What is the recommended trazodone dose for insomnia in an adult without severe hepatic impairment, pregnancy, or contraindicating medications, and how should it be adjusted for elderly patients?

Trazodone Dosing for Insomnia

The American Academy of Sleep Medicine explicitly recommends against using trazodone for insomnia treatment, whether for sleep onset or sleep maintenance, because the minimal benefits do not outweigh the potential harms. 1, 2

Why Trazodone Is Not Recommended

The evidence against trazodone is compelling:

• Minimal objective benefit: At the studied dose of 50 mg, trazodone reduces sleep latency by only 10.2 minutes, increases total sleep time by only 21.8 minutes, and reduces wake after sleep onset by only 7.7 minutes—all below clinically significant thresholds 2
• No improvement in sleep quality: Subjective sleep quality showed no significant difference versus placebo (−0.13 points on a 4-point scale) 2
• High adverse event rate: 75% of patients experience adverse events versus 65.4% on placebo, with headache (30% vs 19%) and daytime somnolence (23% vs 8%) being most common 2, 3
• Particular risk in elderly: Increased risk of orthostatic hypotension, falls, and daytime drowsiness 2, 3

Recommended Treatment Algorithm

First-Line: Cognitive Behavioral Therapy for Insomnia (CBT-I)

• CBT-I must be offered before any medication, with superior long-term efficacy and sustained benefits after discontinuation 1
• Core components include sleep restriction therapy and relaxation techniques 1

Second-Line: FDA-Approved Pharmacotherapy

For sleep onset AND maintenance insomnia:

• Eszopiclone 2-3 mg at bedtime (reduce to 1 mg in elderly or severe hepatic impairment) 1, 2
• Zolpidem 10 mg at bedtime (reduce to 5 mg in elderly) 1, 2
• Temazepam 15-30 mg at bedtime (reduce to 7.5 mg in elderly) 4, 1

For sleep onset ONLY:

• Zaleplon 10 mg at bedtime (reduce to 5 mg in elderly) 4, 1
• Ramelteon 8 mg at bedtime (preferred when substance abuse history exists; no addiction potential) 4, 1

For sleep maintenance ONLY (nocturnal awakenings):

• Doxepin 3-6 mg at bedtime (most effective for maintenance insomnia with minimal side effects and no abuse potential) 1, 3
• Suvorexant 10-20 mg at bedtime 1, 3

Third-Line: Trazodone (Only in Specific Scenarios)

If trazodone must be used despite recommendations:

• Standard adult dose: 50 mg at bedtime (the studied dose, though minimally effective) 1, 2, 3
• Dosing range: 25-150 mg at bedtime, though lower doses (25 mg) have not been systematically studied and would likely provide even less benefit 1, 2
• Timing: Administer at least 1 hour before bedtime on an empty stomach to maximize effectiveness 4, 5

Appropriate clinical scenarios for trazodone:

• Comorbid depression is present (though 50 mg is inadequate for treating major depression; full antidepressant dosing of 150-300 mg would be needed) 4, 1, 2
• All first- and second-line treatments have failed or are contraindicated 1, 2
• Patient is already on a full-dose antidepressant and needs additional sleep support 1

Elderly dosing considerations:

• Exercise extreme caution and consider dose reduction due to increased risk of orthostatic hypotension, falls, and daytime drowsiness 1, 2, 3
• Maximum tolerated doses in elderly are typically 300-400 mg/day for depression (not insomnia dosing) 6

Critical Safety Warnings

Absolute contraindications and cautions:

• Avoid in pregnancy and nursing 1
• Caution with compromised respiratory function (asthma, COPD, sleep apnea), hepatic impairment, or heart failure 4, 1
• Dose reduction required in hepatic impairment 1
• Risk of priapism (rare but serious) 1

Patient counseling requirements:

• Allow 7-8 hours of sleep time to reduce residual sedation 1
• Avoid alcohol and other CNS depressants due to additive effects 4, 1
• Watch for complex sleep behaviors (sleepwalking, sleep-driving) 4, 1
• Monitor for progressive sedation, dizziness, and psychomotor impairment 1, 7

Follow-up protocol:

• Assess effectiveness and adverse effects every few weeks initially 1
• Use the lowest effective dose for the shortest duration possible 1
• Taper when conditions allow 1

Common Pitfalls to Avoid

• Never use trazodone as first-line therapy for primary insomnia 1
• Never prescribe trazodone without attempting CBT-I or FDA-approved hypnotics first 1
• Never combine two sedating antidepressants 1
• Never use over-the-counter antihistamines (diphenhydramine) as alternatives—they lack efficacy data and tolerance develops within 3-4 days 1
• Never use benzodiazepines (lorazepam, clonazepam) for chronic insomnia due to dependency risk, falls, and cognitive impairment 1