Trazodone Dosing for Insomnia
Do not increase trazodone to 100mg for insomnia—the American Academy of Sleep Medicine explicitly recommends against using trazodone at any dose for insomnia treatment, and if it must be used despite this recommendation, doses above 50mg provide no additional benefit while increasing adverse effects. 1, 2
Why Trazodone Should Not Be Used for Insomnia
The evidence against trazodone for insomnia is compelling:
The American Academy of Sleep Medicine gives trazodone a "WEAK" recommendation AGAINST its use for both sleep onset and sleep maintenance insomnia in adults. 1, 2
Clinical trials of trazodone 50mg showed only minimal improvements that fall below clinical significance thresholds: sleep latency reduced by only 10.2 minutes, total sleep time increased by only 21.8 minutes, and wake after sleep onset reduced by only 7.7 minutes. 2
Subjective sleep quality showed no significant improvement versus placebo (−0.13 points on a 4-point scale). 2
The Department of Veterans Affairs/Department of Defense guidelines also explicitly advise against trazodone for chronic insomnia disorder. 1
Why Higher Doses Are Not Recommended
The studied dose for insomnia is 50mg at bedtime, and this dose already showed minimal clinical benefit with significant adverse effects. 2
75% of subjects experienced adverse events on trazodone versus 65.4% on placebo, with headache and somnolence being most common. 2
The FDA-approved dosing for depression starts at 150mg/day in divided doses 3, but these antidepressant doses are inappropriate for insomnia and carry substantially higher risk of adverse effects including daytime drowsiness, dizziness, psychomotor impairment, and orthostatic hypotension. 1, 4
One study found that lower doses (25-75mg) had 100% response rates while higher doses (100-150mg) had only 42.85% response rates, suggesting higher doses are actually less effective. 5
Recommended Alternatives
First-line treatment:
- Cognitive Behavioral Therapy for Insomnia (CBT-I) should be offered as initial treatment for chronic insomnia. 1, 2
Second-line pharmacological options if CBT-I fails or is unavailable:
For sleep onset insomnia:
For sleep maintenance insomnia:
Third-line consideration:
- Trazodone may only be appropriate when comorbid depression is present, though the low doses used for insomnia (25-50mg) do not constitute adequate treatment for major depression. 1, 2
Critical Safety Concerns
Elderly patients are at particular risk for orthostatic hypotension, falls, and daytime drowsiness with trazodone. 2, 4
Trazodone should be avoided in pregnancy and nursing. 1
Caution is warranted in patients with compromised respiratory function, hepatic impairment, or heart failure. 1
Rare but serious adverse effects include priapism, which has led to treatment discontinuation in clinical studies. 1
Clinical Bottom Line
If the patient is already on trazodone for insomnia, the appropriate action is to transition them to evidence-based alternatives (CBT-I and/or FDA-approved sleep medications like zolpidem, eszopiclone, or ramelteon) rather than increasing the dose. 1, 2 The harms of trazodone potentially outweigh its minimal benefits, and increasing from any current dose to 100mg will not improve efficacy while substantially increasing adverse effects. 2, 4