Buzz Westfall Justice Center, St. Louis, Missouri, USA.
Pharmacotherapy. 2010 Apr;30(4):145e-50e. doi: 10.1592/phco.30.4.423.
Tricyclic antidepressants decrease rapid eye movement (REM) sleep and may suppress sleep atonia. Reports indicate that these agents can induce visual hallucinations, sometimes characterized as hypnopompic or associated with a dissociated sleep-wakefulness state. In addition, disturbing dreams and confusional states were reported during clinical trials and in subsequent studies. To our knowledge, only two cases of nightmares associated with mirtazapine, a tetracyclic antidepressant, have been previously reported. We describe a 43-year-old Caucasian man with major depressive disorder who started mirtazapine 15 mg at bedtime because he had poor symptom control with other antidepressant drugs. Three days later, vivid dream activity was noted, evolving into realistic nightmares that the patient was not able to distinguish from reality on awakening. Acute paranoia was suspected, and haloperidol was started. The dream activity then ended, and within 3 days the patient was able to identify the dreams as unreality. Haloperidol was discontinued, but mirtazapine was continued, and the vivid dream activity persisted; however, reality testing when awake was intact. A short course of haloperidol restored the patient's reality testing, and mirtazapine was eventually replaced with bupropion. The unusual nocturnal activity resolved as a result. Clinicians should be aware of the possible transition from exceptionally vivid dreams to REM sleep behavior disorder and psychosis based on dream content as an adverse effect of mirtazapine.
三环类抗抑郁药可减少快速眼动（REM）睡眠，并可能抑制睡眠时的肌肉松弛。有报道称，这些药物可诱发视幻觉，有时表现为催眠期或与睡眠-觉醒状态分离相关。此外，在临床试验和后续研究中也有报告称，这些药物会引起令人不安的梦境和意识混乱状态。据我们所知，此前仅报道过两例与米氮平（四环抗抑郁药）相关的梦魇病例。我们描述了一位 43 岁的白人男性，患有重度抑郁症，因其他抗抑郁药物对其症状控制不佳，开始在睡前服用米氮平 15 毫克。三天后，患者出现生动的梦境活动，逐渐发展为逼真的噩梦，以至于在醒来时无法将其与现实区分开来。怀疑患者出现急性偏执，开始使用氟哌啶醇。随后，梦境活动停止，三天内患者能够识别出这些梦是不真实的。停用氟哌啶醇，但继续服用米氮平，生动的梦境活动仍在持续；然而，患者在清醒时的现实检验仍保持完整。短期使用氟哌啶醇恢复了患者的现实检验能力，最终用安非他酮替换了米氮平。异常的夜间活动随之得到解决。临床医生应意识到，米氮平可能会出现异常生动的梦境转变为 REM 睡眠行为障碍和精神病，这取决于梦境内容。
