Medication helps many to manage their mental health, but one side-effect could really be the stuff of nightmares…
One second you’re in your office, and the next you’re being chased by a stranger in the cafeteria of your old school. Nothing appears quite as it should be – the colours are brighter, the sounds are more jarring, and you wake up in a cold sweat.
Antidepressants are a lifeline for many people, myself included, but they can play havoc with your dreams. When I started taking sertraline – a selective serotonin reuptake inhibitor (SSRI) – my anxiety began to ease. But at night, my dreams became far more vivid than any I had experienced before.
For me, intense dreams aren’t a problem compared with the struggle of daily anxiety. But why might antidepressants affect how you dream – and if they are disrupting your sleep, what can you do about it?
In a 2013 report published in Sleep Medicine Reviews, Gotthard G Tribl and his research team examined the impact of antidepressants on dream content. They examined 21 clinical studies, and 25 case reports, published over a period of 60 years.
The team looked at dream content across a spectrum of different antidepressants, including SSRIs and tricyclics, an older class of medications still in use today. SSRI antidepressants – as well as serotonin-norepinephrine reuptake inhibitors (SNRIs) – were found to intensify dreams and increase the frequency of nightmares. Meanwhile, tricyclics tended to produce more positive dreams.
Neurotransmitters
Different antidepressants work in different ways, but in general, they change the levels of chemicals called neurotransmitters in your brain. For example, SSRIs increase the amount of serotonin, which is associated with mood regulation.
It is these changes in brain chemistry that may affect how we dream, says Dr Carmine Pariante, a psychiatrist and professor of biological psychiatry at King’s College London.
“Neurotransmitters like serotonin and adrenaline are involved in brain activity and circadian rhythms – 24-hour cycles that are part of the body’s internal clock – so it makes sense that medications that affect these chemicals also affect sleep and dreams,” he says.
However, the exact mechanism involved is unknown. Because these chemicals regulate emotions, increasing them could make dreams more intense. Pleasurable dreams may be more enjoyable – and nightmares scarier.
REM sleep changes
Serotonin and dopamine are ‘mood’ chemicals, but they also play important roles in the regulation of sleep, wakefulness, and transitions between sleep stages. A 2021 study, published in the International Journal of Molecular Sciences, found that SSRIs can increase the time between falling asleep and the onset of the first rapid eye movement (REM) sleep stage. So, it’s possible that these changes to our sleep stages can alter how we dream, especially with regards to changes in REM sleep – when dreaming and memory consolidation occur.
“Antidepressants tend to suppress REM sleep. But as the body gets used to the medication, there’s often a ‘REM rebound’ – a period in which the intensity and frequency of REM sleep increases,” says Dr Pariante.
This may result in more vivid and intense dreams. However, Dr Pariante adds, this rebound period is only temporary, and any side-effects usually settle down as you get used to the medication.
The impact on sleep also depends on the class of medication and the specific drug. “At first, tricyclic medications tend to have a sedative effect, which can help people sleep better,” says Dr Pariante.
“SSRIs have an activating effect, which is why people can experience an initial increase in anxiety,” he says. “But even if there is initially a negative effect on sleep, it’s likely this will improve as the medication has its intended effect. Antidepressants may also start helping someone sleep more deeply, affecting how they dream.”
Depression and sleep
One reason the relationship is so complex is because mental health problems like depression and anxiety can also cause vivid dreams – regardless of the potential effect of antidepressants.
“People with trauma or depression may have dreams with content that is really upsetting. There may be a direct reliving of a distressing experience, or a symbolic manifestation that you can interpret,” says Dr Pariante.
One review, published in Sleep Medicine Reviews, also suggests that coming off antidepressants – which should be done gradually with medical guidance to avoid unpleasant or even serious reactions – can lead to an increase in nightmares and dream recall.
What to do if you’re having nightmares
If your sleep is being negatively affected by your antidepressant regimen, there are steps you can take. However, it’s important to speak to your doctor before making any changes because of potential side-effects – and do not stop taking your medication.
It’s vital to give antidepressants time to work – which can take at least one or two weeks – and to let your body adjust to the medication. “My first piece of advice would be to see how it goes,” says Dr Pariante. “The side-effects, like nausea, go away after time and they improve.”
Change when you take it
“If possible, take it in the morning rather than the evening, so the peak of the effect on the brain doesn’t happen during the night,” says Dr Pariante. However, the correct timing of your medication can depend on the type of drug you’re on, if you’re taking any others, and how many pills you take in a day.
Switch medications
An antidepressant that works well for one person may not suit another, so finding the right one can involve trial and error. “If the side-effects are really impairing and don’t go away in a few weeks, then you could try a different medication,” says Dr Pariante. “Even within drug classes like SSRIs, you may switch from one to another and the side-effects differ for individuals.”
Lifestyle changes
Making small changes to your evening routine may also help improve the quality of your sleep in general. Create a bedtime routine, and before bed do an activity you find relaxing, like reading or having a bath. If you’re struggling with nightmares, it may be helpful to speak to a therapist to address underlying stress or other problems.
Antidepressants can provide a really helpful way to manage a mental health problem, but like all medications, they carry side-effects. For many people, the benefits outweigh these – but if not, you can always speak to your doctor about trying a new treatment. The answer to a mental health problem isn’t always straightforward, but with the right support, it can be manageable.
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