Sleep Medicine Reviews 15 (2011) 269e281

Contents lists available at ScienceDirect

Sleep Medicine Reviews

journal homepage: www.elsevier.com/locate/smrv

PHYSIOLOGICAL REVIEW

Serotonin control of sleep-wake behavior

Jaime M. Monti*
Department of Pharmacology and Therapeutics, School of Medicine Clinics Hospital, Montevideo 11600, Uruguay

a r t i c l e i n f o s u m m a r y

Article history: Based on electrophysiological, neurochemical, genetic and neuropharmacological approaches, it is

Received 28 August 2010 currently accepted that serotonin (5-HT) functions predominantly to promote wakefulness (W) and to
Received in revised form inhibit REM (rapid eye movement) sleep (REMS). Yet, under certain circumstances the neurotransmitter
27 November 2010
contributes to the increase in sleep propensity. Most of the serotonergic innervation of the cerebral cortex,
Accepted 28 November 2010
Available online 2 April 2011
amygdala, basal forebrain (BFB), thalamus, preoptic and hypothalamic areas, raphe nuclei, locus coeruleus
and pontine reticular formation comes from the dorsal raphe nucleus (DRN). The 5-HT receptors can be
classied into at least seven classes, designated 5-HT1e7. The 5-HT1A and 5-HT1B receptor subtypes are
Keywords:
Serotonin
linked to the inhibition of adenylate cyclase, and their activation evokes a membrane hyperpolarization. The
Brain stem actions of the 5-HT2A, 5-HT2B and 5-HT2C receptor subtypes are mediated by the activation of phospholipase
Sleep C, with a resulting depolarization of the host cell. The 5-HT3 receptor directly activates a 5-HT-gated cation
Wakefulness channel which leads to the depolarization of monoaminergic, aminoacidergic and cholinergic cells. The
Slow wave sleep primary signal transduction pathway of 5-HT6 and 5-HT7 receptors is the stimulation of adenylate cyclase
Rapid eye movement sleep which results in the depolarization of the follower neurons. Mutant mice that do not express 5-HT1A or 5-
Dorsal raphe nucleus HT1B receptor exhibit greater amounts of REMS than their wild-type counterparts, which could be related to
5-HT receptors
the absence of a postsynaptic inhibitory effect on REM-on neurons of the laterodorsal and pedunculo-
Laterodorsal and pedunculopontine
pontine tegmental nuclei (LDT/PPT). 5-HT2A and 5-HT2C receptor knock-out mice show a signicant
tegmental nuclei
Basal forebrain increase of W and a reduction of slow wave sleep (SWS) which has been ascribed to the increase of cate-
cholaminergic neurotransmission involving mainly the noradrenergic and dopaminergic systems. Sleep
variables have been characterized, in addition, in 5-HT7 receptor knock-out mice; the mutants spend less
time in REMS that their wild-type counterparts. Direct infusion of the 5-HT1A receptor agonists 8-OH-DPAT
and esinoxan into the DRN signicantly enhances REMS in the rat. In contrast, microinjection of the 5-HT1B
(CP-94253), 5-HT2A/2C (DOI), 5-HT3 (m-chlorophenylbiguanide) and 5-HT7 (LP-44) receptor agonists into
the DRN induces a signicant reduction of REMS. Systemic injection of full agonists at postsynaptic 5-HT1A
(8-OH-DPAT, esinoxan), 5-HT1B (CGS 12066B, CP-94235), 5-HT2C (RO 60-0175), 5-HT2A/2C (DOI, DOM),
5-HT3 (m-chlorophenylbiguanide) and 5-HT7 (LP-211) receptors increases W and reduces SWS and REMS.
Of note, systemic administration of the 5-HT2A/2C receptor antagonists ritanserin, ketanserin, ICI-170,809 or
sertindole at the beginning of the light period has been shown to induce a signicant increase of SWS and
a reduction of REMS in the rat. Wakefulness was also diminished in most of these studies. Similar effects
have been described following the injection of the selective 5-HT2A receptor antagonists volinanserin and
pruvanserin and of the 5-HT2A receptor inverse agonist nelotanserin in rodents. In addition, the effects of
these compounds have been studied on the sleep electroencephalogram of subjects with normal sleep.
Their administration was followed by an increase of SWS and, in most instances, a reduction of REMS. The
administration of ritanserin to poor sleepers, patients with chronic primary insomnia and psychiatric
patients with a generalized anxiety disorder or a mood disorder caused a signicant increase in SWS. The
5-HT2A receptor inverse agonist APD-125 induced also an increase of SWS in patients with chronic primary
insomnia. It is known that during the administration of benzodiazepine (BZD) hypnotics to patients with
insomnia there is a further reduction of SWS and REMS, whereas both variables tend to remain decreased
during the use of non-BZD derivatives (zolpidem, zopiclone, eszopiclone, zaleplon). Thus, the association of
5-HT2A antagonists or 5-HT2A inverse agonists with BZD and non-BZD hypnotics could be a valid alternative
to normalize SWS in patients with primary or comorbid insomnia.
2010 Elsevier Ltd. All rights reserved.

* Tel.: 598 2 710 58 07.

E-mail address: jmonti@mednet.org.uy.

1087-0792/$ e see front matter 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.smrv.2010.11.003
270 J.M. Monti / Sleep Medicine Reviews 15 (2011) 269e281

Abbreviations LH posterior lateral hypothalamus

MCH melanin-concentrating hormone
ACh acetylcholine mPRF medial pontine reticular formation
AMPA alpha-amino-3-hydroxy-5-methyl-4-isoxazole MRN median raphe nucleus
propionate NE norepinephrine
BFB basal forebrain NREMS non-REM sleep
BNST bed nucleus of the stria terminalis OX orexin
BZD benzodiazepine PCPA p-chlorophenylalanine
CNS central nervous system PPT pedunculopontine tegmental nucleus
DA dopamine REM rapid eye movement
DRN dorsal raphe nucleus REMS REM sleep
5-HT serotonin s.c. subcutaneous
GABA gamma-aminobutyric acid SNc substantia nigra pars compacta
GLU glutamate SSRI selective serotonin reuptake inhibitor
HA histamine SWS slow wave sleep
i.c.v. intracerebroventricular VLPO ventrolateral preoptic area
IL-1 interleukin-1 VPGM ventral periaqueductal gray matter
i.p. intraperitoneal VTA ventral tegmental area
LC locus coeruleus W wakefulness
LDT/PPT laterodorsal and pedunculopontine tegmental nuclei

