Does Trazodone (an antidepressant medication) suppress Rapid Eye Movement (REM) sleep?

Does Trazodone Suppress REM Sleep?

Trazodone does not significantly suppress REM sleep, unlike many other antidepressants, making it a more favorable option for patients with insomnia who need to preserve normal sleep architecture. 1, 2, 3

Effects of Trazodone on Sleep Architecture

Trazodone has a unique profile regarding its effects on sleep stages compared to other antidepressants:

REM Sleep Effects

• Unlike traditional antidepressants such as imipramine that significantly suppress REM sleep and prolong REM latency 1, trazodone has minimal impact on REM sleep percentage
• In studies of depressed patients with insomnia, trazodone increased REM latency by approximately 28% (from 74.6 to 95.6 minutes) but did not reduce the overall percentage of REM sleep 2
• This contrasts with SSRIs and tricyclic antidepressants, which typically cause significant REM suppression

Other Sleep Architecture Effects

• Trazodone significantly increases:

  • Total sleep time (14% improvement in one study) 2
  • Slow wave sleep (more than doubling stage IV sleep in one study) 2
  • Sleep efficiency (improvement from 80.6% to 91.9%) 2
  • Sleep continuity 3

• Trazodone decreases:

  • Sleep latency (44% improvement in one study) 2
  • Stage 1 sleep 3
  • Number of awakenings 3
  • Fast-frequency EEG activity during NREM sleep 4

Clinical Implications

For Insomnia Treatment

• Trazodone is commonly used off-label for insomnia treatment at lower than antidepressant doses (typically 25-100mg) 5
• Its preservation of REM sleep makes it potentially advantageous over other sedating medications that may disrupt normal sleep architecture

For REM Sleep Behavior Disorder (RBD)

• Interestingly, while most antidepressants can exacerbate RBD, there are recent case reports suggesting trazodone may actually improve symptoms in some patients with isolated RBD at doses of 50-100mg 6
• However, guidelines note that trazodone has been reported to increase arousals in a small RCT 5, so its effects may be variable

For ICU Patients

• In critically ill patients, sleep disruption often includes decreased REM sleep 5
• When medications are needed for sleep in this population, those that preserve REM sleep would be preferable

Important Considerations and Precautions

1. Dosage matters: Lower doses (25-100mg) are typically used for insomnia, while higher doses (150-400mg) are used for depression

2. Individual variation: Some patients may experience different effects on sleep architecture

3. Monitoring: When using trazodone primarily for sleep, monitor for:

   • Morning sedation/hangover effects
   • Orthostatic hypotension
   • Priapism (rare but serious)

4. Comparison to other sleep medications:

   • Unlike benzodiazepines and non-benzodiazepine hypnotics which can suppress slow wave sleep
   • Unlike most antidepressants (especially SSRIs) which significantly suppress REM sleep
   • Melatonin receptor agonists may have less impact on sleep architecture overall

In conclusion, trazodone's relative preservation of REM sleep while improving other sleep parameters makes it a useful option for treating insomnia, particularly in patients where preservation of normal sleep architecture is important.