Trazodone for Disturbed Sleep Initiation in PTSD
Associate Professor of Psychiatry
Harvard Medical School
Brockton Division of the VA Boston Healthcare System
Last updated: December 5, 2017
In this video, Dr. David Osser reviews the evidence base for the use of trazodone in PTSD patients with disturbed sleep initiation.
He also comments on side effects, with a focus on priapism.
This video is an excerpt from the presentation “Psychopharmacology of PTSD Algorithm”. The full presentation is available for Premium Members of our CME program
So, what if sleep smoothness through the night is improved, but they still have trouble initiating sleep? This is Node 2b of the algorithm.
They still have trouble falling asleep, even though they are doing better with their nightmares and disturbed awakenings.
Our first-choice option for helping them fall asleep is trazodone. I’m sure you are familiar with trazodone, it is a sedating antidepressant. It has shown some effectiveness for sleep disturbances in PTSD, but only in open-label studies.
It also has a short half-life, no weight gain, low risk of dependence, no problems with sexual side effects. It has a lot of things that make it a relatively ideal choice for many patients.
As far as what evidence we do have with trazodone, there is one open-label study. What I do offer, though, is two studies of using trazodone versus placebo for SSRI-induced insomnia.
It also has been compared with zolpidem for primary insomnia. It was in a large trial which also had a placebo control, and it proved comparable in efficacy for primary insomnia.There is a variety of lines of evidence that trazodone is a reasonable insomnia treatment that you might apply in this situation.
Perhaps the most often-mentioned side effect in males is priapism, and that is a concern. It is an infrequent concern. Serious priapism only occurs in 1 in 2000 or 3000 patients, but you do need to warn people about it, and in theory the risk of priapism may be increased if you combine trazodone with prazosin.
Some have thought that you shouldn’t combine prazosin with trazodone, because of a possible increased risk of priapism. So far, there has not been any reported cases of priapism in this commonly-used combination. Nevertheless, extra caution and warning about priapism are certainly necessary when combining them, and we do that routinely.
Trazodone is usually started at 50 mg at bedtime, with instructions to reduce to 25 mg if it is too sedating. Sometimes people have done well with just 12.5 mg.
- Stahl SM. Mechanism of action of trazodone: a multifunctional drug. CNS Spectr 2009;14:536–46
- Hertzberg MA, Feldman ME, Beckham JC, Davidson JR. Trial of trazodone for posttraumatic stress disorder usinga multiple baseline group design. J Clin Psychopharmacol 1996;16:294–8
- (Warner, 2001; Kaynak, 2004; Nierenberg, 1994;)
- Walsh JK. Subjective hypnotic efficacy of trazodone and zolpidem in DSM III–R primary insomnia. Hum Psychopharmacol 1998;13:191–8
- Warner MD, Dorn MR, Peabody CA. Survey on the usefulness of trazodone in patients with PTSD with insomnia or nightmares. Pharmacopsychiatry 2001;34:128–31.
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