Introduction regulating mechanisms are not disrupted in PCPA-treated rats.15

Within the central nervous system serotonin (5-HT) participates
in a great number of functions including sleep-wake behavior,
cognition, affect, sexual function, thermoregulation and food
intake. It has been established, in addition, that increases or
decreases of 5-HT at central sites correlate with improved or
worsened depression. In this respect, most of the drugs used to
treat mood disorders including the selective serotonin reuptake
inhibitors (SSRIs), the tricyclic antidepressants and the monoamine
oxidase inhibitors increase synaptic levels of 5-HT. The SSRIs are
also the rst line drugs for the treatment of anxiety disorders such
as generalized anxiety disorder, panic disorder and obsessive
compulsive disorder1.
Although many questions remain about the complicated role of
5-HT and its receptors in regulating sleep and wakefulness (W),
recent studies have revealed much detailed information about this
process. It should be mentioned that in the 1970s, based on lesion
studies and neuropharmacological analysis, 5-HT was hypothesized
to be responsible for the initiation and maintenance of slow wave
sleep (SWS).2 However, a series of ndings from several laboratories
seriously challenged the serotonergic hypothesis of sleep. Thus, the
ring rate of 5-HT-containing dorsal raphe nucleus (DRN) neurons
decreases during SWS relative to W3; reduction of brain 5-HT by p-
chlorophenylalanine (PCPA) fails to disrupt sleep in humans, and in
some studies, also in the rat4,5; 5,7-dihydroxytryptamine, which
produces a more selective and extensive depletion of brain 5-HT
than the raphe lesions, does not signicantly affect SWS6; and
there is no signicant difference between tryptophan-decient
and -replete rats in time spent in SWS.7 Concerning those studies
showing that PCPA increases W in the rat,8,9 it should be taken into
consideration that this 5-HT synthesis inhibitor also induces
increased responsiveness to noxious or neutral environmental
stimuli and enhances motor activity, aggressivity, and sexual
activity.10e13 Therefore, insomnia after PCPA in the rat and the cat
could be related to a general hyper-responsiveness to stimuli rather
than to impairment of sleep regulation itself. Even in the studies in
which insomnia followed PCPA administration, the effect was
a transitory one, and SWS returned while 5-HT levels remained
depleted.14 Moreover, in rats subjected to combined treatment with
PCPA and sleep deprivation, delta activity reached the same high
levels as after deprivation alone, which tends to indicate that SWS-
With regard to an alternative hypothesis,16 there is no rm
evidence to support the proposal that 5-HT released during W might
act as a neurohormone and induce the synthesis and/or release of
hypnogenic factors secondarily responsible for SWS and REM (rapid
eye movement) sleep (REMS) occurrence.
More recently it has been posed that 5-HT should not be
considered either wake-promoting or SWS-promoting, and that the
effect of 5-HT on sleep-wake behavior would depend upon the
degree to which the serotonergic system is activated (systemic
administration of low vs. high doses of the 5-HT precursor
5-hydroxytryptophan), and the time at which the activation occurs
(light vs. dark period of the light-dark cycle).17e19 It has been
hypothesized that the 5-hydroxytryptophan-related increase of
SWS during the dark period depends upon the synthesis or release
of as yet to be identied sleep-promoting factors.17 Alternatively,
sleep occurrence might be associated with a 5-HT1A receptor-
mediated reduction in the activity of cholinergic waking-
promoting neurons in the basal forebrain (BFB).20,21
On the basis of results obtained from genetic, neurochemical,
electrophysiological and neuropharmacological studies conducted
over the past three decades it is proposed that 5-HT functions
predominantly to promote W and to inhibit REMS. Notwith-
standing this, under certain circumstances the indolamine seems to
contribute to the increase in sleep propensity. The evidence that 5-
HT is involved in the regulation of the behavioral state and its
relationship to other sleep-wake regulatory neurotransmitters is
the focus of this review.
The brain regions and neurotransmitter systems involved in the
regulation of the behavioral state will be described next.
Brain regions and neurotransmitter systems involved in the
regulation of wakefulness
The brain regions involved in the promotion of the waking state
are located in the brain stem, hypothalamus and BFB. The nuclei
found in the brain stem include serotonin [5-HT: dorsal raphe
nucleus (DRN), median raphe nucleus (MRN)]; norepinephrine [NE:
locus coeruleus (LC)]; dopamine [DA: ventral tegmental area (VTA),
substantia nigra pars compacta (SNc), ventral periaqueductal grey
matter (VPGM)]; acetylcholine [ACh: laterodorsal and pedunculo-
pontine tegmental nuclei (LDT/PPT); BFB]; and glutamate [GLU:
 J.M. Monti / Sleep Medicine Reviews 15 (2011) 269e281 271

Fig. 1. Main neuroanatomical structures that receive afferent projections from the dorsal raphe nucleus (B6 and B7) in the rat CNS. Abbreviations: LDT, laterodorsal tegmental
nucleus; PRF, pontine reticular formation.

medial pontine reticular formation (mPRF); BFB]-containing system participates in the response. In this respect, the DRN
neurons. The structures located in the hypothalamus include contains IL-1 receptors; IL-1b inhibits the ring rates of DRN 5-HT
histamine [HA: tuberomammillary nucleus (TM)]; and orexin [OX: neurons in a slice preparation; and microinjection of IL-1b into the
posterior lateral hypothalamus (LH) around the fornix ]-containing DRN of freely behaving rats increases SWS.27 It has been deter-
cells. The cholinergic and glutamatergic neurons of the BFB involved mined, in addition, that IL-1b inhibits DRN 5-HT cells by potenti-
in the regulation of the behavioral state are located predominantly ating GABAergic inhibitory effects.28
in the medial septum and the diagonal band of Broca.22,23
The neural structures that participate in the regulation of W give
Brain regions and neurotransmitter systems involved in the
rise to mainly ascending projections. In this respect, a) 5-HT-, NE-,
regulation of REM sleep
and HA-containing neurons send long ascending projections to the
thalamus, cerebral cortex, and BFB; b) DA-containing cells project
On the grounds of studies in which the cholinergic agonist
into the basal ganglia (caudate and putamen, external and internal
carbachol was microinjected into rostral pontine structures of the
globus pallidus, subthalamic nucleus) and the frontal cortex;
cat, it has been proposed that the critical areas for REMS generation
c) cholinergic neurons from the midbrain tegmentum (LDT/PPT)
could be one or more of the following: a) the most ventral and
project to the thalamus (ventromedial, intralaminar, and midline
rostral part of the pontine reticular nucleus; b) the perilocus
nuclei) and the BFB, and cholinergic BFB neurons have widespread
coeruleus alpha nucleus (peri-LCa) of the mediodorsal pontine
rostral projections to the cerebral cortex and the hippocampus; d)
tegmentum; c) the rostral part of the rostral pontine tegmentum;
orexin-containing neurons from the LH project to the entire fore-
d) the medial pontine reticular formation which encloses the
brain and brain stem arousal systems; and e) glutamatergic neurons
rostral and caudal part of the pontine reticular nucleus and dorsally
make up the projection neurons of the mPRF and thalamus.23,24 All
reaches the locus coeruleus alpha (LCa), or e) the ventral part of the
these ascending projections into the forebrain follow a dorsal and
pontine reticular nucleus.29e31 The reciprocal interaction hypoth-
a ventral route.23 The dorsal route terminates in nonspecic thalamic
esis of REMS generation identies cholinergic neurons of the LDT/
nuclei, which in turn project to the cerebral cortex. The ventral route
PPT as promoting REMS and posits the inhibition of these neurons
passes through the hypothalamus and continues into the BFB, where
by, among others, serotonergic afferents from the DRN.32 The REMS
cells in turn project to the cerebral cortex and the hippocampus. In
induction region of the mPRF, one of the neuroanatomical struc-
addition, a number of neural structures send descending projections
tures proposed to be responsible for REMS generation, includes
to the spinal cord that modulate muscle tone.
predominantly glutamatergic neurons, which are in turn activated
by efferent connections of the LDT/PPT. The DRN provides the
principal source of 5-HT innervation to the LDT/PPT and the REMS
Brain regions and neurotransmitter systems involved in the
induction zone of the mPRF.33 Accordingly, serotonergic terminals
regulation of slow wave sleep
have been characterized that make synaptic contacts with the soma
and the proximal dendrites of cholinergic tegmental neurons, and
Neurons of the preoptic area, anterior hypothalamus, and
with non-cholinergic, presumptively glutamatergic, neurons of the
adjacent BFB constitute the sleep-inducing system.25 Sleep active
REMS induction zone of the mPRF.34 The DRN also sends ascending
neurons of the preoptic area are mainly located in the ventrolateral
non-serotonergic projections to the LDT/PPT.35,36
preoptic area (VLPO). A majority of these neurons contain g-ami-
nobutyric acid (GABA) and galanin, and project to the BFB and to
brain stem and hypothalamic areas involved in the promotion of W The structure and efferent and afferent connections of the
including the DRN, LC, LDT/PPT and LH neurons. During SWS, the dorsal raphe nucleus
neurons of the VLPO inhibit the W-producing structures. A similar
role has been proposed for the melanin-concentrating hormone Serotonergic neurons of raphe regions of the brain stem are
(MCH). Accordingly, MCH-containing neurons located in the zona regarded as forming caudal and rostral cell groups. The most caudal
incerta, perifornical nucleus and lateral hypothalamic area facilitate nuclei project mainly to the medulla and the spinal cord, whereas
sleep occurrence by inhibiting 5-HT, NE, ACh and OX neurons the most rostral cell aggregates innervate the telencephalon,
involved in the promotion of W.26 Of note, interleukin-1 (IL-1) diencephalon, mesencephalon, and rhombencephalon.37,38 In this
increases SWS in several animal species, and the serotonergic respect, most of the serotonergic innervation of the cerebral cortex,
272 J.M. Monti / Sleep Medicine Reviews 15 (2011) 269e281

Table 1
Efferent and afferent connections of the dorsal raphe nucleus of the rat.

