![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 19 of 19. This is the beginning of the thread.
Posted by mtom on May 29, 2019, at 13:05:11
Hi, I don't see all that much in recent years posted about Mirtazapine. My Doctor suggested it as an add on or substitution for Escitalopram (Lexapro) which had little if any AD effect for me but lots of side effects, including intense anxiety, nightmares, and others.
I never got above 7.5 mg of Escitalopram because of these, and have reduced to 5 mg, side effects slightly improved but still there.
I have the impression that Mirtazapine/Remeron is not prescribed nearly as often as other AD's. Is that because of the Sedation/Weight Gain side effects, or other reasons?
I have also read very contradictory information about Mirtazapine, articles and research studies.
I read it is frequently prescribed off-label for anxiety (in addition to depression) and found to be effective. However I also have read that it can increase anxiety. This seems to make sense as it increases norepinephrine activity which has made me wonder how it could also help with anxiety as NE is stimulatory?
Research on efficacy for depression is also widely variable. Some say better than many other AD's, others say about the same.
Am interested in hearing from those now on it, or who have tried in past - whether it helped with depression and/or anxiety, or increased anxiety - and what other side effects e.g. nightmares (which I've read Mirtazapine can also cause).
I know about the sedation and weight gain, but articles on that also vary as to how many people actually experience these, and many imply these are temporary effects that decrease over time. Thanks!
Posted by TH on May 29, 2019, at 15:23:52
In reply to Mirtazapine/Remeron recent experience, SE's, etc?, posted by mtom on May 29, 2019, at 13:05:11
I haven't personally taken it, but I believe its real world effectiveness is much lower than its clinical trials suggested.
Posted by mtom on May 29, 2019, at 16:35:02
In reply to Re: Mirtazapine/Remeron recent experience, SE's, etc? » mtom, posted by TH on May 29, 2019, at 15:23:52
> I haven't personally taken it, but I believe its real world effectiveness is much lower than its clinical trials suggested.
From the research I've done (and I've done a lot), this seems to be the case with most if not all antidepressants. That is, the clinical trials done by the Pharma companies to gain approval do not seem to reflect post-marketing follow-ups done by others. The initial trials also seem to generally show lower percentages of adverse effects than are later reported (although not many post-marketing studies are done for these, and most are small - they don't have the funding the Pharma companies do to perform large studies).
In studies I have found where they compared head to head with placebo, it appears the antidepressant response rate often isn't all that much higher than the placebo response rate on average....
Still, interested in hearing from others as there are a few studies showing Mirtazapine is more effective than most others. However, some of these are review studies, looking at many small studies with varying degrees of bias, possible confounding factors, varying rates of compliance and drop-outs, etc. Difficult to find really "good" data.
Posted by TH on May 29, 2019, at 16:47:10
In reply to Re: Mirtazapine/Remeron recent experience, SE's, etc? » TH, posted by mtom on May 29, 2019, at 16:35:02
As far as prescription goes, a few of my friends in NZ have been on it, so it does get used around here. They didn't seem to get great results from it, but I don't see why (taken before bed) it couldn't be a useful augment for someone with insomnia. I have heard a few people on the internet using it effectively in this way, even at very low doses.
Posted by Radish on May 29, 2019, at 19:39:12
In reply to Re: Mirtazapine/Remeron recent experience, SE's, etc?, posted by TH on May 29, 2019, at 16:47:10
I took it for 3 or 4 months this past fall/winter. I did not experience any positive response for my atypical depression or anxiety, however I am proving to be rather treatment resistant and also have multiple diagnoses. It sedated me really well about 15 minutes after taking it sublingually so Id only ever take it right before bed. I did not experience weight gain or an increase in appetite. And discontinuing it was no problem. Overall for me it was the most ineffectual drug Ive tried both in principal effects and side effects, but Im just n=1.
Posted by linkadge on May 31, 2019, at 15:19:21
In reply to Re: Mirtazapine/Remeron recent experience, SE's, etc?, posted by Radish on May 29, 2019, at 19:39:12
Mirtazapine has a completely different profile than other antidepressants. Certain side effects (i.e. sedation or increased appetite) can be difficult for some to tolerate, but it is relatively devoid of certain SSRI side effects (akathisia, insomnia, apathy, nausea, sexual dysfunction etc). I have used it, in conjunction with Effexor, lithium and medical cannabis for a few years now.
