Trazodone is an antidepressant medication used to treat major depressive disorder, anxiety disorders, and insomnia. It is a phenylpiperazine compound of the serotonin antagonist and reuptake inhibitor (SARI) class. The medication is taken orally.
Common side effects include dry mouth, feeling faint, vomiting, and headache. More serious side effects may include suicidal ideation, mania, irregular heart rate, and pathologically prolonged erections. It is unclear if use during pregnancy or breastfeeding is safe. Trazodone also has sedating effects.
Trazodone was approved for medical use in the United States in 1981. It is available as a generic medication. In 2023, it was the 21st most commonly prescribed medication in the United States and the fifth most common antidepressant, with more than 24million prescriptions.
Medical uses
Depression The primary use of trazodone is the treatment of unipolar major depression with or without anxiety. Data from open and double-blind trials suggest that the antidepressant efficacy of trazodone is comparable to that of amitriptyline, doxepin, and mianserin. Furthermore, trazodone has shown anxiolytic properties, low cardiotoxicity, and relatively mild side effects.
Because trazodone has minimal anticholinergic activity, it was especially welcomed as a treatment for geriatric patients with depression when it first became available. Three double-blind studies reported trazodone had antidepressant efficacy similar to that of other antidepressants in geriatric patients. Unfortunately, a side effect of trazodone, orthostatic hypotension, may cause dizziness and increase the risk of falling. This may have devastating consequences for elderly patients. Therefore, this side effect, along with sedation, often makes trazodone less acceptable for this population compared to newer compounds that share its lack of anticholinergic activity (but not the rest of its side effect profile). Still, trazodone is often helpful for geriatric patients with depression who have severe agitation and insomnia.
Trazodone is usually used at a dosage of 150 to 300mg/day for the treatment of depression. Lower doses have also been used to augment other antidepressants or when initiating therapy. Higher doses, up to 600mg/day, have been used in more severe cases of depression (in hospitalized patients, for example). Trazodone is usually administered multiple times per day, but once-daily administration may be similarly effective.
Insomnia Low-dose trazodone is used off-label in the treatment of insomnia and is considered to be effective and safe for this indication. It may also be used to treat antidepressant-related insomnia. Trazodone was the second-most prescribed agent for insomnia in the early 2000s even though most studies of trazodone for the treatment of sleep disturbances have been in depressed individuals.
Systematic reviews and meta-analyses published in the late 2010s, including a Cochrane review, found low-dose trazodone to be an effective medication for short-term treatment of insomnia in both depressed and euthymic people. Trazodone slightly improves subjective sleep quality ( = –0.34 to –0.41) and reduces the number of nighttime awakenings ( = –0.31, = –0.51), on average. Conversely, it does not appear to affect sleep onset, total sleep time, time awake after sleep onset, or sleep efficiency. It appears to increase deep sleep—in contrast to certain other hypnotics. The quality of evidence of trazodone for short-term treatment of insomnia was rated as low to moderate. There is no evidence available at present to inform the long-term use of trazodone in the treatment of insomnia.De Crescenzo F, D'Alò GL, Ostinelli EG, Ciabattini M, Di Franco V, Watanabe N, et al. Comparative effects of pharmacological interventions for the acute and long-term management of insomnia disorder in adults: a systematic review and network meta-analysis. The Lancet. 2022 Jul;400(10347):170-84.
The benefits of trazodone for insomnia must be weighed against potential adverse effects, such as morning grogginess, daytime sleepiness, cognitive and motor impairment, and postural hypotension, among others. Quality safety data on the use of trazodone as a sleep aid are currently lacking.
Trazodone is used at low doses in the range of 50 to 150mg/day for insomnia. Higher doses of 200 to 600mg/day have also been studied.
The American Academy of Sleep Medicine's 2017 clinical practice guidelines recommended against the use of trazodone in the treatment of insomnia due to inadequate evidence and due to harms potentially outweighing benefits.
Other disorders Trazodone is often used in the treatment of anxiety disorderssuch as generalized anxiety disorder and panic disorderas well as in post-traumatic stress disorder (PTSD) and obsessive–compulsive disorder (OCD). Trazodone is often used as an alternative to benzodiazepines in the treatment of anxiety disorders. However, use of trazodone in anxiety disorders is off-label and evidence of its effectiveness for these indications is variable and limited. Benefits for OCD appear to be mild. Trazodone has been used to treat sleep disturbances and nightmares in PTSD.
Combination with other antidepressants Trazodone is often used in combination with other antidepressants such as selective serotonin reuptake inhibitors in order to augment their antidepressant and anxiolytic effects and to reduce side effects such as sexual dysfunction, anxiety, and insomnia.
Available forms Trazodone is provided as the hydrochloride salt and is available in the form of 50mg, 100mg, 150mg, and 300mg oral tablets. In Italy, it is also available as an oral solution (Trittico 60 mg/mL) with a dosing pipette marked at 25 mg and 50 mg.
