Using Trazodone as an antidepressant

[Chrismander]

Have any of you used it as an antidepressant? How were the results? So far I've only ever prescribed it as a sleep aid (though I've seen a few VA patients using 300-400/noc as an alleged "prn").

Occasionally I see patients who aren't touched by Trazodone 100+ at all for sleep--do people like this tend to also not get sleepy in the ~400/day or so antidepressant range? Cause Trazodone minus sleepiness seems to equal a pretty benign antidepressant...

I've got this depressed patient who reluctantly came to us 4 years after leaving tx with another psychiatrist because of sexual side effects (tried on wellbutrin at that time but didn't like it), and is now all like "give me anything i don't care about the side effects I just want to feel better". So I have her on Pristiq (no results so far, we're about 3 weeks in) but I also gave her trazodone for sleep (100/night) with *zero* effect. Since sexual side effects were a big issue for her before (and presumably will crop up again), an antidepressant with no sexual side effects would be ideal. Would you guys ever consider trazodone as antidepressant monotherapy, or is that way outside standard practice at this point? I only seem to see it used as a sleep aid. If it is ever used as an antidepressant these days, where would it fit into your personal algorithm?

Thanks for the input!

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[Faebinder]

Have any of you used it as an antidepressant? How were the results? So far I've only ever prescribed it as a sleep aid (though I've seen a few VA patients using 300-400/noc as an alleged "prn").

Occasionally I see patients who aren't touched by Trazodone 100+ at all for sleep--do people like this tend to also not get sleepy in the ~400/day or so antidepressant range? Cause Trazodone minus sleepiness seems to equal a pretty benign antidepressant...

I've got this depressed patient who reluctantly came to us 4 years after leaving tx with another psychiatrist because of sexual side effects (tried on wellbutrin at that time but didn't like it), and is now all like "give me anything i don't care about the side effects I just want to feel better". So I have her on Pristiq (no results so far, we're about 3 weeks in) but I also gave her trazodone for sleep (100/night) with *zero* effect. Since sexual side effects were a big issue for her before (and presumably will crop up again), an antidepressant with no sexual side effects would be ideal. Would you guys ever consider trazodone as antidepressant monotherapy, or is that way outside standard practice at this point? I only seem to see it used as a sleep aid. If it is ever used as an antidepressant these days, where would it fit into your personal algorithm?

Thanks for the input!

It rarely works on its own.

 

[billypilgrim37]

Is it that it doesn't work on its own, or it's simply poorly tolerated at antidepressant doses?

CM brings up a great point, in that trazodone does have 5HT2A blocking effects, which can be pretty important for folks with unacceptable sexual side effects.

 

[BabyPsychDoc]

Trazodone is not a very good antidepressant, even in the 300-400 mg dosage range. It is a very good sedative, though - especially loved by geripsych over here, for verbal aggression & irritability.

 

[whopper]

I think people don't put much scrutiny into the meds they prescribe. This is a shame. E.g. guy is manic, and the psychiatrist prescribes trazodone to help him sleep.Hmm--the guy's manic, and you're giving an antidepressant? Its not like there aren't 30 other meds you can try that don't induce mania.

I have not given it as a first line medication to treat depression, though I do think that it needs to be part of any doctor's algorithm.

 

[clowden]

How about remeron? If trazadone doesn't make her sleepy then maybe remeron won't either.

 

[whopper]

I'm not a big fan of Remeron unless the person needs to gain weight. There is some data that after its been raised past 30mg, the weight gain effect of Remeron stops--the theory being that at the higher doses, the adrenergic effect counteracts the antihistamine effect, however I've never seen much data where people were on low doses vs higher doses that actually made that discrimination.

There was some recent data from Jefferson showing that it can lower WBC count. For that reason, I don't like to give Remeron to post chemotherapy patients. That goes counter to what several psychiatrists I've seen on consult service do--give Remeron to a chemo patient. However for that same reason, it has made me consider giving Remeron to those with an inflammatory bowel disorder --> It'll stimulate appetite, and may reduce their inflammation.

 

[clowden]

However for that same reason, it has made me consider giving Remeron to those with an inflammatory bowel disorder --> It'll stimulate appetite, and may reduce their inflammation.

Funny you should mention that. I'm a medical student and when I was rotating on C/L my attending used a combination of ritalin and remeron on a 17yo who was post-op total colectomy with ileostomy due to ulcerative colitis. He had severe depression, wasn't eating (bmi 15/on tpn), and would not participate in a psychiatric interview for days. There was also a certain degree of mental ******ation as he had been attending a special education program for all of his education. My attending put him on a combination of remeron and ritalin. Basically ritalin for motivation and remeron for depression and appetite. He was concerned the ritalin would be counteractive because as a stimulant it could cause more weight loss, but he tried anyway. The results were pretty interesting... after two days on this combination he was up and walking around his room and eating white castle (before he was struggling eating jello). Not only was he participating in psych interviews, we had a long discussion about the sports he likes and the subjects he likes in school. Obviously just one example but a pretty dramatic turnaround for this one patient. The antidepressant effect of remeron can't exactly be given the credit because it was only over two days but the norepinephrine effect of ritalin plus the histaminergic effect of remeron may have led to these interesting results.

 

[whopper]

Some doctors do a treatment with a stimulant because stimulants offer short term, and quick benefits to depression. Then they taper the stimulants off a few weeks later when the antidepressant should be kicking in.

An attending of mine (while in residency) would try that, but only in extreme cases, such as the person has severe vegetative depression where they don't even want to get up & move. Ironinc thing was that this guy was very much against meds of possible abuse and only gave benzos when patients were withdrawing from alcohol or benzos.

