September 5


REM Sleep Disorder: Which Antidepressants to Avoid

By Joshua Turner

September 5, 2023

Antidepressants are commonly used to treat depression, anxiety, and other mental health conditions. However, these can have side effects – disrupting Rapid Eye Movement (REM) sleep.

REM sleep behavior disorder (RBD) is a condition in which a person acts out their dreams, which can result in injuries to themselves or their bed partner.

Studies have shown that certain meds for mental health conditions can cause RBD in some people, particularly those already at risk due to age or other factors. This can be a serious concern, as RBD can lead to injuries, poor sleep quality, and other complications.

Understanding the link between antidepressants and RBD is important for patients and healthcare providers.

Key Takeaways

Understanding REM Sleep Disorder

REM sleep disorder is a parasomnia that occurs during the rapid eye movement (REM) sleep phase. During this phase, the body is typically in a state of atonia, which means the muscles are relaxed and immobile. However, this atonia is disrupted in individuals with this sleep disorder, causing them to act out their dreams physically.

The symptoms can include kicking, punching, yelling, and even jumping out of bed. These can be dangerous not only for the individual experiencing them but also for their bed partner.

Researchers believe that it is caused by a disruption in the brainstem mechanisms responsible for regulating this sleep phase. Various factors, including medications, neurological disorders, and brain injuries, can cause this disruption.

Antidepressants are one class of medication linked to the development of REM sleep disorder. Some studies have found that drugs for mental health conditions, such as selective serotonin reuptake inhibitors (SSRIs), can increase the risk of developing this disorder.

If you are taking an antidepressant and are experiencing symptoms of this sleep disorder, it is vital to talk to your doctor. They may be able to adjust your medication or recommend other treatments to help manage your symptoms and improve the quality of your sleep.

Symptoms of REM Sleep Behavior Disorder

The symptoms of RBD can vary from person to person, but some common symptoms include punching, kicking, laughing, yelling, talking, crying, and shouting during sleep.

In addition to these vocalizations, it can also cause limb movements, muscle twitches, and arm and leg movements during sleep. These movements can be violent and may injure the person or their bed partner. RBD is not the same as sleepwalking, as people with RBD are fully aware of their surroundings during the episodes.

The onset of the sleep disorder usually occurs in middle age or later, which is more common in men than women. It is also associated with certain medical conditions, such as Parkinson’s disease and multiple system atrophy.

Treatment options may include medication, such as clonazepam, or changes to sleep habits, such as avoiding alcohol and caffeine before bed.

Risk Factors and Causes

Age is a significant factor, as older adults are more likely to experience this disorder. Certain medications, such as tricyclic antidepressants, can also increase the risk of REM sleep disorder. Neurological conditions, such as Parkinson’s disease and multiple system atrophy, can cause this disorder.

Alcohol and smoking can also contribute to it, disrupting the normal sleep cycle. Head injury and stroke are also risk factors, as they can damage the areas of the brain that regulate sleep. Certain medications used to treat dementia can increase the risk.

Farmers are also at a higher risk of developing this disorder due to pesticide exposure and other chemicals. These chemicals can damage the brain and disrupt the normal sleep cycle.

Antidepressants and REM Sleep Disorder

Nefazodone has been associated with an increased risk of REM sleep disorder. Studies have shown that nefazodone use can result in vivid and intense dreams, leading to physical movements during sleep.

Bupropion has been shown to increase the amount of time spent in REM sleep, which can lead to an increased risk of acting out dreams.

Studies have shown that trazodone can increase the risk of sleepwalking and other parasomnias.

Diagnosis and Tests

Diagnosing this sleep behavior disorder can be challenging as it requires a combination of clinical evaluation, neurological examination, and sleep study.

Polysomnography (PSG) is the gold standard test for diagnosing RBD and involves monitoring brain activity, muscle tone, and eye movements during sleep. PSG can help distinguish between RBD and other sleep disorders that may cause similar symptoms.

A neurological exam may also be conducted to assess motor function, reflexes, and coordination. The Unified Parkinson’s Disease Rating Scale (UPDRS) II and III may be used to assess motor symptoms and the severity of RBD. Neurodegenerative markers may be measured to evaluate the risk of developing neurodegenerative diseases in patients with RBD.

The diagnosis of RBD is based on the International Classification of Sleep Disorders criteria, which include the presence of REM sleep without atonia (RSWA) during PSG and clinical symptoms of RBD.

RSWA is characterized by muscle activity during this sleep phase, which is normally suppressed to prevent acting out dreams.

