What medications, such as Selective Serotonin Reuptake Inhibitors (SSRIs) like fluoxetine (Prozac) and sertraline (Zoloft), and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) like venlafaxine (Effexor), should be stopped before a Polysomnography (PSG) study to diagnose REM Sleep Behavior Disorder (RBD)?

Medications to Stop Before PSG for REM Sleep Behavior Disorder Diagnosis

Selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and other antidepressants should be discontinued before polysomnography (PSG) when evaluating for REM sleep behavior disorder (RBD), as these medications can induce or exacerbate RBD symptoms and affect diagnostic accuracy. 1

Medications That Should Be Discontinued

• Selective Serotonin Reuptake Inhibitors (SSRIs) such as fluoxetine, paroxetine, sertraline, escitalopram, and citalopram can induce or exacerbate RBD symptoms and should be discontinued before PSG 1, 2
• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) including venlafaxine should be stopped as they can cause REM sleep without atonia and dream enactment behaviors 3
• Tricyclic Antidepressants (TCAs) such as clomipramine and amitriptyline have been shown to induce or worsen RBD symptoms 1, 3
• Monoamine Oxidase Inhibitors (MAOIs) like phenelzine and selegiline should be discontinued as they can induce RBD/REM sleep without atonia 2, 3

Timing of Medication Discontinuation

• Medication discontinuation should be done under medical supervision, as abrupt cessation can lead to withdrawal symptoms 1
• The American Academy of Sleep Medicine recommends discussing medication changes with the prescribing provider before stopping antidepressants 1
• Typically, medications should be tapered and discontinued several weeks before the PSG to allow for washout of the drug effects 4

Diagnostic Considerations

• Drug-induced/exacerbated RBD (5-HT RBD) is characterized by dream enactment and elevated REM sleep motor tone after starting or increasing serotonergic medications 1
• Polysomnographic diagnosis of RBD requires evidence of REM sleep without atonia (RSWA) or excessive transient muscle activity in REM sleep 1
• PSG should document the percentage of REM sleep epochs that meet criteria for REM without atonia to distinguish patients with and without RBD 5

Special Considerations

• In patients who cannot safely discontinue antidepressants, the clinician should note this limitation when interpreting PSG results 1
• If RBD symptoms persist after discontinuing the suspected causative medication, the patient should be diagnosed with either isolated RBD or secondary RBD (if there is a clear underlying disorder) 1
• For patients who still require antidepressant therapy, switching to an agent with a lower serotonergic profile (such as bupropion) may be considered 1

After Diagnosis

• If RBD is confirmed, first-line treatments include clonazepam (0.25-2.0 mg at bedtime) or melatonin (3-15 mg at bedtime) 6
• For patients with cognitive impairment, gait disorders, or obstructive sleep apnea, melatonin may be preferable to clonazepam 2
• Environmental safety measures should be implemented regardless of pharmacologic treatment 1

Common Pitfalls

• Failing to recognize that some medications can mask or mimic RBD symptoms, leading to false-positive or false-negative results 5
• Not distinguishing between drug-induced RBD and idiopathic or secondary RBD, which have different prognostic implications 1
• Overlooking the need to rule out other sleep disorders that may mimic RBD, such as obstructive sleep apnea, non-REM parasomnias, and nocturnal seizures 5