This goes to show you you have to have a broad mind when it comes to medicine. All medications have several effects, and you just can't thrown 1 pill at a disorder. We got several SSRIs, SNRIs, among other antidepressants, and while they pretty much all have the same efficacy, they have several other effects--which if put with the right patient can give them added help.

I don't know if you will go into psychiatry, but remember that. This applies to all medicine. We are supposed to treat the whole person whenever possible.

 

[kugel]

Adjunctive treatment with a stimulant is a known, documented, decades-old choice when an antidepressant is not working well enough. Seems they used to tell us that it's a very common choice in post-stroke depressed pts - but the C/L folks will know more about current thoughts on that.

Do not forget about the fastest, safest treatment for serious depression - ECT. Esp useful is very vegetative and/or catatonically depressed pts. Don't have to stop the antidepressant meds to do ECT. NO absolute contrainidications. Safer in many forms of serious medical illness than many meds. Safe in pregnancy.

Trazodone was an interesting newcomer to the depression field before SSRI's were popular, and the other choices were basically MAOI-s and Tricyclics (BOTH options that should still be considered) It's use has waned since then to that of a bit player as a sedative - but don't go thinking that it's entirely safe. It has most of the cardiac problems of tricyclics and (if memory serves me) significant possible alpha-blockade - overall kind of a "dirty" drug hitting lots of different receptor types, each of which can cause problems. And, or course, the known possibility of priapsm. Send a pt to the ED with that, and it's hard to earn trust back.

With that said, I have used it as an effective hypnotic in LOTS of pts and used smaller doses as PRN sedative when I need to avoid anything addictive and need to avoid adding a different med as sedative (already on multiple meds, multiple side effects, etc).
e.g., 150mg HS and 50 mg q 6hrs PRN anxiety/agitation.

Haven't seen it work effectively as monotherapy for depression.
When I see pt's needing 300-400mg HS as a hypnotic, I begin to wonder what's going on. Do they really need a sedative? Are they trying to manipulate back to a BZD? Selling some of their meds? Or does it just not work for this pt and we need to move in another direction (Rozerem? Ambien/Lunesta/Sonata?)

At the beginning of insomnia complaints AND anytime things change or go astray, be sure to review the exact nature of the insomnia, sleep hygiene, review meds list for possible offenders, look for substance abuse, caffeine levels, exercise regimes, family problems, bedroom problems (noise, light, safety, etc.).

Rozerem works pretty rarely (~30% in my experience), but it's so clean and when it works it's soooo nice that it's often worth a try. I've even had a few substance abuse pt's for whom it worked.

 

[whopper]

I consider Rozarem if I believe there is a circadian rhythm issue causing the sleep problems. (I do try sleep hygiene first).

However I haven't seen any data that it is superior to OTC melatonin, and given that the latter is far cheaper, I usually go for that.

 

[kugel]

I consider Rozarem if I believe there is a circadian rhythm issue causing the sleep problems. (I do try sleep hygiene first).

However I haven't seen any data that it is superior to OTC melatonin, and given that the latter is far cheaper, I usually go for that.

Before there was a Rozerem, studies I read about Melatonin showed Melatonin almost always stops working after just a few nights (and pt's said the same thing). Before I Rx Rozerem, I ask if they've ever tried Melatonin, and I very often hear that same story @ OTC Melatonin use, "stopped working after 3-4 nights". If Rozerem works, it tends to work consistently.

And there is the comfort of knowing that the pt is getting very close to the listed dose - as opposed to such varying doses possible in OTC supplements.

Another arrow in the quiver.

 

[whopper]

True.

And the data does support that Rozarem does work consistently.

Thanks for the info. Another quiver is always helpful, especially in this field where you got plenty of patients where for some reason the usual meds just don't work.

 

[DebDynamite]

What do you think about the need for Rozarem on a long term basis?

The only time I have seen it used (and successfully) was for a patient who was s/p total knee replacement + two weeks PT. She had c/o inability to sleep more than two hours at a time after the procedure and rehab ( during the two weeks after the procedure the nurses were waking her often in the rebab facility). She started with both Melatonin and Rozarem and needed the Rozarem for about 2.5 months. She was able to wean off of it once she got back into a regular sleep routine. As expected, the Melatonin did not work for long, perhaps a week. But it took the Rozerem about three- four weeks to really kick in.

This is a drug I have yet to write for in residency very often. I am wondering specifically about the need to remain on it long term, as it seems to me that once the circadian rhythm is restored, it could be dc'd.....

 

[whopper]

This is a drug I have yet to write for in residency very often. I am wondering specifically about the need to remain on it long term, as it seems to me that once the circadian rhythm is restored, it could be dc'd.....

As is my reasoning. It doesn't cause sleep tolerance, and several other sleep meds do that, but its expensive, and I figure if the circadian rhythms are stabilized, get them off the med since they should be able to sleep without it there's stabilization.

 

[kugel]

No particular reason that I know of that Rozerem can't be helpful for many of the types of problems, including chronic. My memory of the studies is that there was no particular search for "circadian rhythm problems" for testing Rozerem. Although the melatonin system is a huge part of setting the circadian rhythms, I don't know of any reason you can't utilize the melatonin system in order to reduce sleep symptoms caused by most any of the multitude of sleep problems.

It is expensive, but not as expensive as all the other problems that result from chronic sleep disturbance or some the many problems that can be caused by other hypnotics. I often tell people about to start a new, expensive med, that they should ask for the first Rx to only be filled for one week. If it works out, they can get the rest filled. If not, they can call the clinic and ask the MD for "plan B, since that didn't work at all," and we can just move on. If Rozerem hasn't worked in a week, it probably won't, so why wait for the next appt in 2.5 months?
[Of course, i give almost opposite instructions for antidepressants.]