Trazodone Side Effects and Considerations

Common Side Effects

The American Academy of Sleep Medicine reports that trazodone's most common side effects are somnolence (drowsiness/sedation), dizziness, headache, and dry mouth, with the sedation being more pronounced than other antidepressants like bupropion, fluoxetine, mirtazapine, paroxetine, or venlafaxine 1
Somnolence/sedation is the predominant side effect and occurs at higher rates than with other second-generation antidepressants 1
Dizziness is commonly reported, particularly when changing positions 1
Headache is a frequent complaint among users 1
Nausea and vomiting are gastrointestinal effects that occur regularly 1

In a study of 74 patients, 14 (19%) discontinued trazodone due to intolerable side effects, including priapism, daytime sedation, more vivid nightmares, dry mouth/sinuses, muscle pain, and severe agitation 2, 3
Priapism was reported in 5 patients (approximately 7%) who discontinued trazodone 2
Daytime sedation was a reason for discontinuation in 5 patients 2
60% of patients continuing trazodone in clinical studies experienced some side effect, with daytime sedation and dizziness being most common 2, 3

Trazodone is associated with higher rates of somnolence than bupropion, fluoxetine, mirtazapine, paroxetine, or venlafaxine, according to Praxis Medical Insights 4
QT interval prolongation and potential for torsade de pointes, though this is relatively rare, as reported in Circulation 5

Trazodone has minimal anticholinergic activity compared to tricyclic antidepressants, making it potentially better tolerated in elderly patients, as noted by Praxis Medical Insights 6
Caution is required in patients with premature ventricular contractions due to potential cardiovascular effects, as advised by Praxis Medical Insights 6

Trazodone is commonly used off-label at lower doses for insomnia, as recommended by Praxis Medical Insights 6
It may be used for agitation in dementia at initial doses of 25 mg per day, with a maximum of 200-400 mg per day in divided doses, according to Praxis Medical Insights 6
Trazodone has shown efficacy in reducing nightmare frequency in PTSD at a mean dose of 212 mg/day, as reported by Praxis Medical Insights 6

Trazodone avoids the common sexual dysfunction problems seen with SSRIs, including decreased libido, delayed orgasm, and erectile difficulties, according to the American College of Physicians, with a mechanism as a serotonin receptor antagonist and reuptake inhibitor (SARI) that may overcome these tolerability issues 7
Bupropion remains the only antidepressant with lower sexual side effects than trazodone, showing significantly reduced sexual adverse events compared to fluoxetine or sertraline 7

The most serious sexual side effect of trazodone is priapism (prolonged erection >4 hours), which occurs rarely but requires immediate medical attention to prevent permanent corporal tissue damage, and patients must be explicitly warned about this risk and given a clear action plan by the American Urological Association 8
All patients prescribed trazodone must be instructed to seek emergency care if an erection lasts 4 hours or longer, as early intervention with nonsurgical measures is usually successful when treatment occurs promptly 8, 9, 10

The American Urological Association explicitly states that trazodone is NOT recommended for treating erectile dysfunction, as randomized controlled trials showed no statistically significant benefit over placebo 8, 9, 11

Counsel ALL male patients about priapism risk and provide explicit instructions to seek emergency care for erections lasting >4 hours, according to the American Urological Association 8
Consider trazodone advantageous for patients who experienced sexual dysfunction on SSRIs (particularly paroxetine) or SNRIs, as it avoids these common problems, according to the American College of Physicians 7
Do NOT prescribe trazodone specifically to treat erectile dysfunction, as evidence shows no efficacy over placebo despite its mechanism, according to the American Urological Association 8, 11

Never dismiss patient reports of prolonged erections - priapism is a urological emergency requiring intervention within 4 hours to prevent permanent damage, and patients must be explicitly warned about this risk and given a clear action plan by the American Urological Association 8, 9, 10

The American Heart Association acknowledges that many psychotropic drugs, including those potentially co-administered with trazodone, can cause taste disturbances 12
The American College of Cardiology recognizes QT prolongation and potential torsade de pointes as rare but documented serious adverse effects of trazodone, particularly with overdose 12

The American Heart Association suggests evaluating other medications the patient is taking for potential polypharmacy interactions that can cause taste disturbances 12