Trazodone is only slightly faster than fluoxetine in relieving insomnia in adolescents with depressive disorders.

This retrospective chart review examined the relative effectiveness of fluoxetine and trazodone in relieving insomnia associated with depressive disorders in adolescents (aged 13-17 years). We reviewed the hospital charts of consecutively admitted adolescents with a depressive disorder and insomnia, who received one of three treatments: fluoxetine (20 +/- 2.2 mg), trazodone (71 +/- 32 mg), or a fluoxetine-trazodone combination (fluoxetine 29 +/- 2.2 mg, trazodone 68 +/- 29 mg). Each treatment was examined in 20 patients. Insomnia was defined as a change in sleep patterns characterized by decreased total sleep time that was sufficient to cause clinical concern, and insomnia resolution was defined as sleep starting by midnight and lasting 6 hours. Mean time to resolution of insomnia was significantly faster in adolescents treated with trazodone rather than fluoxetine (2.5 vs. 5.1 days, p < 0.05). Trazodone seemed to save only about 3 days and insomnia resolved in all subjects by the 11th day of antidepressant treatment. Median time to insomnia resolution was 2 days (range 1-5 days) in the trazodone group and 4 days (range 1-11 days) in the fluoxetine group. This difference between trazodone and fluoxetine, although statistically significant, was generally not clinically significant in the management of insomnia associated with depressive disorders in adolescents. The resolution of insomnia was not faster for treatment with a combination of fluoxetine and trazodone in comparison to fluoxetine monotherapy. Insomnia resolution was slightly later in older children. These clinical findings await confirmation by a controlled study. Both drugs seemed effective in ameliorating sleep symptoms in this sample, although it is likely that they produced these changes by different mechanisms.

A possible clonidine-trazodone-dextroamphetamine interaction in a 12-year-old boy.

A 12-year-old boy on a dextroamphetamine-clonidine-trazodone treatment regimen had a recurrence of insomnia, and his bedtime trazodone dose was doubled from 50 mg to 100 mg. Within 45 mins after taking the first 100-mg trazodone dose on an empty stomach, the patient had a syncopal episode associated with hypotension, bradycardia, and sedation. The drug reaction could have resulted from either trazodone or clonidine, but it is more likely to have resulted from a pharmacodynamic clonidine-trazodone interaction, presumably aggravated by rapid absorption (on an empty stomach) of a recently increased dose of trazodone. It is conceivable but less likely that the psychostimulant was a clinically significant factor. However, a drug interaction between clonidine and D-amphetamine does not need to be postulated to explain this child's syncopal reaction. The authors advise that (1) if trazodone and clonidine are used concurrently, the doses of both agents should be changed slowly, (2) blood pressure and pulse should be carefully monitored at baseline and then periodically during treatment, and (3) administration of trazodone on an empty stomach, and especially dose increases on an empty stomach, should be avoided. Physicians should remain aware that trazodone has the potential to produce hypotension and sedation, especially when combined with other agents (such as clonidine) that might produce the same adverse effects.