Brain Drugs Filter: Trazodone Going Tango Uniform after 26 years.
November 28, 2021 3:02 PM   Subscribe

For 26 years, after a major depression/anxiety episode in college, Trazodone has been my rock when it comes to getting sleep. And then, last week, for no discernible reason and pretty much overnight, it stopped working.

I've been a fire/medical first responder since 1998: through years of crazy work schedules; both parents getting cancer; losing friends and coworkers to accidents, illness and suicide; plenty of challenging and stressful events at work even BEFORE COVID, etc, etc., I could always count on getting solid sleep. This was a good thing, as any hint of insomnia scares the hell out of me because of said depression/anxiety episode back in 1995-96. (I've also been doing well on Effexor for over a decade, and pray it doesn't decide to tank on me as well.) The upshot is, whatever stress I felt last week, it was not out of the ordinary.

Predictably, this has caused the bottom to drop out from my world. Ridiculous, I know, but at the slightest whiff of insomnia, the ghosts of my college episode come out to play. Cue the anxiety, rumination and deep fear that this is the end of my career and everything I hold dear: independence, reliability, competence in my work, the ability to be of use to others. In just a few days I've become almost paralyzed with this stupid, unnecessary but inexorable distress. I desperately need to nip it in the bud, NOW. And the interwebs have been next to useless - can't find any articles from reliable sources or peer-reviewed literature on this happening, at all.

So the question, for anyone experienced with Trazodone, either on the prescribing or receiving end, has this ever happened to you? Are there any other sleep-aid drugs out there with the same durable, non-addictive, low-side-effect, no-tolerance-buildup profile? Pretty sure I'll have to be on some sort of sleep medication for the rest of my life.

Thanks in advance.
posted by Lycaon_pictus to Health & Fitness (13 answers total) 6 users marked this as a favorite
Best answer: Looking closely at the actual pills you got, are they the right ones? (And on the off chance, there was a Trazodone recall a year ago, which seems very unlikely it would still be in the supply chain but just in case...) Can you talk to the pharmacist to be sure what you got is what it should be? They might be able to identify other oddball things that reduce (or improve) efficacy of Trazodone as well.

I would encourage trying doxylamine succinate (over the counter, drugstore brand will suffice) and a magnesium supplement for a bridge treatment for the moment, which is what I'm using now with trazodone as a backup if it stops working. It could simply be that you need a short-term vacation from the Trazodone and can go back to it later, in which case your in-between solution does not need to be permanent. Let your doctor know ASAP - a phone call might be enough to get a Plan B started.

I would also suggest maybe a quick round of CBT for the insomnia anxiety as soon as you're able, because that's actually the most important thing that's ever happened for me in my lifetime of insomnia. I used to spin up into a panicked rage at the first sign of sleeplessness, and not doing that anymore opened up a lot more options to flexibly treating the actual symptoms of my insomnia as the fluctuate by season and age.
posted by Lyn Never at 3:32 PM on November 28, 2021 [5 favorites]

Good advice above, but also you could consider a switch to a tricyclic antidepressant. Desipramine is supposed to be the lightest on side effects, but they're all sedating to some degree. The later-generation ADs aren't actually much, if any, more effective in treating depression, they're just less likely to make you crave peanut butter.
posted by praemunire at 4:33 PM on November 28, 2021 [1 favorite]

Best answer: Agree about trying doxylamine succinate and magnesium as an interim measure. (Magnesium glycinate is often specifically recommended for sleep and is what I use. There are a bunch of types of magnesium floating around.) Keep in mind that the doxylamine should only be used as a stop gap. You can develop rebound insomnia from it if you take it too many days in a row (ask me how I know). Also for me, I kept having to take higher and higher doses to get an affect.

Trazodone never worked for me, personally. But I've been using clonidine for 12 years now to help me sleep and it's been my miracle drug. No tolerance, doesn't leave me groggy the next morning. It doesn't exactly "knock me out" but it just relaxes me so that I can fall asleep. Clonidine also can be good for anxiety, so it might also help with your sleep anxiety. I've had zero side effects from it. Taken the same dose for years.

I've also previously taken Seroquel for sleep. It does work, and it doesn't build tolerance in my experience, but it is an atypical antipsychotic, so it can have some serious side effects. I also found it led to me being more drowsy the next day. I think Seroquel is often recommended when first line treatments like Trazodone fail. that's how I ended up on it. Personally, I think psychiatrists hand out antipsychotics too freely for non-psychotic patients, but IANAD/IANYD, just a patient who has frequently been pressured to try this kind of drug always with poor results.

Another potential option is Vistaril. It's a first gen antihistamine, similar to benadryl/diphenhydramine and doxylamine, but only available with a prescription. It's generally prescribed for anxiety, but I've found it helpful for sleep as well. My understanding is it's better tolerated longer term vs other first gen antihistamines, but I can't speak to whether a tolerance to sedation will be an issue, since I generally take it for anxiety as needed.

Also seconding the CBT recommendation. It sounds like your anxiety around sleep is really the bigger problem.
posted by litera scripta manet at 4:37 PM on November 28, 2021

Best answer: "for no discernible reason and pretty much overnight, it stopped working."

You mention you are an EMT/First responder, and suddenly things suck.

