What adjustments should be made to the treatment plan for a patient with depression and anxiety, experiencing sleep disturbance and ongoing anxiety symptoms, currently taking trazodone and Prozac, as well as Vistaril?

Treatment Adjustments for Depression and Anxiety with Sleep Disturbance

Increase trazodone to 100 mg at bedtime to address the early morning awakening at 4 AM, as the current 50 mg dose is providing insufficient sleep maintenance. 1, 2

Rationale for Trazodone Dose Adjustment

The patient's recent onset of 4 AM awakening despite initial improvement indicates inadequate sleep maintenance with trazodone 50 mg. The therapeutic dosing range for trazodone is 150-300 mg/day for full antidepressant efficacy, with doses weighted at bedtime 3. For sleep-specific indications, trazodone 25-100 mg at bedtime is recommended 1. Given the patient's partial response, increasing to 100 mg represents a logical intermediate step before considering higher antidepressant doses.

Sleep Architecture Benefits

• Trazodone improves sleep without causing tolerance or REM rebound on discontinuation 3
• The 3-9 hour half-life favors bedtime dosing for sleep maintenance 3
• Single nighttime dosing produces better sleep with less daytime drowsiness compared to divided doses 3

Current Medication Assessment

Prozac (Fluoxetine) 60 mg Daily

Continue the current Prozac dose, as the patient reports significant improvement in hopelessness/helplessness and describes it as providing a "buffer" during stressful times. 4 The patient denies side effects, and the 60 mg dose is within the therapeutic range (maximum 80 mg/day for depression) 4.

• Morning anxiety and racing heart may reflect situational stress from divorce rather than medication inadequacy 4
• Fluoxetine can cause anxiety and insomnia in 12-16% of patients, but the patient attributes symptoms to life circumstances 4

Vistaril (Hydroxyzine) 25 mg TID

Continue Vistaril as prescribed, since the patient reports it helps with anxiety. 1 However, monitor for:

• Anticholinergic effects, particularly if combined with higher trazodone doses 2
• Daytime sedation that may contribute to low energy 1

Addressing Low Energy and Activation

The patient specifically requests "more activation." Consider adding bupropion 150 mg SR in the morning if low energy persists after optimizing sleep with increased trazodone. 1, 5

Bupropion Advantages in This Context

• Activating properties that reduce apathy and improve energy 1, 5
• No sexual dysfunction (unlike SSRIs) 5
• Does not cause weight gain 5
• Second dose should be given before 3 PM to minimize insomnia risk 1
• Contraindicated if patient has seizure history or eating disorder 1, 5

Alternative Activation Strategy

If bupropion is contraindicated or not tolerated:

• Methylphenidate 2.5-20 mg PO BID, with second dose no later than 6 hours before bedtime 1
• Modafinil 100-400 mg PO each morning 1

Monitoring and Follow-Up

Re-evaluate in 1-2 weeks after trazodone increase to assess:

• Sleep maintenance (ability to stay asleep until desired wake time) 1
• Morning sedation or "hangover" effect 2, 3
• Orthostatic hypotension, particularly given hydroxyzine co-administration 2, 6
• Daytime energy levels and functional capacity 1

Safety Considerations with Trazodone Increase

• Monitor for priapism (erection >6 hours), though rare 2
• Watch for dizziness upon standing (orthostatic hypotension) 2, 6
• QT prolongation risk, especially if patient has cardiac history 2
• Serotonin syndrome risk is low but monitor for agitation, confusion, tremor, or GI symptoms given concurrent SSRI use 2

Cognitive Behavioral Therapy Optimization

Ensure the BetterHelp therapist is providing evidence-based CBT-I (cognitive behavioral therapy for insomnia) techniques, as this enhances medication efficacy and facilitates eventual medication tapering. 1

• Stimulus control therapy and sleep restriction are guideline-recommended 1
• CBT-I combined with pharmacotherapy produces superior outcomes to either alone 1
• Sleep hygiene education should supplement, not replace, structured CBT-I 1

Common Pitfalls to Avoid

• Do not add benzodiazepines for sleep - they may worsen depression and cause dependence 1
• Do not discontinue trazodone abruptly - taper over 10-14 days if discontinuation becomes necessary to avoid withdrawal symptoms 2
• Do not exceed trazodone 400 mg/day in outpatient settings 5, 7
• Avoid taking trazodone on an empty stomach - should be taken shortly after a meal or light snack 2