It is very good for sleep, and offsetting poor quality of sleep from SSRIs. I took it with citalopram a few years back with excellent results. It has been a godsend for chronic insomnia that otherwise only responded to antipsychotics.
In lower doses <= 7.5mg it is very good for sleep and insomnia. Even 15mg likely won't cause any anxiety. In higher doses, the noradrenergic side effects become more pronounced, and some people can have transient anxiety, or irritability.
Personally, I would try agumenting escialopram with a lower dose of mirtazapine rather than doing a complete switch. Mirtazapine can be a good antidepressant for certain individuals, but the feel of it is very different than SSRIs and, depending on your level of activity, the side effects might be deal breakers.Linkadge
Posted by Ruuudy on May 31, 2019, at 18:49:56
In reply to Re: Mirtazapine/Remeron recent experience, SE's, etc? » Radish, posted by linkadge on May 31, 2019, at 15:19:21
Linkage,
Are you the member I'm thinking of that has told me/us that you have a pretty sizable arsenal of medications to pull from, but seldom remain taking one or the other for extended periods of time?Did you experience any weight-related issues with the mirtazapine?
I've gotten myself into a horrible pattern of sleep hygene and am thinking perhaps a low dosage of mirtazapine to augment my fluoxetine might be a good combo.
Rudy
> Mirtazapine has a completely different profile than other antidepressants. Certain side effects (i.e. sedation or increased appetite) can be difficult for some to tolerate, but it is relatively devoid of certain SSRI side effects (akathisia, insomnia, apathy, nausea, sexual dysfunction etc). I have used it, in conjunction with Effexor, lithium and medical cannabis for a few years now.
>
> It is very good for sleep, and offsetting poor quality of sleep from SSRIs. I took it with citalopram a few years back with excellent results. It has been a godsend for chronic insomnia that otherwise only responded to antipsychotics.
>
>
> In lower doses <= 7.5mg it is very good for sleep and insomnia. Even 15mg likely won't cause any anxiety. In higher doses, the noradrenergic side effects become more pronounced, and some people can have transient anxiety, or irritability.
>
>
> Personally, I would try agumenting escialopram with a lower dose of mirtazapine rather than doing a complete switch. Mirtazapine can be a good antidepressant for certain individuals, but the feel of it is very different than SSRIs and, depending on your level of activity, the side effects might be deal breakers.
>
> Linkadge
>
>
>
>
>
>
>
>
Posted by linkadge on June 1, 2019, at 16:16:07
In reply to Re: Mirtazapine/Remeron recent experience, SE's, etc?, posted by Ruuudy on May 31, 2019, at 18:49:56
Hi Rudy,
Yes that's me. It I take the exact same meds, at the exact same doses, I seem to become stagnant (in my functioning / wellness). For example, after a few weeks on effexor (even 37.5mg) I start to feel numb. I usually taper off before this happens. But, if depression returns, I can resume, and usually be ok.
Mirtazapine can be great for sleep. The key is to keep the dose low. Even 1mg (tiny piece of a tablet) can knock you out and provide restful, restorative sleep.
Linkadge
Posted by mtom on June 2, 2019, at 19:09:11
In reply to Re: Mirtazapine/Remeron recent experience, SE's, etc?, posted by linkadge on June 1, 2019, at 16:16:07
I can't find a lot of patients reports. Most responses to this post talk about it for insomnia, which is not my biggest challenge right now (has been on and off in past).
Lancet found it #2 for efficacy for depression in a review study:
https://www.thelancet.com/action/showPdf?pii=S0140-6736%2817%2932802-7
It is also widely prescribe off label for anxiety.I've found a few other studies showing it effective for depression as add-on medication. However one large review study found no evidence of a clinically significant benefit as add-on (although they describe lots of possible reasons for this and why more studies might be needed) - and they grouped all SSRI's and SNRI's together - didn't comment on head to head results, just did an average as far as I can tell.
Conversely there was another study, although smaller, published more recently, that specifically found clinical improvement in depression when Mirtazapine was added to escitalopram.
Wish some of the patients from these studies who found it effective were reading this forum and could comment......
I don't like subscribing to other forums because of their privacy policies. Also - as has been noted by posters in past, most people subscribing to AD forums are those "not" happy with their meds, people doing well don't tend to post as much......