Maybe you are having a perfectly reasonable reaction to an extended stressor? I can't think of any relevant ones.... oh wait *cough cough* COVID

I mean, this could be biological, but in my experience (psychologist, not your psychologist) abrupt "phase changes" like this are often psychological.

Another way of framing it: imagine you were on zero meds, and this happened to you. What would you do? Probably, talk to a shrink first, and if that didn't work after some time *maybe* start meds.

If your pharma solution worked for 20 years, my first impulse would not be to alter it. Look into other psycho-social issues first, and address those?
posted by soylent00FF00 at 6:07 PM on November 28, 2021 [1 favorite]

I do not currently have trouble sleeping, but I did for many years. One idea is the actual valerian root, as in a root, not the capsules. Available online or in a Latino market. Make a tea out of it. Caution: it’s hard to say how herbs will interact with whatever other medications you’re taking.
posted by 8603 at 6:07 PM on November 28, 2021

Have you tried mirtazapine? I alternate it with trazodone at times, when it feels like the traz isn't working enough.
posted by ChristineSings at 8:05 PM on November 28, 2021

This probably doesn't apply to you because I had a huge blind spot but just in case: I have generalized anxiety disorder that manifested as insomnia for around a decade before it occurred to me to try plain, over the counter melatonin. I figured there was no way it would help when SSRIs didn't. But it has been a miracle.
posted by Threeve at 10:57 PM on November 28, 2021 [3 favorites]

Best answer: Trazadone has a pretty large acceptable dosage range. Have you concidered talking to your doctor and just increasing the dose?

I'm currently taking it for sleep and if I'm stressed sometimes I increase my dosage by 25 or 50mg for a bit and lower it later (or I don't). It does stay in my body for an annoying 9 hours (not 8) but I also consistently sleep so there's that.
posted by AlexiaSky at 12:56 AM on November 29, 2021

I am so sorry you are dealing with this problem. Alas, I have no direct experience with the drug in question. For about 30 years I have wrestled with difficulty in falling asleep and/or waking in the middle of the night and being unable to go back to sleep for several hours.

Last summer I moved to a new place and decided to use the principals outlined in this Guardian article at my new place to see if that improved my sleep. It did! I also have a prescription for diazepam (Valium) for sleeping problems. I take half a tablet (10 mg) maybe every other week if I’ve had a couple of bad nights in a row.

When my psychiatrist at the time suggested diazepam, I was extremely wary. He’s kind of a cranky geezer and claimed he had been taking it to helm himself sleep since the 1960s without any problems and if it was good enough for him, it was good enough for me.

Obviously, I am not a doctor, diazepam might be a terrible choice for you, yadda yadda. I will also note that using my bedroom solely for sleeping, and keeping the room cool and very dark has really improved my sleep. When I lived in a small studio, I could not do that. Good luck!
posted by Bella Donna at 7:15 AM on November 29, 2021

Best answer: I have had this happen several times over the last 20+ years I've taken Trazodone. Somebody above mentioned the dose range being quite large. I take 150 regularly. If I don't fall asleep within 60-90 minutes, I take a second one. That usually does it. A quick look told me max outpatient dosage is 400mg. Max inpatient dosage is 600. I call my doc if this goes on beyond a few days. But usually, it resolves within a day or two.
posted by kathrynm at 9:51 AM on November 29, 2021

Trazodone just stopped working for me at some point too. This blog entry has two tables of the extensive list of stuff I've tried for sleep.

I concur on the magnesium - I use several forms, topical and sublingual. I don't sleep if my calcium's too low either.

For myself, I know there are times when my regimen has fallen apart because my absorption of the meds has fallen. I take my sleep meds with a couple tablets of this betaine hydrochloride so that they actually get on board, and there have been times when a daily serving of yogurt for a while has seemed to get my sleep regimen back on track. (If you need calcium with betaine, take citrate and not carbonate - betaine and calcium carbonate cancel each other out.)
posted by jocelmeow at 11:05 AM on November 29, 2021

1. To echo Lyn Never - double check the actual pills. All of them. After several years of taking Ambien regularly, it just completely stopped working, and I know how you feel, because I FREAKED. I went through all the pills left in the bottle and they were all Ambien, except one, a nearly-identical Paxil. (When I reported this to the pharmacy they were completely unconcerned, yay.) I concluded that the other non-working pills must've been Paxil as well, and was just thankful that there was one left in the bottle or I would've thought I was losing my mind.

2. Have you started a new diet / eating schedule recently? When I was on Trazodone, it worked infinitely better with a snack. If I was religiously sticking to my "no eating after dinner" plan I could count on a lot more tossing and turning.
posted by storminator7 at 6:51 PM on November 29, 2021

Response by poster: Thanks, everyone.

During the past few days it's become pretty clear that - as soylent00FF00 and others noted - anxiety and hypervigilance are the real problems here. Traz can only do so much against 'em. Guess two years of constant background worry about COVID and the health of family members + long periods of intense, job-related stress + some huge fault lines running through the foundation of my coping skills and support system were bound to catch up eventually. I'm currently reaching out to a couple of first responder mental health organizations for help in locating a therapist in my area to work on that last item.

I did mark some 'best answers' here, but appreciate the whole range of replies. Gonna save some suggestions which aren't relevant now but may be worth a look down the line.
posted by Lycaon_pictus at 11:08 AM on November 30, 2021 [3 favorites]

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