Is Risperdal (risperidone) effective for treating nightmares?

Risperidone for Nightmares

Risperidone may be used for the treatment of PTSD-associated nightmares, but is not a first-line treatment for nightmare disorder due to limited evidence and potential side effects. 1

Evidence for Risperidone in Nightmare Treatment

Risperidone has shown moderate to high efficacy in treating PTSD-associated nightmares in small studies:

• Two Level 4 case series demonstrated that risperidone (1-3 mg/day) significantly reduced PTSD-related nightmares 1:

  • A 6-week open-label trial showed a statistically significant reduction in the proportion of diaries documenting trauma dreams (38% to 19%, p=0.04) 1
  • A retrospective study of 10 adult burn patients reported improvement in nightmares 1-2 days after starting risperidone (0.5-2 mg; average 1 mg) 1

• More recent evidence from a retrospective chart review at a VA Medical Center found risperidone had a 77% success rate (partial to full nightmare cessation) at doses of 1.0-6.0 mg 2

• A small case series of four combat veterans reported that low-dose risperidone (1-3 mg) at night reduced the severity and frequency or completely stopped the recall of PTSD combat nightmares 3

Treatment Algorithm for Nightmares

1. First-line treatment: Image rehearsal therapy (IRT) - recommended by the American Academy of Sleep Medicine as the primary non-pharmacological intervention for nightmare disorder 1

2. First-line pharmacological treatment: Prazosin - has the strongest evidence for PTSD-associated nightmares 1, 4

3. Second-line pharmacological options (if prazosin is ineffective or not tolerated):

   • Clonidine (0.1-2.0 mg)
   • Risperidone (1.0-6.0 mg)
   • Olanzapine (2.5-10.0 mg)
   • Quetiapine (12.5-800.0 mg)
   • Terazosin (50.0-300.0 mg)

Dosing and Administration of Risperidone

• Starting dose: 0.5-1 mg at bedtime
• Titration: Increase by 0.5-1 mg every 3-7 days as needed and tolerated
• Effective dose range: 1-6 mg daily, typically administered at night 3, 2
• Some patients may experience complete cessation of nightmares at doses as low as 2 mg nightly 3

Monitoring and Side Effects

Risperidone's side effect profile requires careful monitoring:

• Common side effects include sedation, weight gain, and hyperprolactinemia 5
• Extrapyramidal symptoms may occur at higher doses 5
• Metabolic effects including hyperglycemia require monitoring 6
• Unlike some other medications, risperidone has minimal anticholinergic effects 5

Important Clinical Considerations

• Risperidone appears to work quickly for nightmares, with some patients reporting improvement within 1-2 days of starting treatment 1, 3

• The American Academy of Sleep Medicine positions risperidone as a medication that "may be used" for PTSD-associated nightmares, not as a first-line recommendation 1

• Prospective sleep logs may be more sensitive than retrospective scales for detecting improvements in nightmare frequency with risperidone treatment 7

• Risperidone may be particularly effective for combat-related PTSD nightmares 3, 2

• The medication should be avoided in patients with dementia-related psychosis due to increased mortality risk

• When prescribing risperidone for nightmares, always start with the lowest effective dose and titrate slowly to minimize side effects while maximizing therapeutic benefit