What is the recommended dosing of Trazodone (antidepressant medication) for a patient with insomnia?

Trazodone Dosing for Insomnia

The American Academy of Sleep Medicine explicitly recommends AGAINST using trazodone for insomnia, as trials show only modest improvements in sleep parameters without significant improvement in subjective sleep quality, and harms outweigh benefits. 1, 2

Why Trazodone Is Not Recommended

• The American Academy of Sleep Medicine gives trazodone a "WEAK" recommendation against use for both sleep onset and sleep maintenance insomnia based on evidence showing no meaningful improvement in patient-reported sleep quality despite some objective sleep parameter changes. 1, 2

• The Department of Veterans Affairs/Department of Defense guidelines similarly advise against trazodone for chronic insomnia disorder. 2

• Potential harms include daytime drowsiness, dizziness, psychomotor impairment, and rare but serious effects like priapism. 2

If Trazodone Must Be Used (Third-Line Only)

Trazodone should only be considered after first-line benzodiazepine receptor agonists and second-line alternatives have failed, or when comorbid depression is present. 2

Dosing When Prescribed

• Start with 25-50 mg at bedtime (substantially lower than antidepressant doses of 150-600 mg/day). 2, 3

• The National Comprehensive Cancer Network specifically recommends trazodone 25-100 mg at bedtime for insomnia in palliative care settings. 2

• Research suggests the minimum effective dose of 25 mg corresponds to the highest response rate (37.93% of successful responders), with efficacy decreasing at higher doses. 4

• Studies demonstrate that 50-100 mg/day improves sleep disorders, particularly at the 100 mg/day dosage when administered as a single dose before bedtime. 5

• The FDA label indicates trazodone should be taken shortly after a meal or light snack to optimize absorption. 3

Treatment Algorithm Position

1. First-line: Short/intermediate-acting benzodiazepine receptor agonists (zolpidem 10 mg, eszopiclone 2-3 mg, zaleplon 10 mg) or ramelteon 8 mg 1, 2

2. Second-line: Alternative benzodiazepine receptor agonists if initial agent unsuccessful, or doxepin 3-6 mg for sleep maintenance 1, 2

3. Third-line: Sedating antidepressants including trazodone, particularly when comorbid depression/anxiety is present 1, 2

Critical Safety Considerations

• Contraindications: Avoid in patients with seizure disorders (especially important if patient is on bupropion, which already increases seizure risk), pregnancy, nursing, or those taking MAOIs (require 14-day washout period). 2, 3

• Elderly patients: Consider dose reduction due to increased sensitivity and fall risk. 2

• Avoid in patients with: Compromised respiratory function, hepatic failure, or heart failure. 2

• Gradual discontinuation required: Taper medication gradually rather than stopping abruptly to prevent withdrawal symptoms. 2, 3

Mandatory Concurrent Treatment

Cognitive Behavioral Therapy for Insomnia (CBT-I) must be initiated before or alongside any pharmacotherapy, as it provides superior long-term outcomes with sustained benefits after medication discontinuation. 1, 2

• CBT-I includes stimulus control therapy, sleep restriction therapy, relaxation techniques, and cognitive restructuring. 1, 2

• CBT-I can be delivered via individual therapy, group sessions, telephone-based programs, web-based modules, or self-help books—all showing effectiveness. 1

Common Pitfalls to Avoid

• Do not use trazodone as first-line therapy for primary insomnia—FDA-approved hypnotics should be tried first. 2

• Do not prescribe without attempting CBT-I or FDA-approved hypnotics first. 2

• Do not combine two sedating antidepressants due to risks of serotonin syndrome, excessive sedation, and QTc prolongation. 2

• Do not use over-the-counter antihistamines (diphenhydramine) as alternatives—they lack efficacy data and carry safety concerns including daytime sedation and delirium risk in elderly patients. 1, 2

Patient Education Requirements

• Discuss treatment goals, safety concerns, and potential side effects including daytime drowsiness and psychomotor impairment. 2

• Advise taking on an empty stomach (per research) or with light snack (per FDA label) and allowing 7-8 hours for sleep. 2, 3

• Warn about potential complex sleep behaviors (sleepwalking, sleep-driving). 2

• Assess effectiveness and side effects every few weeks initially, using the lowest effective maintenance dose. 2