Hi Miranda

If you look at the Cipriani meta-analysis (Lancet) or the Bandolier review of that, you will see mirtazapine is a highly effective antidepressant, if not possibly the most efficacious one.

It is also v useful for anxiety & probably chronic pain

However, it does have 2 significant commonly occurring side-effects, namely sedation and weight gain. Not everyone gets the weight gain but its more than 10% frequency.

So in summary I often prescribe it long term but do warn the user against the potential weight gain and sedation. Having said that, many folk with anxiety & depression welcome the nocturnal sedation

I agree. Can be very effective when you push the dose.

Hi Miranda,

Before prescribing any antidepressant, I would recommend you read Antonuccio and Healy (2012). Re-labelling the medications we call antidepressants. Scientifica. doi: 10.6064/2012/965908. I am currently analysing results of 5 Cochrane Database meta-analyses of antidepressant effectiveness. No antidepressant has been found to be more than about 10% more effective than placebo. However, the adverse reactions can be mild or catastrophic, depending on the individual (including suicidality, aggression and/or homicidality). No ADP is without serious and significant side effects if taken for more than a few months at recommended doses. The first few months usually the patient only feels emotional "numbness", but later - once tolerance is achieved - the real adverse reactions are manifested. Any antidepressant used for more than a few months results in chemical dependency, which can be as difficult to withdraw from as any opioid. Unfortunately the real adverse effects are never researched properly via randomized trials because the participants are not asked the right questions, or followed up for more than 8-10 weeks (it takes that long for the emotional numbness to wear off).

I would recommend reading Joseph Glenmullen "The Antidepressant Solution", which is - in my extensive clinical experience - the most reliable guide to antidepressant actions and use. In short, you cannot rely on official medical reference material because it is almost all funded by pharmaceutical companies (no conspiracy theory, but as Glaxo-Smith-Kline recently stated in response to a legal action they lost "we consider it the cost of doing business"). If you care about your patients, please read some of the material I have mentioned, and follow-up with their reference lists, or search the Cochran Database of Systematic Reviews yourself. Unfortunately, even Cochrane cannot give much guide on side-effects because the research has never been done properly.

If you have a real patient in need, a psychiatrist should be consulted a.s.a.p., as anyone prescribed an antidepressant should be monitored closely for suicidality.

I hope this helps.

The Cipriani meta-analysis (Lancet) highlights mirtazapine as a good antidepressant but not a stand out compared to other first, second or third choices commonly used antidepressants such as SSRIs and SNRIs.

The two most significant side-effects are sedation and weight gain, though the latter may not be substantial. it may add a kg but in the real world, many patients are not fussed by it. Sedation is known and patients should be warned about that- however for many patients with sleep disturbance, it is not necessarily a problem.

Clinically it is useful for anxiety and is highly tolerated in the over 65s- hence it is the choice before tricyclics, though skilled use of the latter often minimises side effects. I am not sure If the evidence base in chronic pain is as strong as amitriptyline or duloxetine.

In my clinical experience, one unexpected side effect is the very rare patient experiences incredible dysphoric side effects from it and ceases it themselves. These patients have usually been on other antidepressants before so can tolerate initial side effects. Therefore these complaints should be taken seriously.

For Chinese and Asian patients, I sometimes halve the dose or even start at 7.5mg at night. Many patients of Chinese and Asian origin have an emphasis on somatic symptoms, so you want to start low.

Doses can go as high as 60mg; 90mg is getting heroic

Hello Miranda

Adding to Mark Taylor, I consider that the two main drawbacks of mirtazapine are also what make of it a great synchronizer.

Mirtazapine is a great medication to organize sleep, and in some patients, the increase of appetite takes place at the mealtimes.

Many of mine patients, after the initial sedation and weight gain during the first 5/6 months of treatment, report great night sleeps, with appetite getting healthier every passing week.

I usually recommended exercise along with mirtazapine (which is an additional antidepressant). In the first months I recommend close monitoring of potential emotional/cognitive alterations (e.g., nightmares, irritability, suicidal thoughts, and grandiosity).

That said, I must add that I am a clinical psychologist and that I followed my patients closely in weekly regimen and that, among the various antidepressants that assisted my work, mirtazepine was the best.

In my experience,mirtazapine is a fair , second-line, antidepressant.

Its optimal dosage lies between 10 and 30 mg.

It can be added with other group antidepressants.

Hi Miranda,

From my clinical practice, I agree with many previous answers: Mirtazapine is an effective medication, often as a second line treatment mainly due to regular sedation and weight gain, particularly interesting in anxiety and sleep problems. Also interesting in combination for residual symptoms, starting low.

In my experience, any antidepressant, if efficient, will lead to disappearance of all depressive signs: psychic, relationnal and somatic as well.

Highly effective 2nd line antidepressant, as said by many others weight gain and sedation, is a worrisome problem. Weight gain is found in more than 50%

It has to be considered that mirtazapine is one of the most commonly prescribed antidepressants for the elderly because of fewer cardial side effects. On the other hand antidepressants, like mirtazapine and other are only the one side oft an effective treatment for depression (and sometimes not the most important). The other side is a good psychotherapy, where the intrapsychic and interpersonal conflicts are discussed.

Thanks to all of you. Do you have patients who can also wean off using Mirtazapine? Or must it always be 'lifetime' episode of using it?

When you have pro-active patients who do not want to be dependent on it, what is your advice to them?

Dear Miranda.

This is an important problem.

I start questionning the patient if he (or she) feels that he is dependent of the air he breathes. Usually, his responds yes. Then I ask him wether it is better to have air to breath or not. He admits that it's better to have air. Then, I ask the same question for antihypertensive medications. Finally, I suggest that the concept of dependance puts together 2 very different problems: to be dependant of something beneficial or of something harmful.

In my experience, when a perfect equilibration has been obtained, after a plateau of 6 months, one can test a slow decrease of dosage by 2 months steps. Approximately every 2 patients can be weaned, but it is only a secondary task.

For more details see the attached abstract.

Sorry it is a wrong file

Thanks Bernard.

One assumption is the antidepressant is taken for what would have been the natural history of the depressive episode. Four to six months is usually advised though all sorts of other factors count. Mirtazapine is not addictive. The significance of a depressive episode is the risk of recurrence: 50% after the first episode and maybe 90% after the second. So its the underlying depressive propensity, not mirtazapine, that determines the need for continuation and maintenance treatment

Mertazipine like other antidepressants is a drug with side effects. Doctors must give patients the full facts regarding side effects before prescribing and monitor their symptoms. To prescribe medication and ask if a patient requires it in the same way he requires 'air to breath' to justify prescribing could be questioned as irresponsible.

Good morning, Miranda

This is an interesting question that leads me to think about the clinical practice in my work setting (primary care in Catalonia). Mirtazapine is often used in frail and elderly patients, often to help with night rest. My perception is that its antidepressant effect is not valued well enough, and that its potential adverse effects and safety issues (especially excessive sedation, postural hypotension, and risk of falls) are trivialized.

It should be remembered that mirtazapine is an antidepressant and has no indication as a hypnotic, much less when sleep problems are not associated with active depression.

Best regards,

Enric