What are the best management options for a patient with a history of Major Depressive Disorder (MDD) and social anxiety, currently on trazodone (50mg), Abilify (10mg) (aripiprazole), and Lamictal (25mg) (lamotrigine), who experiences difficulty falling asleep and waking up during the night?

Management of Sleep Disturbance in MDD Patient on Current Medications

Increase trazodone from 50mg to 100-150mg at bedtime as the first-line intervention for this patient's sleep-onset and sleep-maintenance insomnia. 1, 2

Rationale for Trazodone Dose Optimization

Your patient is already on trazodone 50mg, which is a subtherapeutic dose for insomnia management. The evidence strongly supports dose escalation:

• Trazodone 25-100mg at bedtime is recommended as first-line adjunctive therapy for refractory insomnia, with initial doses of 25-50mg that can be increased to 100mg based on response. 1
• For depression-related insomnia specifically, therapeutic dosing ranges from 150-300mg/day for antidepressant effects, though lower doses (50-100mg) are effective for sleep alone. 3
• Trazodone addresses both sleep-onset latency and sleep maintenance, making it ideal for this patient's specific complaint pattern. 4, 3

Concurrent Medication Considerations

The current regimen requires careful evaluation:

• Lamictal 25mg is a subtherapeutic dose for mood stabilization (typical therapeutic range is 100-400mg for bipolar disorder or MDD augmentation). This low dose is unlikely contributing meaningfully to treatment. [@General Medicine Knowledge@]
• Abilify 10mg may be contributing to insomnia as aripiprazole is activating and can worsen sleep disturbances in some patients. Consider timing adjustment (move to morning) or re-evaluation of necessity. 1
• Trazodone can be safely combined with both aripiprazole and lamotrigine without significant drug-drug interactions. 5

Specific Dosing Algorithm

Step 1: Increase trazodone to 100mg at bedtime immediately (taken shortly after a meal or light snack). 5

Step 2: If inadequate response after 1-2 weeks, increase to 150mg at bedtime. 1, 3

Step 3: If still inadequate at 150mg, consider adding melatonin 3mg taken 30 minutes before bedtime as adjunctive therapy. 1

Step 4: If sleep remains problematic, implement Cognitive Behavioral Therapy for Insomnia (CBT-I) as the gold-standard non-pharmacologic intervention, which should have been initiated earlier but can still be added. 6, 2

Critical Non-Pharmacologic Interventions to Implement Immediately

• Sleep hygiene education: consistent sleep-wake schedule, avoid caffeine after noon, limit screen time 1 hour before bed, keep bedroom dark and cool. 6, 2
• Stimulus control: bed only for sleep and sex, leave bedroom if unable to sleep within 20 minutes, return only when sleepy. 6
• Evaluate and treat anxiety symptoms that may be perpetuating insomnia, as social anxiety disorder is undertreated in this patient. 2

Medication-Specific Warnings

Common side effects to monitor with trazodone dose increase:

• Orthostatic hypotension (particularly relevant given dose increase) - advise patient to rise slowly from sitting/lying. 5, 3
• Daytime sedation (though less likely with bedtime dosing). 5
• Priapism (rare but serious - educate male patients to seek emergency care for erections >4-6 hours). 5

Drug interactions to monitor:

• Additive CNS depression with other sedating medications. 5
• Serotonin syndrome risk is low but monitor for agitation, confusion, tremor, especially if SSRIs/SNRIs added later. 5

What NOT to Do

Avoid adding antihistamines (diphenhydramine, hydroxyzine) despite their common use, as they cause daytime sedation, delirium risk, and have anticholinergic effects with limited efficacy data. 2

Avoid benzodiazepines for chronic management - while lorazepam 0.5-1mg could be used short-term (maximum 4-5 weeks), this creates dependence risk and doesn't address underlying pathophysiology. 6, 2

Do not add another antipsychotic - the patient is already on Abilify, and adding agents like quetiapine for sleep has weak evidence and significant metabolic side effects. 1

Re-evaluation Timeline

• Assess response at 1-2 weeks after each dose adjustment using sleep diary (document sleep latency, number of awakenings, total sleep time). 6
• If insomnia persists beyond 7-10 days at therapeutic trazodone dose, re-evaluate for primary sleep disorders (sleep apnea, restless legs syndrome) or inadequately treated mood/anxiety symptoms. 2
• Consider polysomnography if red flags present: loud snoring, witnessed apneas, excessive daytime sleepiness despite adequate sleep duration, or treatment-refractory insomnia. 7

Addressing the Underlying Psychiatric Conditions

The medication regimen suggests undertreated MDD and social anxiety disorder:

• Lamictal 25mg is too low for therapeutic effect. [@General Medicine Knowledge@]
• No SSRI/SNRI on board for social anxiety disorder, which is a first-line indication. [@General Medicine Knowledge@]
• Consider optimizing daytime psychiatric medications before adding more sleep agents, as treating underlying depression and anxiety will improve sleep architecture. 6, 8