In this case study Linda is a 49-year-old female with a history of depression. Her chief complaints are “fatigue, tearfulness and difficulty sleeping”. She is currently taking fluoxetine 20 mg once/day for the last six months.
The first adjustment I would make to her plan of care is to slowly titrate her current dose of fluoxetine up by 10 mg every 4 weeks until there is at least a fifty percent reduction in her current depression symptoms. I would prescribe her 30 mg once/day of fluoxetine and have her follow up in four weeks with me.
The second adjustment I would make to her plan of care is the addition of a SARI (Serotonin Antagonist/Reuptake Inhibitor). In this case I would specifically add Trazadone. Trazadone is well known for its efficacy as a low dose hypnotic. According to Stahl (2021):
“Since insomnia is one of the most frequent residual symptoms of depression after treatment with an SSRI/SNRI, addition of a hypnotic is often necessary in treating patients with a major depressive episode. Not only can addition of a hypnotic potentially relieve the insomnia itself, it may also increase remission rates due to improvement of other symptoms such as loss of energy and depressed mood. Thus, the ability of low doses of trazadone to improve sleep in depressed patients has led to its popular use at low doses as an augmenting option for residual insomnia that persists after treatment with SSRIs/SNRIs” (p. 311).
I would start the patient on adjunct therapy of Trazadone of 150 mg/day. Patient will follow up with me in four weeks and if we need to titrate the dose up at that time we can.
I would advise the patient to take the Trazadone 30 minutes to 1 hour before bedtime (as it causes drowsiness).