An extended-release oral tablet formulation at doses of 150mg and 300mg is also available.
Side effects
Because of its lack of anticholinergic side effects, trazodone is especially useful in situations in which antimuscarinic effects are particularly problematic (e.g., in patients with benign prostatic hyperplasia, closed-angle glaucoma, or severe constipation). Trazodone's propensity to cause sedation is a dual-edged sword. For many patients, the relief from agitation, anxiety, and insomnia can be rapid; for other patients, including those individuals with considerable psychomotor retardation and feelings of low energy, therapeutic doses of trazodone may not be tolerable because of sedation. Trazodone elicits orthostatic hypotension in some people, probably as a consequence of α1-adrenergic receptor blockade. The unmasking of bipolar disorder may occur with trazodone and other antidepressants.
Precautions for trazodone include known hypersensitivity to trazodone and under 18 years and combined with other antidepressant medications, it may increase the possibility of suicidal thoughts or actions.
While trazodone is not a true member of the SSRI class of antidepressants, it does still share many properties of SSRIs, especially the possibility of discontinuation syndrome if the medication is stopped too quickly. Thus, care must be taken when coming off the medication, usually by a gradual process of tapering down the dose over time.
Suicide Antidepressants may increase the risk of suicidal thoughts and behaviors in children and young adults. Close monitoring for the emergence of suicidal thoughts and behaviors is thus recommended.
Sedation Since trazodone may impair the mental or physical abilities required for the performance of potentially hazardous tasks, such as operating an automobile or machinery, the patient should be cautioned not to engage in such activities while impaired. Compared to the reversible MAOI antidepressant drug moclobemide, more impairment of vigilance occurs with trazodone. Trazodone has been found to impair driving ability.
Cardiac Case reports have noted cardiac arrhythmias emerging in relation to trazodone treatment, both in patients with pre-existing mitral valve prolapse and in patients with negative personal and family histories of cardiac disease.
QT prolongation has been reported with trazodone therapy. Arrhythmia identified include isolated PVCs, ventricular couplets, and in two patients short episodes (three to four beats) of ventricular tachycardia. Several post-marketing reports have been made of arrhythmia in trazodone-treated patients who have pre-existing cardiac disease and in some patients who did not have pre-existing cardiac disease. Until the results of prospective studies are available, patients with pre-existing cardiac disease should be closely monitored, particularly for cardiac arrhythmias. Trazodone is not recommended for use during the initial recovery phase of myocardial infarction (heart attack). Concomitant administration of drugs that prolong the QT interval or that are inhibitors of CYP3A4 may increase the risk of cardiac arrhythmia.
Priapism A relatively rare side effect associated with trazodone is priapism, likely due to its antagonism at α-adrenergic receptors. More than 200 cases have been reported, and the manufacturer estimated that the incidence of any abnormal erectile function is about one in 6,000 male patients treated with trazodone. The risk for this side effect appears to be greatest during the first month of treatment at low dosages (i.e. <150mg/day). Early recognition of any abnormal erectile function is important, including prolonged or inappropriate erections, and should prompt discontinuation of trazodone treatment. Spontaneous orgasms have also been reported with trazodone in men.
Clinical reports have described trazodone-associated psychosexual side effects in women as well, including increased libido, priapism of the clitoris, and spontaneous orgasms.
Others Rare cases of liver toxicity have been observed, possibly due to the formation of reactive metabolites.
Elevated prolactin concentrations have been observed in people taking trazodone. They appear to be increased by around 1.5- to 2-fold.
Studies on trazodone and cognitive function are mixed, with some finding improvement and others finding no change.
Trazodone does not seem to worsen periodic limb movements during sleep.
Trazodone is associated with an increased risk of falls in older adults. It has also been associated with increased risk of hip fractures in older adults.
Pregnancy and lactation Sufficient data in humans are lacking. Use should be justified by the severity of the condition to be treated.
Overdose There are reported cases of high doses of trazodone precipitating serotonin syndrome. There are also reports of patients taking multiple SSRIs with trazodone and precipitating serotonin syndrome.
Trazodone appears to be relatively safer than TCAs, MAOIs, and a few of the other second-generation antidepressants in overdose situations, especially when it is the only agent taken. The typical dose is around 150 mg, though some individuals may require higher amounts. However, taking more than 600 mg within 24 hours substantially increases the risk of overdose.
Fatalities are rare, and uneventful recoveries have been reported after ingestion of doses as high as 6,000–9,200mg. In one report, 9 of 294 cases of overdose were fatal, and all nine patients had also taken other central nervous system (CNS) depressants. When trazodone overdoses occur, clinicians should carefully monitor for low blood pressure, a potentially serious toxic effect. In a report of a fatal trazodone overdose, torsades de pointes and complete atrioventricular block developed, along with subsequent multiple organ failure, with a trazodone plasma concentration of 25.4mg/L on admission.
Interactions Cytochrome P450 inhibitors and inducers