. 1, 2
Why Trazodone Is Not Recommended
The 2017 American Academy of Sleep Medicine clinical practice guideline gives trazodone a "WEAK" recommendation against its use for either sleep onset or sleep maintenance insomnia. 1 This recommendation is based on:
Minimal clinical benefit: Trazodone 50 mg reduced sleep latency by only 10.2 minutes, increased total sleep time by only 21.8 minutes, and reduced wake after sleep onset by only 7.7 minutes—all below clinically significant thresholds. 1, 2
No improvement in sleep quality: On a 4-point scale, sleep quality showed no significant improvement versus placebo (−0.13 points). 1, 2
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
Daytime impairments: Trazodone causes significant impairments in short-term memory, verbal learning, equilibrium, and muscle endurance the following day. 3
If Trazodone Must Be Used
Dosing Protocol
Starting dose: 50 mg taken 30 minutes to 1 hour before bedtime on an empty stomach or shortly after a light snack. 1, 4, 5
Dose escalation: If 50 mg is ineffective, may increase to 100 mg at bedtime. 6, 7 However, note that the FDA label for depression starts at 150 mg/day in divided doses, and doses for insomnia (25-100 mg) are below the therapeutic antidepressant range. 8, 4
Maximum dose for insomnia: Generally should not exceed 100 mg for insomnia, as higher doses approach antidepressant dosing and increase side effects. 6, 5
Important Caveats
Timing matters: Trazodone needs to be administered at least 1 hour before bedtime for sleep onset insomnia, which is earlier than hypnotics. 5
More effective for sleep maintenance: Trazodone is more effective for sleep maintenance insomnia (staying asleep) than sleep onset insomnia (falling asleep). 5
Elderly patients: Use extreme caution due to increased risk of orthostatic hypotension, falls, and daytime drowsiness. 2
Drug interactions: Consider dose reduction when coadministered with strong CYP3A4 inhibitors; consider dose increase with strong CYP3A4 inducers. 4
Preferred Alternatives (in order of recommendation)
First-Line Treatment
- Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the initial treatment for chronic insomnia. 8
Second-Line Pharmacologic Options
For sleep onset insomnia:
For sleep maintenance insomnia:
Third-Line Consideration
Trazodone may be appropriate as a third-line agent specifically when comorbid depression or anxiety is present, though the low doses used for insomnia (25-100 mg) do not constitute adequate treatment for major depression. 2, 8, 5
Clinical Scenarios Where Trazodone May Be Considered
Comorbid depression: When insomnia occurs with depression, though higher antidepressant doses would be needed for depression treatment. 8, 5
Patients on activating antidepressants: Trazodone can counteract insomnia caused by SSRIs or other activating antidepressants. 5
Substance use history: When there is concern about abuse potential with benzodiazepine receptor agonists. 9
Deep sleep enhancement: Unlike hypnotics that decrease slow-wave activity, trazodone increases deep sleep duration, which may improve subjective sleep quality. 5
Discontinuation
Gradually reduce the dosage rather than stopping abruptly to avoid withdrawal symptoms. 4 Regular follow-up is essential to assess effectiveness, side effects, and ongoing need for treatment. 8