Efferent connections
Telencephalon - Cerebral cortex [frontal, piriform, insular, occipital, entorhinal, cingulate, and infralimbic cortices]
- Limbic system [ventral hippocampus, lateral septal nucleus, amygdala (central, lateral, and basolateral nuclei)]
- Basal forebrain [diagonal band (horizontal and vertical limbs), bed nucleus of the stria terminalis]
- Neostriatum [posteromedial regions of the striatum]
Diencephalon - Thalamus [midline, intralaminar and anterior nuclei]
- Hypothalamus [preoptic area, lateral hypothalamic area, supramammillary nucleus]
Mesencephalon - [Interpeduncular nucleus, substantia nigra pars compacta, central gray, mesencephalic reticular formation]
Rhombencephalon - [Pontine reticular formation, pedunculopontine tegmental nucleus, laterodorsal tegmental nucleus,
nucleus reticularis pontis oralis, nucleus reticularis pontis caudalis, nucleus reticularis gigantocellularis,
locus coeruleus, median raphe nucleus, nucleus raphe pontis]

Afferent connections
Telencephalon - Cerebral cortex [frontal, cingulate, and insular cortices]
- Limbic system [amygdala (central, anterior, medial, and basolateral nuclei), lateral septal nucleus]
- Basal forebrain [medial septal nucleus, ventral pallidum, bed nucleus of the stria terminalis, diagonal band]
Diencephalon - Hypothalamus [medial and lateral preoptic areas; anterior, lateral and posterior hypothalamic areas;
dorsomedial and ventromedial nuclei; tuberomammillary nucleus]
Mesencephalon - [Substantia nigra pars reticulata, interpeduncular nucleus, central gray]
Rhombencephalon - [Raphe nuclei, locus coeruleus, pontine reticular formation]

