Does citalopram (Selective Serotonin Reuptake Inhibitor) need to be discontinued before a polysomnography (PSG) study for diagnosing REM sleep behavior disorder (RBD)?

Citalopram Should Be Discontinued Before PSG for REM Sleep Behavior Disorder Diagnosis

Citalopram, like other SSRIs, 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

Why SSRIs Like Citalopram Affect RBD Diagnosis

• SSRIs, including citalopram, can induce or exacerbate REM sleep without atonia (RSWA), which is the primary polysomnographic finding in RBD 2, 1
• Case reports and population studies have demonstrated an increased risk ratio of being on antidepressants (including SSRIs) for patients with early-onset RBD 2
• Drug-induced/exacerbated RBD (5-HT RBD) is characterized by dream enactment and elevated REM sleep motor tone after starting or increasing serotonergic medications 2
• Studies have shown that SSRIs can induce RSWA even in subjects without prior RBD symptoms 2
• A specific 8-week open-label study of sertraline (another SSRI) demonstrated that it increased both tonic and phasic RSWA in depressed patients 3

Diagnostic Implications

• The presence of citalopram during PSG may lead to false positive findings of RSWA, complicating the distinction between drug-induced RBD and idiopathic or secondary RBD 1
• Accurate diagnosis is crucial because idiopathic RBD has significant prognostic implications regarding future neurodegenerative disease risk, while drug-induced RBD generally has a more favorable prognosis 2, 1
• The International Classification of Sleep Disorders (ICSD) diagnostic criteria for RBD specify that the sleep disturbance should not be better explained by medication use 2

Protocol for 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
• If RBD symptoms persist after discontinuing citalopram, the patient should be diagnosed with either isolated RBD or secondary RBD (if there is a clear underlying disorder) 2

Special Considerations

• For patients who cannot safely discontinue citalopram, clinicians should note this limitation when interpreting PSG results 1
• If continued antidepressant therapy is necessary, switching to an agent with a lower serotonergic profile (such as bupropion) may be considered 2
• The timing between initiation of citalopram and the emergence of RBD manifestations is typically short (weeks or months, not years) 2
• The risks and benefits of discontinuing citalopram that has been taken uneventfully for a prolonged period should be carefully assessed 2

After Diagnosis

• If drug-induced RBD is confirmed, the American Academy of Sleep Medicine suggests drug discontinuation as the primary treatment approach 2
• Environmental safety measures should be implemented regardless of pharmacologic treatment 1
• For patients who develop RBD while taking citalopram but cannot discontinue it, alternative treatments such as melatonin or clonazepam may be considered 2, 4

This approach ensures accurate diagnosis of RBD by eliminating the confounding effects of citalopram, while balancing the patient's need for antidepressant therapy with the importance of diagnostic clarity.