Posted by plenair on June 20, 2019, at 22:00:46
In reply to Many comment Mirtazapine for sleep.But AD/anxiety?, posted by mtom on June 2, 2019, at 19:09:11
I'm really interested in Mirtazipine as well. I have a filled prescription for it and have been debating taking it for my horrible anxiety and insomnia.
SSRIs cause me a boat load of side-effects with the intolerable ones being louder tinnitus and difficulty urinating. I understand that Mirtazipine may not produce these effects.
For people who split pills - I was under the impression that 7.5mg was the lowest dose, as it was half of the 15mg (smallest) pill. Is it safe to cut pills smaller than the half-pill score line? I would rather start Mirtazipine at a doseage lower than 7.5 mg.
Thanks.
Posted by mtom on June 21, 2019, at 9:36:48
In reply to Re: Many comment Mirtazapine for sleep.But AD/anxiety?, posted by plenair on June 20, 2019, at 22:00:46
Hi Plenair,
I've had tinnitus problems with SSRI's also, specifically citalopram and escitalopram. Also sometime difficulty urinating, mostly in morning. But a ton of other side effects like anxiety, agitation-jitteriness (was worse with citalopram), and vivid dreams, even nightmares. A few years ago I tried very low dose Trazodone for middle of the night insomnia, and it caused even worse tinnitus (and other side effects) so had to stop that after a couple of months. My insomnia improved, but my depression & anxiety kept getting worse, so last year starting trying SSRI's as menntioned above.
I had already been gradually cutting back my escitalopram (Lexapro-Cipralex) to a very small dose with some tinnitus improvement, but the SSRI's helped very little with my depression and although side-effects lessened slightly on lower dose, they didn't completely go away. So 11 days ago my Doctor started me on very low dose Mirtazapine as an add-on initially, and may start cross-tapering to just Mirtazapine depending on how things go.
Because I'm so sensitive to Antidepressants side effects even at very low doses, my doctor started me on a 1/4 of a 15 mg Mirtazapine pill, i.e. 3.75 mg, and I'm still taking this 11 days later. The Pharmacy cut the pills for me (although the prescription specified "take 1/4 pill - I don't know if they would have done it otherwise). They're small, might be tricky to do yourself - you might discuss with your Doctor starting on 1/4 and have her ask the Pharmacy to do this? Upon starting Mirtazapine I reduced my Cipralex dose further. I think the tinnitus has improved a bit, but dreams have been increasing again, last night very vivid. My anxiety may be "slightly" improved, but it may be too soon to attribute this to the Mirtazapine, could be the lower dose of Cipralex that has helped this.
Mirtazapine is known to be very sedating, sometimes causing intense somnolence - and some say worse at lower doses (more of an antihistamine effect at lower doses). The first morning I felt some of this and a bit groggy through the morning, but that seems to have passed since. I think the very low dose I'm taking may not be enough to produce much of a somnolence effect, I'll see what happens as I titrate (increase) gradually.
For people like me who are very sensitive to AD side effects, I believe it might be worthwhile to start very low and increase gradually as tolerated. And stay in touch with your Doctor about Side Effects.
> I'm really interested in Mirtazipine as well. I have a filled prescription for it and have been debating taking it for my horrible anxiety and insomnia.
>
> SSRIs cause me a boat load of side-effects with the intolerable ones being louder tinnitus and difficulty urinating. I understand that Mirtazipine may not produce these effects.
>
> For people who split pills - I was under the impression that 7.5mg was the lowest dose, as it was half of the 15mg (smallest) pill. Is it safe to cut pills smaller than the half-pill score line? I would rather start Mirtazipine at a doseage lower than 7.5 mg.
>
> Thanks.
Posted by plenair on June 23, 2019, at 11:43:10
In reply to Re: Many comment Mirtazapine for sleep.But AD/anxiety? » plenair, posted by mtom on June 21, 2019, at 9:36:48
Hi mtom,
Thanks for your message. I have never heard of a pharmacy manually cutting a pill into quarters. That's great. I don't think my psychiatrist or pharmacy does this. I will ask my doctor, but I think the best I will get is that I should do it myself. I am assuming that the cuts were made parallel to the center score line?
I have my filled bottle of Mirtazipine from several months ago, but I haven't taken any yet.
I've had horrible insomnia...with total insomnia a few nights ago and two nights back to back of three hours of sleep coupled with anxiety, so I'd really like to get some help.