amygdala, BFB, thalamus, preoptic and hypothalamic areas, raphe
nuclei, LC and pontine reticular formation comes from the DRN
(Fig. 1). In turn, inputs to the DRN 5-HT cells have been found from
the cerebral cortex, the limbic system, the BFB, the hypothalamus,
and the cholinergic and monoaminergic nuclei of the brain stem39
(Table 1).
The DRN contains 5-HT and non-5-HT neurons. The latter
express a variety of substances including DA, GABA and GLU. In
addition, nitric oxide and a number of neuropeptides have been
characterized in the DRN. Of note, numerous brain areas have
neurons that project to the DRN and express monoamines (NE, HA),
amino acids (GABA, GLU), ACh or neuropeptides (OX, MCH, corti-
cotropin releasing factor and substance P among others) that
directly or indirectly, through local circuits, regulate the activity of
5-HT cells.40e44
In summary, the DRN serotonergic neurons receive a prominent
innervation from sleep-active GABAergic and MCHergic neurons in
the VLPO and other subregions which contribute to their inhibition
during sleep. The serotonergic cells receive also an excitatory input
from monoamine (NE, DA, HA), OX and ACh-containing neurons in
the brain stem and the hypothalamus which reinforce their acti-
vation during W.
Serotonin receptors
Understanding the mode of action and effects of 5-HT receptors
is fundamental to appreciating the physiological role of 5-HT on the
behavioral state.
The 5-HT receptors can be classied into at least seven classes,
designated 5-HT1e7. The 5-HT1, 5-HT2, 5-HT3 and 5-HT5 classes consist
of ve (5-HT1AeBeDeEeF), three (5-HT2AeBeC) and two (5-HT3AeB and
5-HT5AeB) subtypes, respectively, whereas the 5-HT4, 5-HT6 and 5-HT7
classes have at present one subtype each.45 Except for the 5-HT3
receptor, all other 5-HT receptors are structurally related to the
superfamily of G-protein-coupled receptors.
Early studies proposed that the 5-HT1A receptor is exclusively
located on the soma and the dendrites (somatodendritic autor-
eceptor) of 5-HT neurons and at postsynaptic sites (outside the
DRN). More recently, the 5-HT1A receptor has been found to be
expressed also by non-5-HT cells of the DRN. Most of these cells are
GABAergic interneurons.46 The 5-HT1A receptor couples to Gi/o,
with Gi activation leading to an inhibition of adenylate cyclase.
Stimulation of the somatodendritic 5-HT1A receptor inhibits the
ring rate of serotonergic neurons, whereas activation of the
postsynaptic receptor induces inhibitory responses on target
structures. In this respect, data obtained from in vitro recording in
the rat bed nucleus of the stria terminalis (BNST) slice have shown
that exogenous application of 5-HT or a non-selective 5-HT1A
receptor agonist (carboxamidotryptamine) evokes a membrane
hyperpolarization in approximately one third and one half of the
neurons tested, respectively.21 The expression of 5-HT1A receptors
by GABAergic interneurons of the DRN raises the possibility that
under certain circumstances their activation could actually result in
facilitation of 5-HT cells. Brain areas rich in 5-HT1A receptors
include the telencephalon [cerebral cortex, limbic system (medial
and lateral septal nuclei, hippocampal formation, amygdala), BFB];
the diencephalon [thalamus, hypothalamus (ventromedial and
supraoptic nuclei)]; the mesencephalon (VTA/SNc); and the
rhombencephalon (LDT/PPT, DRN, MRN, raphe pallidus, raphe
obscurus, LC).47
The 5-HT1B receptor is linked to the inhibition of adenylate
cyclase and was initially proposed to be located at presynaptic
(5-HT axon terminals) and postsynaptic (outside the DRN) sites.
The 5-HT1B receptor has been characterized also in the ventro-
medial DRN where it is expressed by non-5-HT cells.48 Of note, bath
application of the selective 5-HT1B receptor agonist CP 93129
reduced the amplitude of evoked excitatory postsynaptic currents
in an in vitro rat BNST slice preparation. The effect of the 5-HT1B
ligand was blocked by the selective 5-HT1B antagonist GR 55562,
and was tentatively ascribed to a reduction of glutamate release at
presynaptic sites in the BNST.49 The 5-HT1B receptor has been found
in the telencephalon [cerebral cortex, limbic system (amygdala,
hippocampus, lateral septal nucleus), BFB, basal ganglia]; the
diencephalon [thalamus, hypothalamus (lateral preoptic area,
anterior, lateral and dorsal hypothalamic areas, suprachiasmatic
nucleus)]; the mesencephalon (central gray, interpeduncular
nucleus, VTA/SNc); and the rhombencephalon (DRN/MRN, LC,
raphe magnus nucleus, cerebellum).50,51
The 5-HT2A, 5-HT2B and 5-HT2C receptors exhibit 46e50%
overall sequence identity. They are primarily coupled to Gq and
their actions are mediated by the activation of phospholipase C,
with a resulting depolarization of the host cell. Receptors of the
5-HT2 subfamily are located within postsynaptic structures,
predominantly on proximal and distal dendritic shafts. The 5-HT2A
and the 5-HT2C receptors have been characterized in the telen-
cephalon [cerebral cortex, olfactory system, limbic system (septal
nuclei, hippocampal formation, amygdala), BFB, basal ganglia]; the
diencephalon [thalamus, hypothalamus (medial and lateral
 J.M. Monti / Sleep Medicine Reviews 15 (2011) 269e281
preoptic areas, ventromedial and dorsomedial nuclei, mammillary
nucleus)]; the mesencephalon (central gray, VTA/SNc); and the
rhombencephalon (LDT/PPT, mPRF, DRN/MRN, LC).52e54 The pres-
ence of 5-HT2B receptors at central sites is restricted to the amyg-
dala, lateral septum, hypothalamus and cerebellum.55
Interestingly, Guo et al.56 have demonstrated that one third and
one fourth of neurons of the rat BNST respond to 5-HT application
with depolarization or hyperpolarization/depolarization, respec-
tively. Prior application of the selective 5-HT1A receptor antagonist
WAY 100635 blocked the inhibitory response. On the other hand,
application of the 5-HT2A antagonist MDL 100907 (volinanserin) or
the 5-HT2C antagonist RS 102221 blocked the excitatory response,
which indicates that 5-HT2A and 5-HT2C receptors intervene in the
5-HT-induced excitation of BNST cells.
The 5-HT3 receptor is not coupled to G proteins. It directly
activates a 5-HT-gated cation channel, which leads to the depo-
larization of monoaminergic, aminoacidergic and cholinergic cells.
The 5-HT3 receptor is present in cortical and subcortical structures
including the cerebral cortex, olfactory system, limbic system
(hippocampus, amygdala), basal ganglia, central gray, mesence-
phalic reticular formation, and DRN.57,58 At the DRN level the 5-HT3
receptor is partly expressed by glutamatergic interneurons.59
The 5-HT6 is a G-protein coupled receptor and its primary signal
transduction pathway is the stimulation of adenylate cyclase.60 The
5-HT6 receptor is located postsynaptically to 5-HT cells and has
been localized in the cerebral cortex, BFB (BNST), limbic system
(hippocampus, amygdala), striatum, nucleus accumbens, thalamus,
hypothalamus and mesencephalon of rat and man.61,62
The 5-HT7 receptor is positively coupled to adenylate cyclase via
GS-proteins. It has been localized in the pyramidal neurons of the
cerebral cortex, BFB (BNST), anterior thalamus, hippocampus (elds
CA1 and CA3 of Ammons horns), suprachiasmatic nucleus, pontine
nuclei, brain stem reticular formation, DRN and MRN.60,63 The 5-HT7
receptor participates together with 5-HT2A and 5-HT2C receptors in
the activation of BNST cells. Hence, prior application of the selective
5-HT7 receptor antagonist SB 269970 blocked or attenuated the
depolarizing response to 5-HT in BNST neurons of the rat.56,64
In conclusion, 5-HT receptors with known operational charac-
teristics exhibit similar regional distribution patterns within the
CNS, especially throughout the brain stem, hypothalamus, thal-
amus, limbic system, BFB and cerebral cortex. Moreover, 5-HT1A, 5-
HT1B, 5-HT2A, 5-HT2C, 5-HT3 and 5-HT7 receptors are part of the key
determinants of 5-HT effects on sleep and W.
Firing pattern of serotonergic neurons of the DRN
Spontaneously active immunohistochemically identied 5-HT
cells recorded in a slice preparation of the rat DRN are characterized
by slow, rhythmic activity, a broad action potential, a large after
hyperpolarization potential, and a decrease of their ring rate in
response to the stimulation of the 5-HT1A somatodendritic
receptor.65 Allers and Sharp66 characterized a group of neurons of the
DRN immunoreactive for 5-HT or both 5-HT and tryptophan
hydroxylase in urethane-anesthetized rats. The neurons red broad
spikes with low frequency and a highly regular pattern. Systemic
administration of the 5-HT1A receptor agonist 8-OH-DPAT markedly
inhibited the ring rate of these cells. Electrophysiological recordings
