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2. Trazodone for disturbed sleep initiation (Node 2b)
David N. Osser, MD,
Associate Professor of Psychiatry
Harvard Medical School
Brockton Division of the VA Boston Healthcare System

3. Recommendation First-choice hypnotic: If sleep initiation is disturbed
Trazodone
If sleep initiation is disturbed

4. Trazodone: “an ideal hypnotic”?
Stahl SM. Mechanism of action of trazodone: a multifunctional drug. CNS Spectr 2009;14:536–46

5. Trazodone: “an ideal hypnotic”?
Short-half life
No weight gain
Low risk of dependence
Low risk of sexual side effects
Stahl SM. Mechanism of action of trazodone: a multifunctional drug. CNS Spectr 2009;14:536–46

6. Sleep initiation disturbed
Trazodone added to prazosin
Sleep initiation disturbed
Trazodone alone
Nightmares, disturbed awakenings

7. Minimal evidence, clinical experience mostly
Sleep initiation disturbed
Minimal evidence, clinical experience mostly
Trazodone alone before using SSRIs
Nightmares, disturbed awakenings

8. Evidence of efficacy Only one open-label study in PTSD
Effective for SSRI-induced insomnia
Two RCTs
Comparable to zolpidem in primary insomnia
One large RCT
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;)

9. Evidence of efficacy Only one open-label study in PTSD
Effective for SSRI-induced insomnia
Two RCTs
Comparable to zolpidem in primary insomnia
One large RCT
Walsh JK. Subjective hypnotic efficacy of trazodone and zolpidem in DSM III–R primary insomnia. Hum Psychopharmacol 1998;13:191–8

10. Trazodone: adverse effects
Potential
Sedation
Dizziness
Orthostatic hypotension
Occasionally
Syncope
Males
Priapism
Infrequent
Risk may be increased if combined
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.

11. Trazodone: adverse effects
Potential
Sedation
Dizziness
Orthostatic hypotension
Occasionally
Syncope
Males
Priapism
Infrequent
Risk may be increased if combined with prazosin
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.

12. If too sedating, reduce to 25 mg
Dosing
Start at 50 mg at bedtime
If too sedating, reduce to 25 mg

13. Next Video: Other options for improving sleep latency in PTSD