Trazodone for management of depression in Parkinson's disease: expert opinion and proposal for a treatment algorithm

Background: Depression is an underrecognized and undertreated condition in Parkinson’s disease (PD). The development of updated, individualized management strategies represents an important unmet need for clinicians and care providers. This review examines the use of trazodone, focusing on its mechanism of action, and proposes a practical algorithm for its use in the management of depression in patients with PD. Materials and methods: Seven neurologists, experts in movement disorders took part in a structured panel on depression management to exchange ideas and experiences for the implementation of best practice. Results: The experts agreed that trazodone can be beneficial in PD patients with comorbid depression. The treatment algorithm proposed considers patients in early or more advanced stages of PD. In early stages with mood alterations and anxiety, the suggested treatments are a mood stabilizer, trazodone, or a tricyclic antidepressant. Serotonergic therapy or an SNRI should be considered for patients with low mood but no agitation. In presence of depressive mood with predominant insomnia, high-dose trazodone should be considered along with mirtazapine. In more advanced stages, in the presence of cognitive deficits without agitation low to medium dose trazodone can be considered along with mirtazapine. In case of cognitive deficits with agitation, low to medium dose trazodone is suggested. Conclusions: The proposed algorithm may assist neurologists in the management of depression in patients with PD by providing specific recommendations on the role of trazodone across different clinical scenarios, allowing for individualized treatment.