in unanesthetized animals allowed McGinty and Harper67 and
Trulson and Jacobs3 to determine the activity of DRN 5-HT neurons
acrcoss the sleep-wake cycle. During quiet W, 5-HT neurons re in
a slow and regular fashion. During active W, the neuronal activity
shows a 30e50% increase. As the animal enters SWS the ring rate
decreases to 50% of the quiet W state and is no longer regular. Finally,
during REMS there is a further decrease or even a cessation of
273
neuronal activity. Notwithstanding the above, numerous presumed
DRN 5-HT neurons do not adhere to this pattern of discharge.68
The role of 5-HT in regulating wakefulness and REMS
Strategies aimed at determining the role of 5-HT receptors in the
regulation of W and REMS have included: 1. genetic (knock-out)
technology of several of the molecularly dened receptor subtypes;
2. local brain delivery of 5-HT receptor agonists and antagonists; 3.
systemic and intracerebroventricular (i.c.v.) administration of 5-HT
receptor ligands.
The 5-HT1A receptor
Flesinoxan and 8-OH-DPAT, two full agonists of the 5-HT1A
receptor at pre- and post-synaptic sites, the azapirones, buspirone,
gepirone and ipsapirone, which behave as full agonists at the
somatodendritic autoreceptor but only as partial agonists at the
postsynaptic level, and the selective high-afnity silent antagonists
WAY 100635 and p-MPPI have been used to characterize the role of
5-HT1A receptor in the regulation of sleep and W.
Mutant mice that do not express 5-HT1A receptors exhibit
greater amounts of REMS than their wild-type counterparts while
W and SWS remain unchanged. As expected, systemic 8-OH-DPAT
has no effect on sleep or W in the mutant mice.69 It can be proposed
that the increase of the behavioral state in the 5-HT1A receptor
knock-out mice is related to the absence of a postsynaptic 5-HT1A
inhibitory effect on REM-on neurons of the LDT/PPT.
Portas et al.70 provided direct evidence that suppression of DRN
serotonergic activity increases REMS. In this study, extracellular
5-HT was measured in the DRN and, simultaneously, behavioral
state changes were determined from polygraphic recordings.
Microdialysis perfusion of 8-OH-DPAT into the DRN decreased 5-HT
levels by 50% during W and signicantly increased REMS. More-
over, direct infusion of either 8-OH-DPAT or esinoxan into the DRN
signicantly enhanced REMS in rats, and this effect was prevented
by local infusion of WAY 100635.71 In contrast, microinjection of
WAY 100635 or p-MPPI into the DRN reduced REMS.71,72 Signi-
cantly, microinjection of 8-OH-DPAT or esinoxan into the LDT or
the mPRF, where structures that act to promote and to induce REMS
are located, selectively inhibited REMS in the cat and the rat
whereas direct infusion of WAY 100635 into the LDT increased
REMS.73,74
Systemic injection of esinoxan increases W and reduces SWS
and REMS in the rat.74 Similar effects have been observed following
the administration of 8-OH-DPAT to vehicle-treated and serotonin-
depleted animals.75e77 Pretreatment with the mixed b-adreno-
ceptor and 5-HT1A/1B receptor antagonist ()pindolol or p-MPPI
reversed the effect of 8-OH-DPAT on W and SWS.72,75
Although it remains unclear how 5-HT1A receptor agonists
inuence W, it is likely through both inhibition of sleep active
GABAergic neurons of the VLPO, and activation of arousal systems
located in the BFB (ACh), brain stem (NE, DA) and hypothalamus
(HA, OX). The inhibition of GABAergic cells that express the 5-HT1A
receptor and make synaptic contacts with neurons of the arousal
systems would result in the increase of W. The reduction of REMS
after systemic esinoxan or 8-OH-DPAT administration would be
related to the activation of postsynaptic 5-HT1A receptors on REM-
on neurons of the LDT/PPT, similar to the physiologic effect of 5-HT.
Buspirone, ipsapirone, and gepirone have been shown to
increase time awake and to reduce SWS and REMS when given
subcutaneous (s.c.) or intraperitoneal (i.p.) to rats.78,79 Subcuta-
neous injection of the azapirones into 5,7-dihydroxytryptamine-
pretreated rats led also to an increase of W and a reduction of sleep;
this result further supports the dependence of these effects on
274 J.M. Monti / Sleep Medicine Reviews 15 (2011) 269e281
Table 2
The role of serotonin 5-HT1A and 5-HT1B receptors in the regulation of sleep and wakefulness in laboratory animals.
5-HT1A receptor
Mutant mice that do not express 5-HT1A receptors
5-HT1A receptor agonists (8-OH-DPAT, esinoxan)
Microinjection into the DRN (somatodendritic)
Microinjection into the LDT or the mPRF (receptor expressed by ACh and GLU neurons)
Systemic administration (postsynaptic)
Partial agonists at postsynaptic sites (buspirone, ipsapirone, gepirone)
Systemic administration
Selective serotonin reuptake inhibitor (uoxetine)
Microinjection into the LDT
Systemic administration (postsynaptic)
5-HT1B receptor
Mutant mice that do not express 5-HT1B receptors
5-HT1B receptor agonists (CP-94253, CGB 12066B)
Microinjection into the DRN (receptor expressed by GABAergic interneurons)
Systemic administration (postsynaptic)
Abbreviations: DRN, dorsal raphe nucleus; LDT, laterodorsal tegmental nucleus; mPRF, medial pontine reticular formation; ACh, acetylcholine; GLU, glutamate; W, wake-
fulness; SWS, slow wave sleep; REM, rapid eye movement; REMS, REM sleep; n.s., non-signicant; , increased; , reduced.
postsynaptic 5-HT1A receptors.79 Similar sleep-disrupting effects of
buspirone and ipsapirone have been described in human subjects
with normal sleep and in patients with insomnia. Thus, buspirone
administration increased W, prolonged REMS latency, and reduced
REMS time in insomniac patients,80,81 whereas ipsapirone pro-
longed REMS latency and reduced REMS and SWS in healthy
subjects.82 The reduction of REMS could be related to the azapir-
ones acting on postsynaptic 5-HT1A receptors in the LDT/PPT nuclei
to inhibit REM-on neurons.
The effects of acute administration of selective serotonin reup-
take inhibitors (SSRIs) on sleep have been studied in laboratory
animals, healthy adults, and depressed patients.83e85 SSRIs are
potent REMS suppressors, prolonging the latency to the rst REM
period. The inhibitory effect of SSRIs on REMS has been proposed to
result from enhancement of central nervous system (CNS) seroto-
nergic neurotransmission. In this respect, direct infusion of uox-
etine into the LDT or the mPRF induced a signicant reduction of
REMS in the rat; pretreatment with WAY 100635 prevented the
reduction of REMS induced by the local administration of uoxetine
into the cholinergic nucleus86 (Table 2).
The 5-HT1B receptor
Mutant mice that do not express the 5-HT1B receptor exhibit
greater amounts of REMS than their wild-type counterparts
whereas W and SWS show no signicant changes.87 The increase of
REMS in 5-HT1B receptor knock-out mice could be tentatively
related to the absence of a postsynaptic 5-HT1B inhibitory effect on
the cholinergic neurons of the LDT/PPT nuclei. However, this
proposal requires further investigation.
Microinjection of the selective 5-HT1B receptor agonist CP-
94253 into the DRN during the light phase caused a reduction of
REMS and of the mean duration of REM periods in the rat.
Pretreatment with the 5-HT1B receptor antagonist SB-224289
antagonized the CP-94253-induced decrease of REMS and of the
mean duration of REM periods. Administration of the GABAA
receptor agonist muscimol, which at the doses given did not
signicantly affect sleep variables, prevented also the effect of CP-
94253 on REMS.88 Activation of the 5-HT1B receptor in the DRN has
been shown to inhibit the release of GABA.89 Thus, the decrease of
GABA inhibitory tone on 5-HT neurons would result in an incre-
ment of 5-HT release at postsynaptic sites and the suppression of
REMS. This conclusion is drawn from the fact that microinjection of
muscimol prevented the CP-94253-induced decrease of REMS.
W SWS REMS Ref.
n.s. n.s. 69
n.s. n.s. 71
n.s. n.s.  74
  74
  78,79
n.s. n.s.  86
n.s. n.s.  84
n.s. n.s. 87
n.s. n.s.  88
  90,91
Systemic administration of the selective 5-HT1B receptor
agonists CGS 12066B and CP-94253 signicantly increased W and
reduced SWS and REMS in the rat.90,91 Pindolol antagonized the
increase of W and reduction of SWS induced by CP-94253;
however, REMS remained suppressed. On the other hand, acute
pharmacological blockade of the 5-HT1B receptor with GR 125939
produced an increase of REMS over 4 hours in wild-type mice.87
Thus, the limited available evidence indicates that 5-HT1B
receptor activation facilitates the occurrence of W and negatively
inuences REMS (Table 2).
The 5-HT2 receptor
5-HT2A and 5-HT2C receptor knock-out mice show a signicant
