December 8, 2022

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All right so you’ve completed the initial evaluation you’ve considered whether they have sleep disturbance that could be from the ptsd you’ve considered a trial of prazosin so what if sleep smoothness through the night is improved but they still have trouble initiating sleep this is node to b of the algorithm they still have trouble falling asleep even though

They’re doing better with their nightmares and disturbed awakenings our first choice hypnotic for helping them fall asleep is trazodone i’m sure you’re familiar with trazodone it’s a sedating antidepressant it’s shown some effectiveness for sleep disturbances in ptsd but really only in open-label studies it has been described though as an ideal hypnotic agent by

Steven stahl in an article he wrote a few years ago because of its triple sleep promoting actions on the 5-ht to a alpha 1 and h1 receptors it also has a short half-life no weight gain low risk of dependence no problems with sexual side-effects so it’s got a lot of things that make it a relatively ideal choice for many patients it has a reasonable role we think

To add to your processing or instead of it if there really are no problems with nightmares but just difficulty falling asleep now if prazosin was not effective you could consider trying it for the total picture for the falling asleep and the difficulties maintaining sleep because of the nightmares before moving on to the ssris but i have to say the evidence for

It is pretty minimal it’s pretty much clinical experience that is all we have as a solo treatment for the major symptoms of ptsd now as far as what evidence we do have with trazadone there is that one open label study what i do offer though is two studies of using trazadone versus placebo for ssri induced insomnia ssris as noted often cause insomnia as a side

Effect maybe fifteen or twenty percent of patients and in two randomized control trials trazodone was an excellent treatment for that 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 so there’s a variety of lines of evidence the trazadone

Is a reasonable insomnia treatment that you might apply in this situation the side effects of trazadone include excess sedation dizziness orthostatic problems occur from time to time and syncope occasionally so you do have to be cautious for warned about and watch for that now perhaps the most often mentioned side-effect though in males is priapism and that is a

Concern it’s an infrequent concern serious priapism only occurs in one in two or three thousand patients but you do need to warn people about it and in theory the risk of priapism may be increased if you combine trazadone with prazosin which has a very rare sometimes not even mentioned in typical patient information sheets that prazosin has been associated with

Priapism so some have thought that you shouldn’t combine processing with trazadone because of a possible increased risk of priapism so far there hasn’t been any reported cases of priapism in this commonly used combination nevertheless extra caution with warning about priapism is certainly necessary in combining them and we do that routinely trazadone is usually

Started at 50 at bedtime with instructions to reduce to 25 if it’s too sedating sometimes people have done well with just twelve point five milligrams of trazodone

Transcribed from video
PTSD Psychopharmacology – Recommendation for Disturbed Sleep Initiation By Psychopharmacology Institute