This patient presents with insomnia, a common complaint in the primary care setting. Trazodone is commonly used off-label as a sleep-aid and works by inhibiting reuptake of serotonin, which is released from the raphe nucleus.
The raphe nucleus (actually a collection of nuclei) is located medially in the brain stem and works to release serotonin. They are acted upon by many medications, including antidepressants such as SSRIs and SNRIs, as well as trazodone. Trazodone's feared side effect is priapism, although this is a rare complication.
Ramakrishnan and Scheid review the initial evaluation and different treatment options for insomnia. Comorbid and contributing medical and psychiatric illnesses must first be considered. Other related symptoms such as daytime somnolence and headaches should be inquired about as possible signals that obstructive sleep apnea is present. Finally, a sleep diary should be utilized to accurately track the patient's actual sleep habits. Medications for insomnia include antihistamines, benzodiazepines, melatonin / melatonin receptor agonists, and non-benzodiazepine sedatives such as zolpidem. These medications all generally have their own side effects in addition to being sedating medications.
Li et al. evaluated the association between different insomnia-related symptoms and cardiovascular mortality in a large cohort of health professionals. After controlling for certain predictive factors, they found an increased mortality risk for patients who endorsed difficulty initiating sleep and those who experienced nonrestorative sleep. Of note, the amount of increased risk was small, and the authors cautioned that further research should be conducted to confirm this.
Illustration A depicts a sagittal schematic of the location of the raphe nuclei in relation to nearby brainstem structures. The nuclei are located medially within the brainstem (which would be shown on an axial image) .
Answer 1: The substantia nigra is the site of dopamine production.
Answer 3: The locus ceruleus is the site of norepinephrine production.
Answer 4: The nucleus accumbens is the site of GABA production.
Answer 5: The posterior pituitary releases ADH and oxytocin into circulation.
Ramakrishnan K, Scheid DC. Treatment options for insomnia. Am Fam Physician. 2007 Aug 15;76(4):517-26.
PMID:17853625 (Link to Abstract)
Li Y et al. The association between insomnia symptoms and mortality: a prospective study of US men. Circulation. 2014 Feb 18;129(7):737-46
PMID:24226807 (Link to Abstract)