increase of W and a reduction of SWS while REMS remains
unchanged.92,93 Systemic administration of non-selective 5-HT2A/2C
receptor agonists or a selective 5-HT2C receptor agonist consistently
increases W and reduces sleep. Thus, opposite effects of gene
deletion versus acute pharmacological activation of the same
protein should have been expected on W and SWS. Although the
basis for this apparent discrepancy is unclear, it has been posed that
the greater amounts of W in 5-HT2C receptor knock-out mice and,
by extension, in 5-HT2A receptor knock-out mice, could be related
to the increase of catecholaminergic neurotransmission involving
mainly the noradrenergic and the dopaminergic systems.92 5-HT2A
and 5-HT2C receptors that participate in the control of DA and NE
release are expressed by inhibitory GABAergic interneurons.94
Consequently, the reduction of GABA release at critical sites in the
CNS of 5-HT2A and 5-HT2C receptor knock-out mice would be
indirectly responsible for the increased availability of NE and DA.
Infusion of the 5-HT2A/2C receptor agonist DOI into the DRN
induced a signicant reduction of REMS and of the number of REM
periods in the rat. Pretreatment with the selective 5-HT2A or 5-HT2C
receptor antagonists EMD 281014 (pruvanserin) or SB-243213,
respectively, prevented the DOI-induced suppression of REMS,
which indicates that it was mediated by the 5-HT2A and 5-HT2C
receptors located in the DRN.95 The serotonin 5-HT2A and 5-HT2C-
receptor containing neurons are predominantly GABAergic inter-
neurons. Systemic or intra-raphe administration of DOI inhibits the
ring of serotonergic neurons in the DRN and reduces the extra-
cellular concentration of 5-HT96; both effects are reversed by the
5-HT2A receptor antagonist pruvanserin or the GABAA antagonist
picrotoxinin.97 Thus, available evidence does not support the direct
involvement of 5-HT cells in the DOI-suppression of REMS. A
 J.M. Monti / Sleep Medicine Reviews 15 (2011) 269e281
Table 3
The role of serotonin 5-HT2A and 5-HT2C receptors in the regulation of sleep and
wakefulness in laboratory animals.
W SWS REMS Ref.
Mutant mice that do not express 5-HT2A/2C receptors  n.s. 92,93
Non-selective 5-HT2A/2C receptor agonists (DOI, DOM)
Microinjection into the DRN n.s. n.s.  95
Microinjection into the LDT n.s. n.s.  98
Systemic administration   76,99
Selective 5-HT2C receptor agonist (RO 60-0175) n.s.  108
Non-selective 5-HT2A/2C receptor antagonists
Ritanserin, sertindole n.s.  76,102
Ketanserin   103
Selective 5-HT2A antagonists
Volinanserin, pruvanserin   93,105
5-HT2A inverse agonist
Nelotanserin   106
Abbreviations: DRN, dorsal raphe nucleus; LDT, laterodorsal tegmental nucleus;
W, wakefulness; SWS, slow wave sleep; REMS, REM sleep; n.s., non-signicant; ,
increased; e, reduced.
reasonable hypothesis is that intra-DRN microinjection of DOI
activates GABAergic neurons projecting to the LDT/PPT which, in
turn, inhibit cholinergic cells that promote REMS.
Amici et al.98 locally microinjected DOI or the 5-HT2 receptor
antagonist ketanserin into the LDT of rats. DOI signicantly
decreased the number of REM episodes, whereas ketanserin
induced the opposite effect. 5-HT2A/2C receptors are located not on
cholinergic cells but on GABAergic interneurons intermingled with
mesopontine cholinergic cells which tends to explain the inhibitory
effect of DOI on cholinergic LDT neurons and the reduction of REMS
episodes. In can be tentatively proposed that the mechanisms
involved in the suppression of REMS would be reinforced by the
activation of 5-HT2 receptors expressed by GABAergic interneurons
and projection neurons located in the LDT/PPT and the DRN,
respectively.
Systemic administration of the non-selective 5-HT2 receptor
agonists DOI and DOM has been shown to reduce SWS and REMS,
and to augment W in the rat.95,99 Injection of the 5-HT2A/2C receptor
antagonists ritanserin, ketanserin, ICI-170,809 or sertindole at the
beginning of the light period induced a signicant increase of SWS
and a reduction of REMS in the rat. Wakefulness was also dimin-
ished in most of these studies.76,100e103 More recently, the action of
the selective 5-HT2A receptor antagonists volinanserin and pru-
vanserin and of the 5-HT2A inverse agonist nelotanserin on sleep
variables was assessed in rats and mice. Systemic injection of the
5-HT2A antagonists or the 5-HT2A inverse agonist signicantly
increased SWS and reduced W and REMS.93,104e107 Furthermore,
pruvanserin prevented the DOI induced increase in W and reduc-
tion in SWS. However, REMS remained suppressed, which tends to
indicate that the effect of DOI is not restricted to the 5-HT
system.104
The actions of the selective 5-HT2C receptor agonist RO 60-0175
on sleep-wake stages have been evaluated in the rat. The
compound provoked an increase of W accompanied by a reduction
of REMS108 (Table 3). Oral administration of the selective 5-HT2C
receptor antagonist SB-243213 signicantly increased SWS and
reduced REMS during the light period.109 However, with subcuta-
neous SB-243213 only a signicant reduction of time spent in REMS
was seen.104 On the other hand, intraperitoneal injection of the
5-HT2B antagonist SB-242084 at light onset increased W and
reduced SWS in the rst hour.110 Similarly, systemic administration
of the 5-HT2B antagonist SB-215505 augmented W and decreased
SWS and REMS in mice and rats.111
275
Thus, available evidence tends to indicate that the injection of
non-selective 5-HT2A/2C or selective 5-HT2C receptor agonists
induces an increase of W and a suppression of REMS in laboratory
animals. Presently, there are no data on the effect of selective 5-HT2A
agonists on the sleep-wake cycle. The injection of non-selective and
selective 5-HT2A antagonists or a 5-HT2A receptor inverse agonist
has been shown to consistently increase SWS and to reduce REMS. In
contrast, the administration of selective 5-HT2C receptor antagonists
induces inconsistent effects on sleep variables.
Is 5-HT directly responsible for the DOI- and RO 60-0175-
induced increase of W? Systemic administration of DOI inhibits the
ring of 5-HT neurons in the DRN and NE neurons in the LC. In
addition, 5-HT and NE levels are diminished at postsynaptic sites.
The reduction of the ring rate of 5-HT and LC cells is reverted by
volinanserin and ketanserin, respectively.96,112 On the other hand,
the i.p. injection of DOI signicantly increases the extracellular
concentration of ACh in the medial prefrontal cortex and the dorsal
hippocampus, and of DA in the medial prefrontal cortex and the
VTA of the rat. The effect of DOI on ACh and DA release is blocked by
volinanserin and the non-selective serotonin 5-HT2 receptor
antagonist LY-53,857, respectively.113e115 Thus, indirect evidence
tends to indicate that ACh and DA are involved, at least in part, in
the DOI-induced increase of W.
The effects of the non-selective 5-HT2 receptor antagonists
ritanserin, ketanserin, seganserin and ICI-169,369, the selective
5-HT2A antagonist eplivanserin and the 5-HT2A inverse agonist
nelotanserin have been studied on the sleep EEG of subjects with
normal sleep. The administration of ritanserin in the evening
increased SWS [stages 3 and 4 non-REM sleep (NREMS)] and
reduced stage 2 sleep and REMS.116 After 2 weeks of ritanserin
treatment SWS remained increased. In addition, ritanserin discon-
tinuation following daily administration for 8 weeks was not asso-
ciated with the occurrence of withdrawal symptoms.117 On the other
hand, the effects of ketanserin on sleep variables were restricted to
an increase of SWS and a reduction of stage 2 sleep.118 During
nighttime sleep after a nap in the evening, seganserin induced an
increase in SWS and an enhancement of power density in the delta
and theta frequencies during NREMS. Compound ICI-169,369 also
induced an increase of SWS,119 whereas eplivanserin increased SWS
and reduced stage 2 sleep. Analysis of the EEG power spectra showed
an increase of delta activity and a reduction of spindle frequency
activity after eplivanserin administration.120
The effects of nelotanserin on sleep in healthy subjects were
assessed using a postnap insomnia model. The duration of SWS and
of REMS latency were signicantly increased by treatment with the
5-HT2A inverse agonist. In addition, the number of stage shifts,
number of awakenings and number of bouts of sleep were dimin-
ished, whereas the duration of bouts of sleep was signicantly
increased.106
Thus, agents that act by competition for agonist binding sites (5-
HT2A receptor antagonists) or stabilize the receptor in its inactive
conformation (5-HT2A receptor inverse agonists) consistently
increase SWS in subjects with normal sleep. The mechanism
involved in the increase of SWS is presently unclear. Possible
