The Prevalence and Characteristics of REM Sleep without Atonia (RSWA) in Patients Taking Antidepressants

Abstract

Study Objectives: The association of REM sleep without atonia (RSWA) as well as REM sleep behavior disorder (RBD) with the intake of selective serotonin reuptake inhibitors (SSRI) and selective norepinephrine reuptake inhibitors (SNRI) is well established. Our study objective was to determine the prevalence of RSWA and RBD among a group of sleep center patients taking SSRI and SNRI. Methods: A retrospective chart review was done at our tertiary sleep center, and 10,746 consecutive records from October 1, 2007, through October 31, 2013, were searched for SSRI and SNRI names using the Sleep Cataloguer Software. Results: The search resulted in 1,444 records, which were then reviewed for keywords of RSWA and RBD. The AASM scoring criteria were used to determine RSWA. Reports of 41 patients with known narcolepsy or α-synucleinopathies were excluded. The remaining records were mined for age, sex, presence of obstructive sleep apnea (OSA), type of antidepressant (SSRI or SNRI), and diagnosis for which antidepressant was prescribed. We used logistic regression analysis to adjust for age, OSA, and sex. Of the 1,444 participants on antidepressants, 176 (12.2%) had RSWA (all confirmed by the investigators) compared to 226 of the entire sleep lab population of 10,746 (2.1%), risk ratio (95% CI) 9. 978 (8.149, 12.22). Seven of the 176 patients on antidepressants had RBD (0.48%) compared to 108 of 10,746 (1%), p = 0.005. Conclusions: SSRI and SNRI are associated with a higher prevalence of RSWA but not of RBD. This is independent of medication type. I NTRO DUCTI O NREM sleep without atonia (RSWA) is a polysomnographic (PSG) finding characterized by increased tonic or phasic motor tone on the electromyography (EMG) channels during REM sleep.1 REM sleep behavior disorder (RBD) is characterized by the presence of RSWA and as well as a history of dream enacting behavior (DEB). Both RSWA and RBD can occur as idiopathic 2 or secondary to narcolepsy, 3 obstructive sleep apnea (OSA), 4 α-synucleinopathies, 5-8 and in the setting of certain medications such as antidepressants. RSWA is one of the hallmarks of RBD, and RBD can be a predictor for neurodegenerative disorders. RBD also can lead to significant injury to self and bed partner. Lastly the presence of RBD in Parkinson disease (PD) is associated with higher risk of cognitive decline. 2Selective serotonin reuptake inhibitors (SSRI) and selective norepinephrine (NE) reuptake inhibitors (SNRI) have been associated with RSWA and in some instances, RBD. About 15% of patients taking the SSRI fluoxetine in a sleep clinic population were shown to have RSWA.9 Although a few case reports have demonstrated resolution of RSWA and RBD upon discontinuation of fluoxetine, [10][11][12] there is a suggestion from casecontrol studies that antidepressants may "unmask" RBD rather than cause it.13 This is all in the setting of increased usage of antidepressants in the United States, as the rate continues to rise with an increase of over 400% in the last two decades, now becoming the third most comm...

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