OH MY GOD. Are you ever hilarious. Wish you were my shrink. Love your cats.
I take An SNRI and if I don’t take 50 mg of trazodone at bedtime I can’t sleep. I am not an insomniac. My sleep is great. I’m on duloxetine and would love to discontinue however the symptoms are hard to bear so I keep taking it. Doing somatic stuff and meditating has pretty much handled the so-called depression
I really enjoyed this! As a patient, I was prescribed trazadone for insomnia but didn't take it much because i felt terrible the next day (worse then losing a couple hours trying to fall asleep). I also found the ACSM guidelines and showed them to my primary care, and he basically said "look, everyone's been prescribing trazadone for insomnia forever, why would I trust these guidelines that seem to push benzos and have nothing above low confidence in any recommendation".
I have trouble thinking of this as being about trazodone in particular, since as you mention there are similar findings with Ambien, and I've seen similar findings elsewhere about melatonin. I think of this as part and parcel of the "studies show trivial effects of antidepressants but in clinical practice they seem to work" phenomenon - for some reason all of these drugs don't look as good in studies as in patients. This could be placebo effect (which is still valuable!) or something more like https://www.astralcodexten.com/p/all-medications-are-insignificant
Still, it's interesting you were able to find good studies supporting doxepin. My patients rarely like this and often complain that it lasts too long, but maybe I should give it another try.
First, thanks for reading Scott! It's hard to overstate how influential ACX and SSC have been on me.
Second, generally agree that this is a "medications never work as well as they do in studies" problem, though I think the evidence base for trazodone is particularly bad relative to the other hypnotics and that it has survived purely out of inertia.
Re: Doxepin lasting too long. I'm guessing that, like me, you've been prescribing the 10mg generic capsule, and not the on-patent 3 or 6mg tablets that insurance won't pay for? There is at least a couple studies out there that show no residual morning effects from the 3/6mg preparations. Doxepin is so potent at H1 that I bet the extra 4mg really does make a difference in terms of residual morning effects. I've told some patients to open the capsule and eyeball a half-dose in some cases.
Have had a couple of big SQ improvements with Doxepin recently so I’m happy you’re still endorsing it’s use and I’d be interested in a later further post on it. Thank you for sharing!
OH MY GOD. Are you ever hilarious. Wish you were my shrink. Love your cats.
I take An SNRI and if I don’t take 50 mg of trazodone at bedtime I can’t sleep. I am not an insomniac. My sleep is great. I’m on duloxetine and would love to discontinue however the symptoms are hard to bear so I keep taking it. Doing somatic stuff and meditating has pretty much handled the so-called depression
. AGH.
I really enjoyed this! As a patient, I was prescribed trazadone for insomnia but didn't take it much because i felt terrible the next day (worse then losing a couple hours trying to fall asleep). I also found the ACSM guidelines and showed them to my primary care, and he basically said "look, everyone's been prescribing trazadone for insomnia forever, why would I trust these guidelines that seem to push benzos and have nothing above low confidence in any recommendation".
Thanks for this.
I have trouble thinking of this as being about trazodone in particular, since as you mention there are similar findings with Ambien, and I've seen similar findings elsewhere about melatonin. I think of this as part and parcel of the "studies show trivial effects of antidepressants but in clinical practice they seem to work" phenomenon - for some reason all of these drugs don't look as good in studies as in patients. This could be placebo effect (which is still valuable!) or something more like https://www.astralcodexten.com/p/all-medications-are-insignificant
Still, it's interesting you were able to find good studies supporting doxepin. My patients rarely like this and often complain that it lasts too long, but maybe I should give it another try.
First, thanks for reading Scott! It's hard to overstate how influential ACX and SSC have been on me.
Second, generally agree that this is a "medications never work as well as they do in studies" problem, though I think the evidence base for trazodone is particularly bad relative to the other hypnotics and that it has survived purely out of inertia.
Re: Doxepin lasting too long. I'm guessing that, like me, you've been prescribing the 10mg generic capsule, and not the on-patent 3 or 6mg tablets that insurance won't pay for? There is at least a couple studies out there that show no residual morning effects from the 3/6mg preparations. Doxepin is so potent at H1 that I bet the extra 4mg really does make a difference in terms of residual morning effects. I've told some patients to open the capsule and eyeball a half-dose in some cases.
Thanks, you're right that I was doing that, and I'll try asking them to open the capsule.
Is the metabolite mCPP responsible for any trazodone side effects? Vivid dreams, for example?
I have this impression from lectures that trazodone metabolizes into an hallucinogenic above 150mg dose, but nothing firm to base that on.
Have had a couple of big SQ improvements with Doxepin recently so I’m happy you’re still endorsing it’s use and I’d be interested in a later further post on it. Thank you for sharing!