contributing factors include the inhibition of cell groups involved in
the occurrence of W, and the activation of GABAergic, MCHergic
and galaninergic neurons.
The 5-HT3 receptor
The microinjection of the 5-HT3 receptor agonist m-chlor-
ophenylbiguanide (m-CPBG) into the DRN caused a reduction of
REMS. Pretreatment with the 5-HT3 antagonist ondansetron pre-
vented the m-CPBG-induced suppression of REMS.121 Concerning
the mechanism involved in the reduction of REMS by m-CPBG, it
276 J.M. Monti / Sleep Medicine Reviews 15 (2011) 269e281
Table 4
The role of serotonin 5-HT3, 5-HT6 and 5-HT7 receptors in the regulation of sleep and
wakefulness in laboratory animals.
W SWS
5-HT3 receptor
Selective 5-HT3 receptor agonist (m-chlorophenylbiguanide)
Microinjection into the DRN n.s. n.s.
Injection into the left lateral ventricle  
5-HT6 receptor
Selective 5-HT6 receptor antagonists (SB-399885, RO-4368554)
Systemic administration  
5-HT7receptor
Mutant mice that do not express 5-HT7 receptors n.s. n.s.
Selective 5-HT7 receptor agonists (LP-44)
Microinjection into the DRN n.s. n.s.
Abbreviations: DRN, dorsal raphe nucleus; LDT, laterodorsal tegmental nucleus;
mPRF, medial pontine reticular formation; ACh, acetylcholine; GLU, glutamate; W,
wakefulness; SWS, slow wave sleep; REMS, REM sleep; n.s., non-signicant; ,
increased; , reduced.
has been shown that the 5-HT3 receptor agonist 2-methyl-5-HT
increases the electrically-induced tritium overow from rat
midbrain slices containing the raphe nuclei loaded with [3H]
5-HT.122 Thus, the m-CPBG-induced suppression of REMS would
depend on the increase of 5-HT in areas relevant to the promotion
and maintenance of the behavioral state. The activation of seroto-
nergic cells by m-CPBG could be a direct effect; on the other hand, it
could be an indirect action dependent on the inuence of a modu-
latory system on 5-HT neurons. In this respect, there is evidence in
favour of a role for the glutamatergic system in the 5-HT3 receptor-
induced suppression of REMS. Glutamatergic neurons have been
characterized in the DRN; in addition, glutamatergic inputs to the
DRN have been described that originate in the brain stem, several
hypothalamic nuclei, and the cerebral cortex.123 To date no
attempts have been made to determine the effect of serotonin
5-HT3 receptor activation on GLU release in the DRN. However,
Funahashi et al.124 observed that the application of 5-HT or the
5-HT3 agonist phenylbiguanide increased the frequency of spon-
taneous excitatory postsynaptic currents in neurons from the rat
area postrema in vitro, and this effect was prevented by the 5-HT3
antagonist ICS-205,930 and the alpha-amino-3-hydroxy-5-methyl-
4-isoxazole propionate (AMPA) antagonist CNQX, thus indicating
that synaptic currents are glutamatergic and not serotonergic. We
have found, in addition, that microinjection of the N-methyl-D-
aspartate (NMDA) receptor antagonist D-AP5 into the DRN
prevents the m-CPBG-decrease of REMS in the rat (Monti and
Jantos, unpublished observations).
m-CPBG injected into the left lateral ventricle increased W and
REMS latency, whereas SWS, REMS, and the number of REM periods
were reduced in the rat.125 In contrast, systemic administration of
the 5-HT3 antagonists MDL-72222 and ondansetron signicantly
increased SWS and/or REMS, respectively.125,126 Pretreatment with
MDL-72222 prevented the increase of W and reduction of SWS and
REMS induced by m-CPBG.125 On the basis of a series of neuro-
pharmacological studies, it has been proposed that changes of sleep
variables after i.c.v. administration of m-CPBG are partly related to
the increased availability of DA at central sites127,128 (Table 4).
The 5-HT6 receptor
Not much is known about the role of the 5-HT6 receptor in the
regulation of sleep and W. We have found that systemic adminis-
tration of the selective 5-HT6 receptor antagonists SB-399885 and
RO-4368554 during the light phase causes an increase of W and
a reduction of SWS and REMS in the rat (Table 4). The injection of
SB-399885 during the dark period induced also a decrease of REMS.
On the other hand, no signicant changes of values corresponding
to sleep variables were observed following the injection of RO-
4368554 during the dark phase.107 A series of neurochemical
REMS Ref. studies have ascertained the inuence of 5-HT6 receptor blockade
on various neurotransmitter systems. Accordingly, using in vivo
microdialysis in the freely moving rat, it has been established that
 121
blockade of the 5-HT6 receptor with SB-271046 or RO-046790
125
increases GLU and ACh levels in the frontal cortex and hippo-
campus, and NE and DA concentrations in the prelimbic/infralimbic
107
subregions of the medial prefrontal cortex of the rat.129e131 It
remains to be established whether the enhancement of W and
reduction of SWS and REMS after administration of 5-HT6 receptor
 132
antagonists is a consequence of the increase of ACh, GLU, NE and DA
 133 levels at critical sites in the SNC or is an independent event.
The 5-HT7 receptor
Hedlund et al.132 have characterized sleep variables in 5-HT7
receptor knock-out mice. The mutants spent less time in REMS than
their wild-type counterparts, mainly during the light period. There
were no differences between the 5-HT7 receptor knock-out mice
and the wild type animals with respect to W and SWS duration.
The effects of LP-44, a selective 5-HT7 receptor agonist, micro-
injected directly into the DRN during the light period were studied
in adult rats. Infusion of LP-44 induced a signicant reduction of
REMS and of the number of REM periods. Pretreatment with the
5-HT7 receptor antagonist SB-269970 averted the LP-44 suppres-
sion of REMS.133 It was tentatively proposed that the activation by
LP-44 of projection GABAergic neurons located in the DRN could be
responsible for the inhibition of cholinergic cells in the LDT/PPT and
the decrease of REMS. However, the evidence supporting this
assertion is currently lacking.
Intraperitoneal administration of the 5-HT7 receptor agonist LP-
211 during the light phase signicantly increased W and reduced
REMS and the number of REM periods in the rat. Pretreatment with
SB-269970 prevented the action of LP-211 on the sleep-wake cycle
(Monti and Jantos, unpublished observations). As mentioned
earlier, 5-HT depolarizes neurons of the BNST and this effect is
antagonized by SB-269970 (Table 4). Thus, the LP-211 activation of
5-HT7 receptors expressed by neurons of the BFB could be partly
responsible for the increase of W.
Clinical context and perspective
Ritanserin has been administered to poor sleepers, patients with
chronic primary insomnia and psychiatric patients with a general-
ized anxiety disorder (GAD) or a mood disorder. Ritanserin 5 mg
taken by poor sleepers for 20 days caused a large and signicant
increase in SWS during the early and the late drug period compared
to baseline placebo nights. Concomitantly with the increase in SWS,
there was a reduction in stage 2 sleep and in the frequencies of
awakenings.134 The administration of ritanserin 10 mg during the
morning for 5 days to a group of patients with chronic primary
insomnia increased the duration of SWS without modifying stage 2
sleep or REM sleep.135 The effect of ritanserin was additionally
characterized in abstinent alcoholic patients with comorbid
insomnia. The 5-HT2 antagonist was given at a daily dose of 10 mg
for 28 nights. The increase of total sleep time was associated with
greater amounts of NREMS, whereas SWS and REMS were not
notably modied.136 The acute effects of ritanserin 5 mg on sleep
variables in patients with GAD and matched healthy controls was
also examined. Ritanserin produced a signicant increase in SWS
together with a reduction in stage 1 sleep and wake time after sleep
onset.137 Polysomnographic recordings of dysthymia patients who
received ritanserin 10 mg for 4 weeks showed a signicant increase
 J.M. Monti / Sleep Medicine Reviews 15 (2011) 269e281
in SWS. No other variables were modied by the drug.138 Moreover,
acute administration of ritanserin 5 mg in patients with a diagnosis
of major depression induced a signicant increase in SWS without
changing stage 2 sleep or REMS duration.139
The effects of the selective 5-HT2A receptor antagonists voli-
nanserin, eplivanserin and pruvanserin, and of the 5-HT2A receptor
inverse agonists APD-125 and pimavanserin have been studied in
patients with chronic primary insomnia. However, with the
exception of APD-125, no clinical data have yet been released
(ClinicalTrials.gov Identier: NCT00664664). APD-125 (10 and
40 mg) given for 7 days decreased wake time after sleep onset and
the number of nocturnal awakenings while the latency to persis-
