In an adult with bipolar disorder taking quetiapine (Seroquel) 400 mg at bedtime, aripiprazole (Abilify) 5 mg daily, and trazodone 50 mg nightly for insomnia, can buspirone be added for anxiety and the trazodone dose increased to 100 mg at night?

Can You Add Buspirone and Increase Trazodone in This Bipolar Patient?

Yes, you can add buspirone for anxiety, but increasing trazodone from 50mg to 100mg is not recommended because trazodone lacks evidence for insomnia efficacy and the American Academy of Sleep Medicine explicitly advises against its use for sleep disorders. 1, 2

Addressing the Anxiety with Buspirone

• Buspirone is appropriate for anxiety in bipolar disorder because it does not destabilize mood, has no abuse potential, and can be safely combined with mood stabilizers like quetiapine and aripiprazole. 3
• Start buspirone at 5mg twice daily and titrate to 15-20mg daily in divided doses over 2-4 weeks, recognizing that full anxiolytic effects may take 2-4 weeks to manifest. 3
• Buspirone is particularly useful for mild-to-moderate agitation and does not carry the disinhibition risk that benzodiazepines pose in younger bipolar patients. 3, 1

Why NOT to Increase Trazodone

• The American Academy of Sleep Medicine recommends AGAINST trazodone for insomnia based on trials showing only a 10-minute reduction in sleep latency and 8 minutes less wake after sleep onset, with no improvement in subjective sleep quality. 1, 2
• Trazodone 50mg is already at the dose studied in clinical trials that demonstrated minimal benefit; escalating to 100mg increases side effects (sedation, headache) without proportional sleep improvement. 1, 2
• In bipolar disorder specifically, sedating antidepressants like trazodone may destabilize mood or trigger manic episodes unless the patient is on adequate mood stabilization—which this patient is, but the insomnia medication should still be evidence-based. 1, 4

What to Do Instead for Persistent Insomnia

First-Line: Cognitive Behavioral Therapy for Insomnia (CBT-I)

• Initiate CBT-I immediately as the standard of care before adding or changing sleep medications, because it provides superior long-term efficacy and sustained benefits after treatment ends. 1
• CBT-I includes stimulus control, sleep restriction, relaxation techniques, and cognitive restructuring, and can be delivered via individual therapy, group sessions, telephone, or web-based modules. 1

Pharmacologic Options (After or Alongside CBT-I)

For combined sleep-onset and sleep-maintenance insomnia:

• Eszopiclone 2mg at bedtime (1mg if elderly) is the preferred first-line option, increasing total sleep time by 28-57 minutes with moderate-to-large improvements in sleep quality. 1
• Take within 30 minutes of bedtime with at least 7 hours remaining before awakening; reassess after 1-2 weeks and increase to 3mg if tolerated but insufficient (maximum 2mg if elderly). 1

For sleep-maintenance insomnia specifically:

• Low-dose doxepin 3-6mg at bedtime reduces wake after sleep onset by 22-23 minutes, has minimal anticholinergic effects at hypnotic doses, and carries no abuse potential. 1, 2
• Start at 3mg and increase to 6mg after 1-2 weeks if needed; this is safer than trazodone and has actual evidence supporting its use. 1

For patients with substance-use concerns:

• Ramelteon 8mg at bedtime is a melatonin-receptor agonist with no abuse potential, no DEA scheduling, and no withdrawal symptoms, making it appropriate for bipolar patients. 1

Critical Safety Considerations in Bipolar Disorder

• Ensure adequate mood stabilization before treating insomnia pharmacologically—this patient is on quetiapine 400mg and aripiprazole 5mg, which provides appropriate mood stabilization. 1, 4
• Low-dose sedating antidepressants (trazodone, mirtazapine, doxepin) should only be used when the patient is concurrently receiving at least one mood stabilizer to prevent manic switching. 1, 4
• At low hypnotic doses (trazodone ≤50mg, mirtazapine ≤30mg, doxepin ≤6mg), the risk of switching to mania is minimal when combined with mood stabilizers, but trazodone still lacks efficacy evidence. 4

Monitoring and Follow-Up

• Reassess sleep parameters after 1-2 weeks of any new sleep medication: sleep-onset latency, total sleep time, nocturnal awakenings, and daytime functioning. 1
• Monitor for complex sleep behaviors (sleep-driving, sleep-walking) with any benzodiazepine-receptor agonist like eszopiclone; discontinue immediately if these occur. 1
• Watch for mood destabilization when adding any sedating agent, though the risk is low with adequate mood stabilizer coverage. 1, 4
• Reassess buspirone efficacy after 2-4 weeks for anxiety symptoms, as full therapeutic effects are delayed. 3

Common Pitfalls to Avoid

• Do not increase trazodone dose based on the assumption that "more is better"—the evidence shows it doesn't work well even at studied doses. 1, 2
• Do not add multiple sedating agents simultaneously (e.g., increasing trazodone AND adding a benzodiazepine)—this creates dangerous polypharmacy with additive CNS depression, fall risk, and cognitive impairment. 1
• Do not prescribe sleep medications without implementing CBT-I—behavioral therapy provides more durable benefits than medication alone and is mandated as first-line treatment. 1
• Do not use benzodiazepines for anxiety in younger bipolar patients—they can cause disinhibition and worsen mood instability; buspirone is safer. 1