Which Antidepressants Can Cause REM Sleep Behavior Disorder?

By Jordan Stern, MD, CEO and Founder of BlueSleep

Overview

If you or a loved one takes antidepressant medication, it's important to be aware of a potential side effect called REM sleep behavior disorder (RBD). RBD is a parasomnia disorder characterized by vigorous and violent movements during the rapid eye movement (REM) stage of sleep. People with RBD act out their dreams, which can lead to disruptive sleep and even injuries to themselves or their bed partners.

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While RBD can occur in people not taking any medications, several antidepressants have been linked to increasing the risk of this sleep disorder, especially in older adults. Understanding which antidepressants may trigger RBD can help you have an informed discussion with your doctor about your treatment options and lifestyle adjustments that may help mitigate risks.

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SSRIs and RBD Risk Selective serotonin reuptake inhibitors (SSRIs) are one of the most commonly prescribed classes of antidepressants. Research indicates that SSRIs as a group may elevate the chances of developing RBD in some patients, likely due to their effects on serotonin and dopamine signaling in the brain during sleep. Specific SSRIs that studies have associated with higher RBD rates include:

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• Paroxetine (Paxil)
• Fluoxetine (Prozac)
• Sertraline (Zoloft)
• Fluvoxamine (Luvox)

SNRIs and RBD Serotonin-norepinephrine reuptake inhibitors (SNRIs) are another antidepressant drug class that has been linked to RBD, particularly in older adults. SNRIs that may increase susceptibility to RBD include:

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• Venlafaxine (Effexor)
• Duloxetine (Cymbalta)
• Desvenlafaxine (Pristiq)

The Role of Dopamine 

The neurotransmitter dopamine plays a key role in REM sleep and muscle paralysis during that sleep stage. Antidepressants that increase dopamine levels or dopamine receptor binding may disrupt this paralysis and allow for excess movement and dream enactment. Some tricyclic antidepressants like amitriptyline and the NDRI bupropion have been associated with higher RBD risk for this reason.

Other Medications and RBD

In addition to antidepressants and other psychiatric medications may also contribute to RBD in some patients. These include certain antipsychotics like clozapine and olanzapine as well as medications used to treat Parkinson's disease.

Managing Antidepressant-Related RBD

If you experience symptoms of RBD like yelling, flailing, or falling out of bed during sleep while taking an antidepressant, consult the doctor prescribing these medications. They may recommend adjusting your dosage, switching medications, or prescribing a treatment specifically for RBD such as melatonin or clonazepam.

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Making lifestyle changes may also help reduce RBD episodes and prevent injuries:

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• Remove hazardous objects from around the bed area
• Use bed rails or position your mattress on the floor
• Have your bed partner sleep separately if violent behaviors pose safety risks
• Avoid sleep deprivation which can worsen RBD
• Refrain from alcohol, sedatives, or other substances that can exacerbate RBD

With careful medication management and safety precautions, many people are able to get their antidepressant-induced RBD under control. Being proactive about this potential side effect can promote better sleep quality and peace of mind for you and your loved ones.

Is RBD Related to Sleep Apnea (OSA)?

Since OSA is a very common disorder, RBD and OSA may coexist.  If you have both conditions it is very important to properly treat the OSA, as it may help with the RBD treatment. These are distinct sleep disorders, and there is no cause and effect of one or the other, so it is important to follow up with your BlueSleep provider if you are noticing symptoms of RBD, and or OSA.

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The exact mechanisms linking these two sleep disorders are not fully understood, but some proposed explanations include:

1. Intermittent hypoxia: The repeated episodes of oxygen desaturation in OSA may contribute to neurodegeneration and dysfunction of the brain regions involved in REM sleep regulation, leading to RBD.
2. Inflammation: OSA is associated with systemic inflammation, which may play a role in the pathogenesis of RBD.
3. Common risk factors: Both OSA and RBD are more prevalent in older age and are associated with neurodegenerative diseases like Parkinson's disease.

Furthermore, treatment of OSA with continuous positive airway pressure (CPAP) can help with symptoms of RBD when patients are also being treated for the RBD.