tent sleep remained unchanged. Slow wave sleep showed a signif-
icant dose-dependent increase.140
Several benzodiazepine (BZD) and non-BZD (modied-release
zolpidem, zopiclone, eszopiclone, modied-release indiplon)
hypnotics improve sleep induction and sleep maintenance.
However, BZD derivatives induce a further reduction of SWS and
REMS, whereas SWS and REMS values remain decreased during
non-BZD administration. Thus, the association of a 5-HT2A receptor
antagonist or a 5-HT2A receptor inverse agonist with a BZD or
a non-BZD hypnotic could be a valid alternative to normalize SWS
in patients with primary or comorbid insomnia.141
Conclusions
Attempts to characterize the role of serotonin receptors on sleep
variables have been limited to the 5-HT1A, 5-HT1B, 5-HT2A, 5-HT2B,
5-HT2C, 5-HT3, 5-HT6 and 5-HT7 receptors. Most studies have
examined the effect of systemic administration of selective and
relatively selective agonists and antagonists on sleep and W in the
rat. Recently, results from several studies have quantied the
spontaneous sleep/waking cycles in serotonin 5-HT1A, 5-HT1B,
5-HT2A, 5-HT2C or 5-HT7 receptor knock-out mice. Much less is
known about the effect of local microinjection of serotonin receptor
ligands into CNS structures relevant to the regulation of sleep and
W, including the DRN, the LDT/PPT, the mPRF, the BFB and the
VLPO.
Steinbusch142 and Lowry et al.44 have shown that 5-HT cells in the
rat DRN appear in topographically organized groups. These
subpopulations of neurons differ in their morphological character-
istics, cellular properties, and afferent and efferent connections.39,43
In addition, the subpopulations of 5-HT neurons coexpress different
neurotransmitters and neuromodulators including DA, GLU, GABA,
substance P, and corticotropin releasing factor.41,42,142 Thus, the
possibility exists that efferent projections from each subpopulation
of 5-HT neurons form synapses with only one subtype of serotonin
receptor. This would allow different 5-HT subsystems to inuence
specically and separately the neurons involved in the regulation of
W and REMS.
The characterization of subpopulations of 5-HT neurons adds to
the appreciation that each 5-HT receptor family makes use of
a particular signal transduction pathway. Accordingly, the 5-HT1
family, like the 5-HT5 receptor, are negatively coupled to adenylate
cyclase. On the other hand, the 5-HT2 family is coupled to phos-
pholipase C whereas the 5-HT4, 5-HT6 and 5-HT7 receptors are
positively coupled to adenylate cyclase. As an exception, the 5-HT3
receptor incorporates an ion channel that regulates ion ux in a G-
protein-independent manner.37
Activation of the postsynaptic 5-HT1A and 5-HT1B receptors
induces the hyperpolarization of target neurons in the LDT/PPT and
the mPRF. On the other hand, activation of the 5-HT2A, 5-HT2C and
5-HT7 receptors leads to the depolarization of GABAergic cells that
innervate the structures involved in the promotion and the
induction of REMS. The behavioral state is suppressed during both
277
instances. Presently available evidence tends to indicate that the
GABAB receptor is involved in the decrease of REMS. Accordingly,
microinjection of the selective GABAB receptor agonist baclofen
into the pedunculopontine tegmental nucleus (PPT) reduces REMS
in the rat,143 whereas the GABAA agonist muscimol induces the
opposite effect through a still unknown mechanism.144,145
Although the process by which activation of 5-HT receptors
facilitates the state of W is still unknown, it should be mentioned
that many of the GABAergic cells in the BFB, hippocampus and
neocortex on which 5-HT1A and 5-HT1B receptors are expressed, are
hyperpolarized by serotonin released from the DRN.146e148 Thus,
activation of 5-HT1A and 5-HT1B receptors may attenuate GABAergic
input and thereby indirectly increase the release of ACh and GLU at
cortical and subcortical sites.
Activation of 5-HT2A and 5-HT2C receptors enhances the release
of ACh in the medial-prefrontal cortex and the hippocampus, and of
DA in the medial-prefrontal cortex and the VTA of the rat. Thus, the
increased availability of DA and ACh at central sites after 5-HT2A/2C
receptor activation could be responsible, at least in part, for the
increased incidence of W.
Not much is known about the mechanisms subserving the
increase of W and reduction of REMS after activation of 5-HT3 and
5-HT7 receptors. The 5-HT3 receptor is well known for stimulating
the release of 5-HT, NE, DA, HA, GLU, and GABA in the brain stem,
the limbic system, the BFB, and the cortex, which could tentatively
explain its disruption of sleep variables. However, further studies
are needed to resolve this issue.
Limitations of the approaches used to study the role of 5-HT
in the regulation of W and REMS
The selectivity of the knock-out technology has been empha-
sized on the grounds of a more specic impairment of 5-HT
receptors than the neuropharmacological approach.149 However,
the proposal would apply almost exclusively to mutant mice that
do not express 5-HT1A or 5-HT1B receptor. Accordingly, opposite to
animals treated sistemically with selective 5-HT1A or 5-HT1B
receptor agonists where REMS is suppressed, knock-out mice show
an increase of the behavioral state. On the other hand, data
obtained from 5-HT2A receptor knock-out mice do not conrm the
ndings generated by selective 5-HT2A receptor antagonists in as
much as mutant mice show an increase of W and a reduction of
SWS. This outcome would be related to the limited specicity of
presently available knock-out technology. Hence, in knock-out mice
the 5-HT2A receptor is absent not only in neural structures that
participate in the regulation of SWS but also in brain regions
involved in the regulation of W. Thus, the absence of 5-HT2A
receptors in GABAergic cells that control the release of DA in the
prefrontal cortex and the nucleus accumbens and of NE in
the hippocampus, respectively, signicantly increases the release of
the monoamines at postsynaptic sites. As a result W is augmented
and SWS is decreased. An unexpected picture has emerged also
with respect to the 5-HT7 receptor, such that REMS is suppressed in
both mutant mice and animals administered a selective 5-HT7
receptor agonist. It is proposed that the changes of the sleep-wake
cycle in knock-out mice would depend not only on the receptor
involved but also on the type of cell (excitatory or inhibitory) that
expresses the receptor and on its location in the CNS.
Adrien150 has pointed out that the technology of inducible
knock-outs, or lentiviral vectors applied directly into selective brain
structures will help to overcome the limitations of presently
available techniques.
Presently available 5-HT receptor agonists tend to increase W
and to reduce REMS. While 5-HT2A and 5-HT3 receptor antagonists
increase SWS and/or REMS, opposite effects have been described
278 J.M. Monti / Sleep Medicine Reviews 15 (2011) 269e281
following the administration of 5-HT1A, 5-HT1B, 5-HT6 and 5-HT7
antagonists. The so called competitive antagonism, a characteristic
pattern of antagonism, refers to a drug that lacks intrinsic efcacy
but retains afnity to compete with the agonist for the binding
site.151 Although selective 5-HT receptor antagonists compete with
the agonists for the binding site, they do not discriminate between
neural structures with dissimilar functions. In addition, their
afnity for a given 5-HT receptor subtype tends to vary during the
light-dark cycle.107 The limitations inherent to the use of presently
available antagonists will be partly resolved when selective ligands
become available that act at specic sites in the CNS
Practice points
1) All serotonin receptor agonists studied to date share the
ability to promote W and to suppress REMS when given
systemically or by the i.c.v. route.
2) Microinjection of 5-HT1A agonists into the DRN
increases REMS, whereas local administration of 5-
HT1B, 5-HT2A/2C, 5-HT3 and 5-HT7 agonists induces the
opposite effect.
3) Systemic administration of non-selective 5-HT2A/2C
antagonists, selective 5-HT2A antagonists or 5-HT2A
inverse agonists increases SWS in laboratory animals,
subjects with normal sleep and patients with primary or
comorbid insomnia.
Research agenda
1) Evaluation of the effects of systemic and local admin-
istration of selective 5-HT4, 5-HT5 and 5-HT6 receptor
agonists on the sleep-wake cycle.
2) Studies aimed at determining the mechanisms involved
in 5-HT receptor subtypes-induced increase of W and
suppression of REMS.
3) Research is needed to better understand the influence
of 5-HT receptor subtypes on the thalamus, BFB and
cerebral cortex.
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