I agree that one should start slowly due to side-effects. Between me failing medication after medication or me refusing to take certain medications, or starting slowly, being extra-sensitive to uncommon side-effects, I haven't found anything that has helped and I've been suffering with this for decades.
Hope Mirtazipine does well for you, and I'd love an update!
Posted by plenair on June 23, 2019, at 11:45:49
In reply to Re: Many comment Mirtazapine for sleep.But AD/anxiety?, posted by plenair on June 23, 2019, at 11:43:10
p.s. I'm deciding between trying mirtazipine or going back to the failed luvox but starting (and staying) at the child dose of 25mg for a while. I have major trouble making decisions due to my anxiety/ocd.
At 50 - 75mg of Luvox I had urinary retention and tinnitus!
Posted by mtom on June 23, 2019, at 12:30:23
In reply to Re: Many comment Mirtazapine for sleep.But AD/anxiety?, posted by plenair on June 23, 2019, at 11:43:10
The script from my Doctor said Take 1/4 pill daily and the Pharmacy had cut them when I picked them up. In past, when I was using another medication and titrating up slowly, my Doctor wrote on the Script "take as directed". I tried cutting these myself into 1/4's with a pill cutter, but wasn't very good at it. When I told my Pharmacist that "as instructed" meant to start with 1/4 and gradually increase but I was having trouble cutting them accurately, he said they would be happy to cut these for me. But again in both cases, the doctor had instructed for the pills to be cut. You could try just asking your Pharmacist to do this, but they may want instructions from the Doctor before doing so. Otherwise, you could try yourself with a pill cutter or small box cutter razor.
> Hi mtom,
>
> Thanks for your message. I have never heard of a pharmacy manually cutting a pill into quarters. That's great. I don't think my psychiatrist or pharmacy does this. I will ask my doctor, but I think the best I will get is that I should do it myself. I am assuming that the cuts were made parallel to the center score line?
>
> I have my filled bottle of Mirtazipine from several months ago, but I haven't taken any yet.
>
> I've had horrible insomnia...with total insomnia a few nights ago and two nights back to back of three hours of sleep coupled with anxiety, so I'd really like to get some help.
>
> I agree that one should start slowly due to side-effects. Between me failing medication after medication or me refusing to take certain medications, or starting slowly, being extra-sensitive to uncommon side-effects, I haven't found anything that has helped and I've been suffering with this for decades.
>
> Hope Mirtazipine does well for you, and I'd love an update!
Posted by plenair on July 1, 2019, at 22:58:44
In reply to Re: Many comment Mirtazapine for sleep.But AD/anxiety? » plenair, posted by mtom on June 23, 2019, at 12:30:23
Thanks, mtom. How is the Mirtazipine working for you?
Posted by mtom on July 2, 2019, at 8:47:42
In reply to Re: Many comment Mirtazapine for sleep.But AD/anxiety?, posted by plenair on July 1, 2019, at 22:58:44
> Thanks, mtom. How is the Mirtazipine working for you?
Well it's been about 3 weeks and I'm still taking just 1/4 pill, but also still taking 5 mg Escitalopram.
Even at this low dose, I was slightly groggy next morning at first, but that's faded. Tinnitus no worse (caused by Esc & other AD's I've tried, but improved a bit when I lowered dose of Esc). But after 5 days the vivid dreams & nightmares I had on higher doses of Esc returned. Not every night (or maybe they're just not vivid enough to fully wake me every night). I "think" I'm perceiving a slight improvement in anxiety and energy/motivation. Will discuss titrating up or cross-tapering when I see Dr this week. A bit concerned that at higher doses the Norepinephrine effect will kick in and increase my anxiety (although Mirt frequently prescribed off-label for anxiety and I've read lots find it helps, but some people find it worsens). I'll still be taking a low dose, but I'm hypersensitive to AD side-effects.
Also concerned other common side effects might kick in which haven't yet o this low dose, e.g. somnolence & weight gain.
I'll probably start tirating dose up very slowly & see how it goes.
Posted by plenair on July 10, 2019, at 10:17:49
In reply to Re: Many comment Mirtazapine for sleep.But AD/anxiety? » plenair, posted by mtom on July 2, 2019, at 8:47:42
Thanks for the update. Did you go up on the Mirtazipine?
I still am in analysis paralysis between luvox and mirtazipine.
Posted by mtom on July 10, 2019, at 12:16:42
In reply to Re: Many comment Mirtazapine for sleep.But AD/anxiety?, posted by plenair on July 10, 2019, at 10:17:49
> Thanks for the update. Did you go up on the Mirtazipine?
