Trazodone Dosage for Insomnia
The American Academy of Sleep Medicine explicitly recommends against using trazodone for insomnia treatment, whether for sleep onset or sleep maintenance, based on insufficient efficacy that does not outweigh potential harms. 1, 2
Why Trazodone Is Not Recommended
The evidence against trazodone for insomnia is compelling:
Minimal clinical benefit: At the studied dose of 50 mg, trazodone 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 3
No improvement in sleep quality: Subjective sleep quality showed no significant difference versus placebo (−0.13 points on a 4-point scale) 3
Higher adverse event rate: 75% of subjects experienced adverse events versus 65.4% on placebo, with headache and somnolence being most common 3
Daytime impairments: Trazodone 50 mg produces significant impairments in short-term memory, verbal learning, equilibrium, and arm muscle endurance the following day 4
Serious risks: Priapism, orthostatic hypotension, falls (especially in elderly), and daytime drowsiness are concerning adverse effects 2, 3
If Trazodone Must Be Used Despite Guidelines
When prescribed off-label despite recommendations against it, the typical dose is 25-50 mg at bedtime, though this is below the therapeutic range for depression and provides minimal benefit. 2, 5
The FDA-approved dosing for depression starts at 150 mg/day in divided doses, which is far higher than doses used for insomnia 6. Lower doses (25-50 mg) used for insomnia have not been systematically studied and would likely provide even less benefit than the already insufficient effects seen at 50 mg 2.
Recommended Alternatives (Prioritized by Evidence)
First-line treatment:
Second-line pharmacologic options for sleep onset AND maintenance:
For sleep onset only:
For sleep maintenance only:
When Trazodone Might Be Considered (Third-Line)
Trazodone may be appropriate only as a third-line agent in specific scenarios:
Comorbid depression: When depression coexists with insomnia, though the low doses used for insomnia (25-50 mg) are inadequate for treating major depression 2, 3
After other options fail: When benzodiazepine receptor agonists and ramelteon have been unsuccessful 2
Combination therapy: Can be used alongside a full-dose antidepressant in patients with both depression and insomnia 2
Critical Safety Considerations
Special populations requiring caution or avoidance:
- Elderly patients: Increased risk of orthostatic hypotension, falls, and cognitive impairment—consider dose reduction or alternative agents 2, 3
- Pregnancy and nursing: Should be avoided 2
- Compromised respiratory function, hepatic or heart failure: Use with caution 2
Administration guidance:
- Take shortly after a meal or light snack to maximize effectiveness 2, 6
- Allow adequate sleep time (7-8 hours) before activities requiring alertness 2
- Avoid concurrent use with other sedating medications due to additive effects 2
Common Pitfalls to Avoid
- Using trazodone as first-line: This contradicts guideline recommendations and exposes patients to unnecessary risks without proven benefit 1, 2
- Assuming lower doses are safer and equally effective: The 50 mg dose studied showed minimal benefit; 25 mg would likely be even less effective 2, 3
- Prescribing for primary insomnia: The VA/DOD guidelines explicitly advise against trazodone for chronic insomnia disorder 2
- Neglecting non-pharmacologic options: CBT-I should always be considered first 2, 3