Aggression from SSRIs

RBD is characterized by a relative absence of the atonia characteristic of REM sleep. This lack of atonia permits the physical acting out of dream mentation, particularly dreams involving confrontation, aggression and violence. RBD is seen most frequently in older men. RBD occurs in both acute and chronic forms. Acute RBD can occur during withdrawal from alcohol or sedative-hypnotics. RBD has also been induced by the tricyclics, SSRIs and venlafaxine. The chronic form of RBD may occur as part of an identifiable underlying neurological disorder, but typically is idiopathic. RBD may also be an initial manifestation of parkinsonism. RBD is very responsive to clonazepam, although this use has not been FDA approved. 

Over the last decade there has been a debate as to whether SSRIs might increase the risk of suicide in certain individuals. Some patients can respond to SSRIs by becoming agitated and restless and developing symptoms that resemble akathisia. Case reports have suggested that adverse effects of this type could underlie an increased risk of self-harm and aggression. However, results from the placebo-controlled randomized trials carried out for regulatory purposes have not supported the proposal that SSRIs increase the risk of suicide of suicidal behavior. 

Regulation of mood, sleep, and aggression have all been shown to involve the serotoninergic system (17-19), and most antidepressant drugs currently being used inhibit 5-HT reuptake and/or act on 5-HT receptors (of which there are several subtypes). 5-HT is produced centrally from the amino acid tryptophan, and depressed mood can be induced experimentally by acute tryptophan depletion in healthy individuals. This effect is accentuated in those with a family history of depression (18-21). Similarly, depressive relapse can be initiated in individuals treated with MAO inhibitors or selective serotonin reuptake (SSRI) inhibitors by depleting tryptophan (22, 23). 

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