>
> I still am in analysis paralysis between luvox and mirtazipine.Plenair, well the nightmares faded over a couple of weeks, occasional vivid dreams remained but fewer. So late last week I upped the Mirtazapine just very slightly and reduced the Cipralex also very slightly. Had nightmares that night, but they seem to be fading again to vivid dreams which I remember some nights, not others. However I had similar dream experience with Escitalopram. I still have some Tinnitus but that was brought on by the Escitalopram, lessened when I reduced dose, and has not worsened since I started Mirtazapine.
I think my Anxiety is slightly better and I've had a few intermittent days where I felt more motivated and got some long neglected tasks done, but not every day. (Mirtazpine has been said to often take effect faster than other AD's). Maybe a bit groggy in morning (some say this lessens over time and also less on higher doses when the NE effect over-rides the anti-histamine effect). So I will increase slightly again in about a week.
There was a study published in Lancet last year comparing 21 AD's for efficacy and acceptability. They ranked Mirtazapine #2 for efficacy, Fluvoxamine #7. For acceptability Mirtazapine was #11, Fluvoxamine #16.
However they extrapolated this based on a bunch of other studies, some head to head AD's, some AD against placebos, and the evidence level for their findings was limited by the fact that many AD's had less published research than others (including these 2). They also commented on the modest effect sizes (i.e. none looked really outstanding vs placebo), and the possibility of publication bias in their source data. But it seems to be the best comparison out there right now. There just isn't a lot of good data comparing all of the antidepressants. Escitalopram (Lexapro-Cipralex) rated high for a weighted combination of "both" efficacy & acceptability together, yet I had a ton of side effects from Esc that but did not completely go away when I reduced dose. And it had little impact on depression, although I never was able to get up to the full recommended dose because SE's worsened whenever I increased dose.
Most people who stop Mirtazapine seem to complain about somnolence and/or weight gain both of which seem common but do not occur in everyone. Also the somnolence seems to dissipate over time with many. I haven't gained weight, and it's not making me sleepy other than the slight grogginess in a.m. (which may in part be due to sleep disturbance with the dreams), but maybe my dose still too low for side effects (although had lots on very low doses of other AD's I've tried).
So, so far, the worse side-effect for me has been the dreams, which seem to increase with dose increase but then seem to fade over time (at least have so far, have to see how it goes with higher doses). A little concerned that as I go up, the more activating NE effect could increase my anxiety again, can only try it and see if I can find a balance.
I've read that Fluvox seems to be commonly prescribed for OCD (as well as depression and anxiety disorders)? Do you have OCD?
Posted by plenair on July 10, 2019, at 12:56:57
In reply to Mirtazapine-Remeron looking somewhat hopeful » plenair, posted by mtom on July 10, 2019, at 12:16:42
Hi mTom,
Thanks for taking the time to reply, and thanks for making me aware of the Lancet study and summarizing some of the mirtazipine/fluvoxamine material.
I hope that the nightmares fading are a good sign for you.
Yes. I have OCD and GAD and any medication is these - my states are much more anxiety based than depressive. Some months ago, I posted a summary of my issues in another thread on this forum. I have much mental repeated rumination that makes me go into the fight/flight response regularly. It's happening every night overnight and I'm disabled from this.
I have severe insomnia from the OCD and other causes. If I took mirtazipine, I would hope that it would have a positive effect on my ability to sleep. I trialed fluvoxamine previously starting at 25mg, but had the urinary problems and tinnitus starting at 50mg going up to 100mg before tapering off. My current choice is between another go at fluvoxamine and this time start up even more slowly (but the effective dose for OCD is as high as 300mg!) or try mirtazipine with the hope being that it allows me to sleep in the short term and modulates my OCD in the long term.
Regarding mirtazipine, I am concerned about cholesterol and weight gain. My ability to exercise is compromised, so I do not know if this is a good option.
P.S. Among many other meds trialed, I took Citalopram some years ago at a dose of up to 60mg - got lots of side effects and no benefit for anxiety/ocd.
Are you now taking the 7.5mg of mirtazipine?
This is the end of the thread.
Psycho-Babble Medication | Extras | FAQ
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.org
Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
Copyright 2006-17 Robert Hsiung.
Owned and operated by Dr. Bob LLC and not the University of Chicago.