Trazodone Dosage for Insomnia

Recommendations and Guidelines

The American Academy of Sleep Medicine recommends against using trazodone for insomnia treatment, and if it must be used despite this recommendation, the studied dose is 50 mg at bedtime, though this dose showed minimal clinical benefit 1
The 2017 American Academy of Sleep Medicine clinical practice guideline explicitly advises against trazodone for either sleep onset or sleep maintenance insomnia, giving it a "WEAK" recommendation against use 1
Trazodone 50 mg 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, which are all below the clinical significance threshold 1
Sleep quality showed no significant improvement versus placebo, with a difference of −0.13 points on a 4-point scale 1
The harms of trazodone potentially outweigh its benefits, with 75% of subjects experiencing adverse events versus 65.4% on placebo, including headache and somnolence as the most common adverse events 1

The American Academy of Sleep Medicine recommends zolpidem 10 mg at bedtime, zaleplon 10 mg at bedtime, and ramelteon 8 mg at bedtime for sleep onset insomnia 3
The American Academy of Sleep Medicine recommends eszopiclone 2-3 mg at bedtime, doxepin 3-6 mg at bedtime, and temazepam 15-30 mg at bedtime for sleep maintenance insomnia 3, 1

Trazodone may be appropriate as a third-line agent when comorbid depression is present, though the low doses used for insomnia do not constitute adequate treatment for major depression 3, 2
Caution is particularly warranted in elderly patients due to increased risk of orthostatic hypotension, falls, and daytime drowsiness 3, 4