What decreases Rapid Eye Movement (REM) sleep?

Medications and Factors That Decrease REM Sleep

Several medications and substances reliably decrease REM sleep, with antidepressants—particularly SSRIs and SNRIs—having the strongest and most consistent REM-suppressing effects. 1

Antidepressant Medications

SSRIs (Selective Serotonin Reuptake Inhibitors)

• Fluoxetine significantly decreases REM sleep amount, increases sleep-onset latency and REM latency after just 6 days of administration 2
• Paroxetine causes statistically significant decreases in total REM sleep quantity, particularly during the first 6 hours after administration 3
• Sertraline can cause such significant REM suppression that it may lead to REM-related parasomnias like sleep paralysis in some patients 4
• SSRIs decrease REM sleep by increasing serotonergic transmission, which inhibits REM-promoting cholinergic neurons in the brainstem 5

SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)

• Milnacipran causes less REM sleep disruption compared to SSRIs and tricyclic antidepressants, but still decreases REM sleep during the first 4 hours after morning administration 3

Tricyclic Antidepressants

• Imipramine significantly decreases total REM sleep quantity and number of REM episodes while increasing REM episode duration 3
• Tricyclics cause more persistent REM suppression throughout the entire 24-hour period compared to SSRIs and SNRIs 3
• Desipramine has been used specifically for its ability to suppress both phasic and tonic components of REM sleep 6

Benzodiazepines and Related Medications

• Clonazepam (0.25-2.0 mg at bedtime) is recommended as a first-line treatment for REM sleep behavior disorder due to its REM-suppressing effects 7
• Clonazepam works through GABAergic inhibition by increasing the frequency of chloride channel opening, effectively suppressing REM sleep 7
• Other benzodiazepines like temazepam, triazolam, and alprazolam also decrease REM sleep through similar mechanisms 6

Other Medications and Substances

• Melatonin (3-15 mg at bedtime) suppresses REM sleep motor tone and normalizes circadian features of REM sleep 7
• L-DOPA may promote REM sleep behavior disorder in some patients, suggesting it affects REM sleep regulation 6
• Acetylcholinesterase inhibitors like donepezil and rivastigmine may affect REM sleep patterns in patients with neurodegenerative disorders 6
• Angiotensin-converting enzyme inhibitors (ACEIs) like enalapril, perindopril, or ramipril may contribute to sleep apnea and disrupt normal REM sleep patterns in some patients 6

Physiological and Environmental Factors

• Stress can significantly disrupt normal REM sleep patterns by activating the hypothalamic-pituitary-adrenal axis, which has inhibitory effects on REM sleep 8
• Addressing underlying stress factors should be prioritized in patients experiencing stress-related REM sleep disruptions 8

Clinical Implications and Monitoring

• When prescribing REM-suppressing medications, monitor for potential side effects such as daytime sedation, cognitive impairment, and falls, particularly in elderly patients 6
• For patients with REM sleep behavior disorder, the REM-suppressing effects of medications like clonazepam can be therapeutic by reducing dream enactment behaviors 6
• In patients with depression, the REM-suppressing effects of antidepressants may be part of their therapeutic mechanism, as they counteract the increased REM sleep often seen in depression 1

Cautions and Contraindications

• Use clonazepam with caution in patients with dementia, gait disorders, or concomitant obstructive sleep apnea 6
• Some antidepressants may paradoxically induce or worsen REM sleep behavior disorder symptoms in certain patients 7
• Fluoxetine and other SSRIs can cause significant changes in sleep architecture that persist beyond the acute administration period 9

Remember that while REM suppression can be therapeutic in certain conditions like REM sleep behavior disorder, it may be problematic in others, requiring careful medication selection and monitoring.