Trazodone (Desyrel)
Antidepressant (Low dose: antagonist at serotonin 5-HT2 and norepinephrine alpha-1 receptors; antidepressant dose: serotonin reuptake inhition).
- Major Depression3
- Deepens sleep1
- Improves hypoxia in sleep apnea
- Hypnotic (but not safe in elderly)2
- Bulimia3
- Agitation in dementia
Features
Dosing
150-300 mg qhs for depression (start 50 mg/night, raise to 150 over 7-14 days; raising slowly improves response), max 600 mg in depression.
Insomnia: 25-150 mg qhs.
Bulimia: raise to 400 mg.
Agitation and insomnia in dementia: 12.5 mg prn.
INTERACTIONS: Caution when adding to CYP2D6 inhibitors (eg fluoxetine, fluvoxamine, paroxetine, duloxetine, bupropion) as they can raise trazodone’s metabolite (mCPP) causing mood problems. Raise 3-5 fold if taking carbamazepine.
Management
Under-utlilized as an antidepressant, where it can be very effective and tolerable if dosed at night. Lacks sexual dysfunction and sleep disturbance. Not well studied in anxiety disorders. Along with bupropion, is one of the safer antidepressants in mixed states.
Deepens sleep quality in low doses, improves hypoxia in sleep apnea and next-day cognition in elderly/dementia. However, not fully safe in elderly for sleep because of risk of falls.
AVOID: Alcohol use disorder (may worsen relapse).
TOLERABILITY: Dizziness and somnolence.
RISKS: Hypotension. Rare priapism, cardiac conduction delays, edema.
EMR Text
Depression
Trazodone use based on FDA approval in major depressive disorder.
Trazodone’s side effects and risks, including cardiac, hypotension, and priapism, reviewed with patient.
Insomnia
Trazodone use based on controlled trials of insomnia, where it improved sleep quality and initiation (Yi XY et al, Sleep Med. 2018;45:25-32).
Trazodone’s side effects and risks, including cardiac, hypotension, and priapism, reviewed with patient.
Sleep Apnea
Trazodone use based on controlled trials showing improvements in sleep quality and apnea-hypopnea index in sleep apnea (Shahbazi M, et al, Sleep Med. 2024;113:13-18).
Trazodone’s side effects and risks, including cardiac, hypotension, and priapism, reviewed with patient.
Sleep in Dementia
Trazodone use based on controlled trials where it improved sleep paramters in dementia (Camargos EF et al, Am J Geriatr Psychiatry. 2014;22(12):1565-1574).
Trazodone’s side effects and risks, including cardiac, hypotension, and priapism, reviewed with patient.
Bulimia
Trazodone use based on a placebo-controlled trial in bulimia (Pope HG Jr et al, J Clin Psychopharmacol. 1989;9(4):254-259).
Trazodone’s side effects and risks, including cardiac, hypotension, and priapism, reviewed with patient.
Schizophrenia
Trazodone use based on a small controlled trial where it improved negative symptoms of schizophrenia (Decina P et al, Hosp Community Psychiatry. 1994;45(12):1220-1223).
Trazodone’s side effects and risks, including cardiac, hypotension, and priapism, reviewed with patient.