It’s been a stretch for me to accept that trazodone, a sedating antidepressant, is such a popular treatment for insomnia. Clinical trials have never shown it helps put people to sleep or keeps them sleeping longer. And even at low doses (50 mg.), the drug is known to produce cognitive and motor impairments the following day.* Trazodone has never been approved for the treatment of insomnia, yet it rose to the top of the bestseller charts as a medication for sleeplessness in the 1990s and enjoys great popularity still.
Confession: this is the sort of knotty paradox that keeps me awake at night.
Now, I have insomniac friends who swear by trazodone, and I know they’re not delusional. They use low-dose trazodone because it works for them, and they don’t need to understand why.
But I’m a stickler for evidence, and this gap between subjective experience and objective proof is a real sore point. So imagine my thrill at finding a paper that explains why it might be that trazodone works.
Trazodone and REM Sleep
The traditional view of insomnia holds that it’s basically a problem of non-REM (or quiet) sleep. Insomniacs may not be getting the same percent of deep sleep as good sleepers, or the problem may be in how deep sleep is discharged. Deep sleep is the restorative stuff, the kind that “knits up the raveled sleeve of care.” Alternatively, the quality of non-REM sleep may be compromised by lots of high-frequency brain activity that enables you to sense things even while you’re asleep.
But for insomniacs who struggle with frequent awakenings in the middle of the night, the problem may in fact be occurring during REM (or active) sleep, when you’re dreaming. A new analysis shows that percent-wise, people with sleep maintenance insomnia get less REM sleep and awaken more often during REM sleep than good sleepers. The hypothesis is that these insomniacs may be suffering from “REM sleep instability.”**
Despite its otherwise underwhelming characteristics as a sleep medication, trazodone does cut down on nighttime awakenings and make sleep feel easier. Unlike most other antidepressants, the drug does not suppress REM sleep. So as a sleeping pill, trazodone may have a claim to legitimacy after all.
Perhaps you’re one who knew it all along, but I was a skeptic, and this bit of news has done wonders for my sleep!