When is trazodone (an antidepressant) given to patients?

When to Use Trazodone

Trazodone is primarily indicated for major depressive disorder (MDD), but is not recommended as first-line treatment for insomnia disorder despite its common off-label use for sleep problems. 1

Primary Indications

• Major Depressive Disorder (MDD): Trazodone is FDA-approved for the treatment of depression in adults, typically at doses of 150-400 mg/day 2, 3
• Depression with comorbid insomnia: Particularly beneficial when insomnia is a prominent symptom of depression 4
• Depression in patients who cannot tolerate anticholinergic side effects of other antidepressants or have cardiac conduction disturbances 5

Secondary Uses (Off-label)

• Mood stabilization/anti-agitation: For control of problematic delusions, hallucinations, severe psychomotor agitation, and combativeness in patients with conditions like Alzheimer's disease (initial dosage: 25 mg/day; maximum: 200-400 mg/day) 1
• Nightmares in PTSD: May reduce nightmare frequency in patients with post-traumatic stress disorder 1
• Adjunctive sleep aid: When used with another full-dose antidepressant for patients with depression and sleep disturbances 1

Not Recommended For

• Primary insomnia disorder: Guidelines specifically advise against using trazodone for treating chronic insomnia disorder without comorbid depression 1
  • Evidence shows minimal efficacy for sleep outcomes with 50mg dosing 1
  • Benefits do not outweigh potential adverse effects when used solely for insomnia 1

Dosing Considerations

• Depression: 150-300 mg/day in divided doses 2, 3
• Elderly or debilitated patients: Lower starting doses (25-50 mg) with careful titration 1, 6
• Sleep/insomnia symptoms in depression: Lower doses (25-100 mg) are typically used 1
• Mood stabilization in dementia: Start at 25 mg/day, maximum 200-400 mg/day in divided doses 1

Contraindications and Cautions

• Cardiovascular disease: Risk of orthostatic hypotension, especially in elderly patients 2, 3
• QT prolongation risk: May cause QT interval prolongation and cardiac arrhythmias 2, 3
• Priapism: Rare but serious side effect requiring immediate medical attention 2, 1
• Concomitant use with other CNS depressants: May enhance sedative effects 1
• Suicidal ideation: Monitor for worsening depression or suicidal thoughts, especially in young adults 2

Monitoring and Follow-up

• Initial response: Assess therapeutic response and adverse effects within 1-2 weeks of starting therapy 1
• Adequate trial: Allow 6-8 weeks to determine full efficacy for depression 1
• Treatment duration: Continue for 4-9 months after satisfactory response for first episode of MDD; longer for recurrent depression 1
• Side effect monitoring: Watch for sedation, dizziness, headache, and dry mouth as common side effects 2, 3

Clinical Decision Algorithm

1. If patient has MDD with prominent insomnia: Consider trazodone as primary antidepressant (150-300 mg/day) 4
2. If patient has MDD and is taking an activating antidepressant: Consider adding low-dose trazodone (25-100 mg) at bedtime 1
3. If patient has agitation/behavioral symptoms in dementia: Consider trazodone starting at 25 mg/day 1
4. If patient has primary insomnia without depression: Do NOT use trazodone; consider cognitive behavioral therapy for insomnia or approved hypnotics 1
5. If patient has PTSD with nightmares: May consider trazodone (mean effective dose ~212 mg/day) 1

Remember that trazodone's efficacy for depression is comparable to other antidepressants, but its unique side effect profile (sedation with minimal sexual dysfunction or weight gain) makes it particularly useful for specific patient populations 2, 3.