What are the implications and possible causes of a person never entering Rapid Eye Movement (REM) sleep, as indicated by a sleep study, and how do medications such as opiates, benzodiazepines (BZD), and Selective Serotonin Reuptake Inhibitors (SSRI) affect REM sleep?

From the Guidelines

The absence of REM sleep, as indicated by a sleep study, is concerning and requires medical attention as it can lead to cognitive impairment, mood disturbances, and immune dysfunction. Several medications commonly suppress REM sleep, including opiates, benzodiazepines, and SSRIs.

• Opiates like morphine, oxycodone, and hydrocodone significantly reduce REM sleep by inhibiting acetylcholine release in the brainstem, which normally helps initiate REM sleep 1.
• Benzodiazepines such as diazepam (Valium), alprazolam (Xanax), and clonazepam (Klonopin) suppress REM sleep by enhancing GABA activity, which inhibits the neural pathways necessary for REM sleep 1.
• SSRIs including fluoxetine (Prozac), sertraline (Zoloft), and escitalopram (Lexapro) initially suppress REM sleep by increasing serotonin levels, which inhibits cholinergic REM-on neurons. Other potential causes of REM sleep absence include sleep apnea, alcohol use, neurological disorders like Parkinson's disease, and certain antipsychotic medications. The implications of chronic REM sleep deprivation include memory consolidation problems, emotional regulation difficulties, reduced creativity, and potentially worsened depression symptoms. Treatment typically involves addressing underlying causes, potentially adjusting medications under medical supervision, improving sleep hygiene, and in some cases, cognitive behavioral therapy for insomnia (CBT-I) 1. Patients should never discontinue these medications abruptly as withdrawal can cause rebound REM sleep with intense nightmares and further sleep disruption. It is essential to weigh the benefits and harms of long-term use of pharmacologic treatments in adults with chronic insomnia disorder, considering the potential risks of benzodiazepines and nonbenzodiazepine BZRAs, such as dependency, falls, and cognitive impairment in older patients 1. In terms of SSRI's effect on REM sleep, SSRIs can decrease REM sleep, especially during the initial treatment phase. However, the most recent and highest quality study on this topic is not provided in the given evidence. Considering the potential consequences of REM sleep deprivation, it is crucial to prioritize the reduction of medication use, especially benzodiazepines and opiates, and to explore alternative treatments, such as CBT-I and sleep hygiene improvements.

From the Research

Implications of Not Entering REM Sleep

• It is possible for a person to not enter REM sleep, as indicated by a sleep study, although this is not a common finding 2.
• The sustainability of not entering REM sleep is unclear, but it may be associated with various sleep disorders and medical conditions 2, 3.
• REM sleep is an essential stage of sleep, and its absence or reduction can have significant implications for physical and mental health 2, 4, 5.

Effects of Medications on REM Sleep

• Opiates and benzodiazepines (BZD) can prevent or reduce REM sleep, which can lead to sleep disturbances and other health problems 4.
• Selective Serotonin Reuptake Inhibitors (SSRI) can also decrease REM sleep, although the effects may vary depending on the specific medication and individual response 5.
• Reducing the use of these medications or finding alternative treatments may be necessary to minimize their impact on REM sleep 4, 5.

Diagnosis and Treatment of Sleep Disorders

• A thorough sleep history and diagnostic tests, such as polysomnography, are essential for diagnosing sleep disorders and determining the underlying causes of REM sleep disturbances 2, 3.
• Treatment of sleep disorders should focus on addressing the underlying causes and may involve a combination of behavioral therapies, lifestyle changes, and medication adjustments 2, 4, 5, 3.