Dr. Bob's Psychopharmacology Tips

Sleep problems in patients on SSRIs

Date: 8 Feb 1996 11:06:54 -0500
From: "Mike Johnson" <mike_johnson@smtpgw.musc.edu>
Subject: Sleep problems in patients on SSRIs

In addition to voluntary sleep problems (not allowing yourself a full night of sleep), I have found many patients on SSRIs have sleep problems -- some of which are related to the medication. I have had very good luck with adding 50-100 mg of trazodone or 10-75 mg of amitriptyline for this. I have also found a number of occult sleep disorders (PLMS or sleep apnea most commonly) which need to be treated before you will see improvement.

Date: Thu, 18 Apr 1996 15:03:59 -0700 (PDT)
From: fleming@unixg.ubc.ca (Jon Fleming)
Subject: Sleep problems in patients on SSRIs

A man in his late 40s came to our clinic with complaints of conduct disorder during sleep. He lifts his body up from bed, yells something and moves around (but does not stand up and walk), so that he bangs his body against the wall and his wife. It usually occurs after 2 hours of sleep and closer to dawn.

It is very rare for a non-REM parasomnia to present for the first time in the late forties (if it does, consider other organic, CNS causes); RSBD tends to begin in later life. The patho-physiology is loss of REM associated atonia in REM sleep with the patient acting out his or her dreams. Typically the patient will recall dreams of attack or escape and the movements and injuries are consistent with this, whereas in non-REM parasominas the movements and vocalizations don't make much sense.

In many cases of RSBD there is no identifiable CNS pathology, but an organic work-up is advisable. A sleep study would confirm the diagnosis, as the loss of atonia is seen clearly on the EMG.

The treatment of choice is with clonazepam, although a variety of antidepressants including trazodone have been reported to be effective. Interestingly, loss of REM atonia has been seen with treatment with SSRIs.

Reference: Schenck CH et al. Prominent eye movements during NREM sleep and REM Sleep Behavior Disorder associated with fluoxetine treatment of depression and obsessive-compulsive disorder. Sleep 15 (3): 226-235, 1992.

Date: Fri, 19 Apr 1996 01:24:15 EDT
From: MWKR59A@prodigy.com (Dr Frederick C Goggans)
Subject: Sleep problems in patients on SSRIs

I had a patient with similar problems which occured while taking an SSRI. This behavior is probably best characterized as "REM sleep behavioral disorder" and is described in a good chapter devoted to it in Dement et al.'s comprehensive textbook, Principles and Practice of Sleep Medicine. My patient was himself a neurologist and was studied with complete polysomnography which I would also suggest. Consider using a REM suppressing agent such as clonazepam 2 mg hs.

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