REM Sleep Behavior Disorder in Psychiatric Populations

Abstract

To the Editor: Rapid eye movement (REM) sleep behavior disorder (RBD) is a parasomnia characterized by a loss of REMrelated muscle atonia and abnormal motor activities during REM sleep with consequent sleep-related injuries. 1,2 It has been increasingly reported among psychiatric populations and has a potential association with use of psychotropics, particularly selective serotonin reuptake inhibitor (SSRI), tricyclic, and serotonin and noradrenergic reuptake inhibitor (SNRI) antidepressants. [3][4][5][6][7][8] A previous case report 5 found that cessation of SSRI treatment did not result in complete resolution of clinical RBD symptoms and polysomnographic (PSG) abnormalities. Our recent clinical epidemiologic study 8 found that 3.8% of psychiatric outpatients might have RBD features over the past year. The prevalence is 10 times more common than that of the typical RBD in the elderly general population. 9 In addition, the RBD features could result in sleep-related injuries and violence, with potential medicolegal repercussions. 8,10 In the current study, we conducted a comprehensive evaluation of clinical and PSG features as well as follow-up response to an open intervention of antidepressant regimen modification.Method. Fifteen depressed subjects with concurrent antidepressant treatment and features suggestive of RBD were included in this case series, which spans from December 2006 to March 2009. They were interviewed by experienced psychiatrists and neurologists for a thorough clinical evaluation, which included a semistructured psychiatric interview and physical examination with Hoehn and Yahr staging for parkinsonism. 11 They also underwent videopolysomnographic assessments at baseline and follow-up.Modification of their current antidepressant regimen was suggested to all subjects. Bupropion was offered as the treatment of choice in this open intervention, as it has rarely been associated

Gender differences in REM sleep behavior disorder: a clinical and polysomnographic study in China

“…The increased proportion of women with antidepressant use [14] could be due to the increased prevalence of depression in women [17]. A majority of studies suggest antidepressants (eg, tricyclic antidepressants and selective serotonin reuptake inhibitors) may induce RBD [13,18]; however, Wing et al speculated that antidepressants might be a precipitating agent instead of having a causal role in RBD in psychiatric patients [19,20]. In total, 56% of female patients were idiopathic for RBD in our study.…”

Rapid eye movement sleep behavior disorder in adults younger than 50 years of age

“…Furthermore, RBD associated with antidepressants does not necessarily resolve the removal of the potentially causal medication. In a study following 15 individuals with antidepressant associated RBD (most were early-onset), about half of whom were changed to treatment with bupropion (which is not known to be associated with RBD or RWA), while subjective frequency and severity of nocturnal behaviors improved over a mean follow-up of 13 months, the degree of RWA as assessed by vPSG did not improve, and in fact, increased [40]. Overall, past or present antidepressant usage is strongly associated with RBD/RWA, and a key question to be addressed in future studies is whether there is a causal mechanism or simply an association.…”

“…This study found that patients with psychiatric disorder-related RBD had more nightmares and higher scores on depression and anxiety scales, suggesting that psychiatric symptoms confer additional risk for RBD, independent of antidepressant usage. The same investigators have proposed that altered dream content with heightened emotion that occur in psychiatric diseases may contribute to RBD behaviors [12,40]. Since most individuals with psychiatric disease are treated with antidepressant medications at least once, very large and likely multi-center studies will be required to tease apart the potential contributions of psychiatric disease and antidepressants to RBD risk.…”

“…This has not been studied in a well-controlled manner, primarily because insufficient time has passed for most reported cases of early-onset RBD to have reached an age when neurodegenerative diseases become symptomatic. Clearly, only a small proportion of individuals who take antidepressants have RBD; in the largest study, only 5% of patients taking SSRI had RBD-like disorder [40]. This suggests that this subset of individuals has a certain vulnerability, and possibly, that antidepressants unmask or hasten latent RWA or RBD.…”

Prospective outcome of rapid eye movement sleep behaviour disorder: psychiatric disorders as a potential early marker of Parkinson's disease: Figure 1

“…Although antidepressants were suggested as a potential culprit, emerging evidence suggested that residual RBD features persisted even after the discontinuation of psychotropic medications 9. Given our preliminary finding of psychiatric disorders as a possible early neurodegenerative marker in iRBD patients, further research is needed to determine whether this group of RBD patients in the psychiatric populations may also be at risk of predisposition to future neurodegeneration.…”