What is the initial trazodone (antidepressant) dose for someone with uncontrolled insomnia?

Initial Trazodone Dosing for Uncontrolled Insomnia

For uncontrolled insomnia, trazodone should NOT be initiated as first-line therapy, but if used despite guideline recommendations against it, start with 25 mg at bedtime. 1

Critical Context: Trazodone Is Not Recommended for Insomnia

• The American Academy of Sleep Medicine explicitly recommends AGAINST using trazodone for sleep onset or sleep maintenance insomnia in adults, giving it a "WEAK" recommendation against use because potential harms outweigh benefits. 1

• The Department of Veterans Affairs/Department of Defense guidelines similarly advise against trazodone for chronic insomnia disorder. 1

• Clinical trials of trazodone 50 mg showed only modest improvements in sleep parameters (reducing sleep latency by just 10 minutes) with no improvement in subjective sleep quality compared to placebo. 1, 2

If Trazodone Is Used Despite Recommendations

Starting Dose

• Begin with 25 mg at bedtime when used off-label for insomnia, as this represents the lowest dose that provides sedative effects while minimizing adverse effects. 3, 1

• The FDA-approved dosing for depression starts at 150 mg/day in divided doses, but insomnia treatment uses substantially lower doses (25-50 mg) that are below the therapeutic antidepressant range. 1, 4

Dose Titration (If Needed)

• If 25 mg is insufficient after 1-2 weeks, increase to 50 mg at bedtime. 5, 6

• Studies suggest the effective dose range for insomnia is 50-200 mg nightly for 70% of patients, though higher doses increase side effect risk. 6

• Maximum doses for insomnia typically should not exceed 200 mg at bedtime. 3

Administration Details

• Administer on an empty stomach to maximize effectiveness, contrary to the FDA depression dosing which recommends taking with food. 1, 2

• Take 30 minutes before bedtime. 7

• Ensure adequate sleep time (7-8 hours) is available to minimize next-day sedation. 1

Critical Safety Warnings

• Priapism risk: 12% incidence reported in one PTSD study—directly ask male patients about this side effect at follow-up. 6

• Daytime impairment: Trazodone causes significant impairments in short-term memory, verbal learning, equilibrium, and muscle endurance even at 50 mg doses. 7

• Elderly patients require dose reduction due to increased sensitivity to sedative and orthostatic effects. 1

• Avoid in pregnancy, nursing, compromised respiratory function, hepatic or heart failure. 1

• Caution with premature ventricular contractions. 3

Preferred Alternatives (Guideline-Recommended)

First-Line Treatment

• Cognitive Behavioral Therapy for Insomnia (CBT-I) should be offered initially. 1, 2

Second-Line Pharmacologic Options

• Zolpidem 5-10 mg (start 5 mg in women/elderly). 1, 2
• Eszopiclone 2-3 mg for sleep maintenance. 1, 2
• Zaleplon 10 mg for sleep onset only. 1, 2
• Ramelteon 8 mg for sleep onset, no dependence risk. 1, 2
• Temazepam 15 mg for both initiation and maintenance. 1, 2

When Trazodone May Be Appropriate

• Third-line agent after benzodiazepine receptor agonists and ramelteon have failed. 1
• Comorbid depression present, though 25-50 mg doses are inadequate for treating major depression and would require combination with a full-dose antidepressant. 1
• Substance use history where controlled substances are contraindicated (though ramelteon is preferred in this scenario). 1

Clinical Algorithm

1. Offer CBT-I first for all patients with chronic insomnia. 1

2. If pharmacotherapy needed, use zolpidem, eszopiclone, zaleplon, or ramelteon as second-line. 1, 2

3. Only consider trazodone if second-line agents fail or when comorbid depression/anxiety exists. 1

4. If trazodone is chosen: Start 25 mg at bedtime, increase to 50 mg after 1-2 weeks if needed, maximum 200 mg for insomnia. 3, 1, 5

5. Monitor closely for priapism (males), daytime cognitive impairment, orthostasis, and effectiveness at 1-2 week follow-up. 1, 7, 6

6. Taper gradually when discontinuing to avoid withdrawal symptoms. 4