The American Academy of Sleep Medicine recommends that PSG be performed in a sleep laboratory to ensure accurate diagnosis and treatment. PSG can help determine the severity of RBD and guide treatment decisions. A prospective cohort study found that PSG can predict the risk of developing neurodegenerative diseases in patients with RBD.

Treatment and Management

The treatment and management usually involve reducing or discontinuing the medication causing the symptoms. However, this may only sometimes be possible, especially if the drug is necessary for treating other conditions. In such cases, other interventions may be used to manage the symptoms.

One intervention that has shown promise is the use of melatonin supplements. Melatonin is a hormone that regulates sleep-wake cycles, and studies have shown that it can improve sleep quality and reduce the frequency of REM sleep disorder episodes.


Another intervention that may be used is dopamine agonists, medications that stimulate dopamine receptors in the brain. Dopamine is a neurotransmitter that regulates sleep, and studies have shown that dopamine agonists can reduce the frequency and severity of symptoms.

Clonazepam is commonly used to treat anxiety and seizures and has also been shown to be effective in managing them. It works by increasing the activity of GABA, a neurotransmitter that helps to regulate sleep.

Neuroprotective therapy, which involves using meds or other interventions to protect the brain from damage, may also be used to manage it. This is because meds for mental health conditions can sometimes cause damage to the brain, which can, in turn, lead to sleep disorders.

Several interventions can be used to manage the condition. Still, the best approach will depend on the patient’s needs and circumstances and should be determined in consultation with a healthcare professional.

Complications and Effects

Sleep disruption and insomnia are common side effects that can lead to fatigue, irritability, and difficulty concentrating during the day.

In some cases, the disorder can lead to injury or harm to others. This can occur if individuals sleepwalk or act out their dreams while experiencing muscle paralysis. Taking precautions to prevent injury is vital, such as removing sharp objects from the sleeping area and locking doors and windows.

Connection with Other Conditions

Dementia with Lewy bodies, Parkinson’s disease, and Lewy body dementia are all associated with REM sleep disorder. Idiopathic RBD is also often a precursor to neurodegeneration.

Research has shown that it is a significant risk factor for developing Parkinson’s disease and other synuclein-mediated neurodegenerative diseases. Furthermore, the prodromal stages of neurodegenerative disease, including mild cognitive impairment, are often marked by sleep disorders.

While the exact mechanisms behind the link between antidepressants and REM sleep disorder are not yet fully understood, it is clear that this connection has important implications for both neuroscience and clinical practice. Further research is needed to explore the relationship between these two entities fully.

Specific Cases and Studies

A study conducted on a group of depressed patients found that those who took tricyclic antidepressants experienced a significant increase in REM sleep latency, which is the time it takes for someone to enter this sleep phase. This increase in latency can lead to a decrease in the amount of time spent in this phase, which can cause the disorder.

Another study found that selective serotonin reuptake inhibitors (SSRIs) can cause it in some patients. This study found that patients who took SSRIs had a significantly higher percentage of REM sleep without atonia, which is the lack of muscle tone. This lack of muscle tone can cause patients to act out their dreams.

In addition, drugs for mental health issues can also have other side effects. For example, some patients may experience constipation, erectile dysfunction, or changes in blood pressure and heart rate while taking these drugs.

Frequently Asked Questions

What medications are known to cause REM sleep disorder?

Tricyclics, SSRIs, and MAOIs are known to cause it. Other meds that can cause this disorder include antipsychotics, anti-seizure drugs, and medicines used to treat Parkinson’s disease.

Are there any antidepressants that don’t affect REM sleep?

Yes, some don’t affect this sleep phase. These include bupropion, mirtazapine, and trazodone. However, it’s important to note that the effect can vary from person to person.

How does REM sleep behavior disorder differ from other sleep disorders?

REM sleep behavior disorder is a type of parasomnia where individuals act out their dreams during sleep. This disorder differs from other sleep disorders, such as sleep apnea, insomnia, and restless leg syndrome. The disorder can cause injury to the individual or their sleeping partner.

Can melatonin be used to treat REM sleep disorder?

Melatonin has been shown to be effective in treating it. It can help regulate the sleep-wake cycle and improve the quality of sleep.

What are the symptoms of REM sleep behavior disorder?

The symptoms include kicking, punching, flailing during sleep, and talking, shouting, or screaming. Individuals with this disorder may also experience vivid dreams and nightmares and wake up tired or exhausted.

Is there a cure for REM sleep behavior disorder?

There is no cure, but there are treatments available. These include medication, such as clonazepam, and lifestyle changes, such as avoiding alcohol and caffeine before bed.

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