To the Editor: Nightmares are defined as extremely frightening dreams from which a person wakes up directly. The prevalence rates of nightmares are not well established. In 2000, Nielsen and Zadra¹ estimated a prevalence rate of around 4% to 8% of the general population. Nightmares were reported to be related to suicidality, regardless of depression, in a 2005 study.² The most effective treatments reported in the literature were either cognitive-behavior treatment or pharmacological interventions. However, several studies have reported that prazosin seemed to be effective in reducing posttraumatic nightmare frequency,³ but it was still controversial. Herein, we report the case of a patient with major depressive disorder with marked nightmares who was successfully treated by low doses of trazodone. This case report may provide an alternative treatment for nightmares.

A 24-year-old Taiwanese man was admitted for psychiatric inpatient treatment because of major depressive disorder. The patient presented the characteristic symptoms of depressed mood, loss of interest, fatigue, insomnia with vivid nightmares, and feelings of hopelessness for 3 months. He especially complained of easily broken sleep due to nightmares. Initial laboratory blood tests, such as thyroid function, revealed normal ranges. The 17-item Hamilton Rating Scale for Depression (Ham-D) total score was 16 on the first hospital day. Initially, the patient was treated with escitalopram, 10 mg/day, for 14 days. Depressed mood was improved, and the Ham-D total score improved to 9. However, the symptoms of easily broken sleep with vivid nightmares persisted; 50 mg of trazodone per night was then added, and insomnia with vivid nightmares remitted during the following nights. However, he also experienced dizziness, headache, and nausea. Because of the intolerable side effects, trazodone was discontinued, and zolpidem, 10 mg per night, was added. Unfortunately, the nightmares returned when trazodone was discontinued.

Trazodone was indicated as a treatment for major depressive disorder in 1998. Because of its sedative properties, low-dose trazodone has been widely used as an alternative or a treatment in addition to selective serotonin reuptake inhibitors (SSRI) for hypotonic and antidepressant purposes.⁴ Trazodone is a potent antagonist of serotonin 5HT_2A and 5HT_2C receptors, a moderate-to-highly potent α-adrenergic receptor antagonist, and a histaminergic antagonist. Trazodone increases total sleep time and decreases the amount of REM sleep.

Moreover, Kramer and Roth⁵ suggested that REM sleep has a mood-regulatory function, and nightmares usually occur during this stage; blockade of α₁-adrenergic receptors, as caused by prazosin, may normalize REM sleep. For our patient, we added trazodone, a highly potent α-adrenoceptor antagonist, on the 15th hospital day for the persistent insomnia with nightmares related to the depressive symptoms themselves or to the sleeplessness caused by escitalopram. As a result, nightmare frequency decreased during the following nights. Trazodone improved not only SSRI-induced insomnia with nightmares but also depressed mood.

In the future, it would be of interest to undertake a study of potential therapeutic effects of trazodone for nightmares and to develop objective parameters for nightmares.