Mirtazapine increase? Not sure what to do!

[PixieP]

Hi
I'm new on here and this is my first post. Just looking for some other people's experiences of mirtazapine for GAD and how increases have affectd them please.
To cut my long story short, I suffered from severe GAD following a bout of ill health about 3 years ago. Tried various SSRIs but none suited for one reason or another. After 6 moths of trial and error my GP put me on venlafaxine which was brilliant. Was on it for 2 years and finally came off last summer feeling great. However, GAD returned in October, I went back on the ven but for whatever reason it did nothing this time.
So....my experience with mirt so far - took first 15mg tablet 2nd week in December and have to say I felt the benefits immediately. Slept properly for the first time in 2 months and within 3 weeks no anxiety at all. However, about 3 weeks ago I was out one afternoon and suddenly felt anxious again for no reason i could fathom. Saw my GP a few days later for a routine review and she said thre was always the option to titrate upwards as 15mg is a low dose. I increased to 22.5mg by taking 1.5 tablets about 2 weeks ago but not really feeling much benefit (anxiety seems to be increasing) and woke really early again today with intense anxiety feelings. I don't really want to take meds at all as my experience with SSRIs and increasing those was horrendous. Ven was great and I'm so disappointed that it didnt work this time around. I think what's been good about the mirt so far is the sedating effect as I felt that I was totally hyped to breaking point before starting them.
I just wondered what others' experienced when they increased mirt as I've read on here and several other places that they lose their sedating effect at higher dosages and can actually increase anxiety. I've also read that some people are great on mirt for a few weeks and then it stops working for them. I really hope this isn't the case for me as I'm running out of options medication wise! I practice midnfulness and acceptance of the anxuety but when it takes over your life and is all consuming I think you have to accept that medication is needed.
My GP is fantastic and very understanding but she is just that - a GP and unlike a physical illness where she knows exactly what to prescrice to cure it, mental illness just seems to be trial and error where medication is concerned,
Sorry for the long post but any help and feedback would be most appreciated!
Thank you:unsure:

[LisaCM]

Hi there,
I'm new too and in a similar situation to yourself. Mirtazapine helped me for a long time but since going back on it I find it's not working, even with increasing the dose. The only thing it does for me is to help me sleep.
I have a CPN coming to assess me on Tuesday as like you I am trying everything and seem to be just getting worse.
I know I need my meds changed. I've been given two lots of Diazepam 2mg x 15 and am halfway through the second lot but don't want to keep having them.
It sounds like you need a referral to your community mental health team who are best placed to review meds and offer other therapies. With the best will in the world, GPs are limited in what they can do as you say. I remember afew years ago a GP (who I used to work with when I was a nurse), handed me the BNF and asked ME what meds I should try next!
I hope you get things sorted and find some relief soon.
Take care,
Lisa

[toothless]

Hi, I started on 15mg and after a set back of anxiety a month later I upped the dose to 30mg, I felt abit off for a few days after the upped dose, I still slept well but I took me a little longer to fall asleep, I was really worried about upping the dose but glad I did.

I have still had set backs since upping the dose and noticed I was much more likely to have these anxiety days before my period and ovulation but as time has gone on this has got better. I last had a setback nearly four months ago, I have been on mirtazapine 8 months. Im not sure if any med will completely get rid of anxiety forever.

[panic_down_under]

Hi
I'm new on here and this is my first post.

Welcome to No More Panic :welcome:


After 6 moths of trial and error my GP put me on venlafaxine which was brilliant. Was on it for 2 years and finally came off last summer feeling great. However, GAD returned in October, I went back on the ven but for whatever reason it did nothing this time.

It happens. There is growing evidence that antidepressants become progressively less effective every time they are stopped and restarted, often requiring higher doses to achieve the previous level of control. They may also produce more severe, and/or different, initial side-effects. Two studies, Amsterdam JD (https://www.ncbi.nlm.nih.gov/pubmed/27805299), 2016 and Amsterdam, 2009 (http://www.karger.com/Article/FullText/226611) found the likelihood of antidepressants working after each restart drops by between 19-25% (see also: Amsterdam JD (http://www.ncbi.nlm.nih.gov/pubmed/18694599), 2009; Leykin Y (http://www.ncbi.nlm.nih.gov/pubmed/17469884), 2007). This applies whether returning to a previously taken antidepressant or a different one.


I've read on here and several other places that they lose their sedating effect at higher dosages and can actually increase anxiety. I've also read that some people are great on mirt for a few weeks and then it stops working for them.

I'm not a mirtazapine fan. Is is mostly just a powerful antihistamine which eases anxiety by sedation. It is also very prone to stop working.


I really hope this isn't the case for me as I'm running out of options medication wise!

No you're not. SSRIs are not the only antidepressants and arguably they are not even the most effective. I'd be asking for either the SNRI duloxetine (Cymbalta), which unlike venlafaxine (Effexor) is a true SNRI, or one of the older tricyclic class antidepressants (TCAs) such as imipramine (Tofranil), or amitriptyline (Elavil). Amitriptyline is more sedating, but imipramine is the more potent med.

Your GP will probably prefer to prescribe duloxetine because it is the safer med in overdose, but I think either of the TCAs would be the better bet. They usually produce less severe side-effects initially, and are generally easier to quit than SSRIs and SNRIs (though I think you should consider remaining on the med permanently). TCAs come in much smaller dose tablets relative to their therapeutic range which makes it very easy to start on a small dose and work your way up to the therapeutic range. OTOH, except for venlafaxin, SSRIs come in relatively high dose slow-release pills which cannot be cut.

The downside to TCAs is they tend to have more ongoing side-effects than the SSRIs (desipramine (Norpramin) is the exception), mostly nuisance ones such as dry-mouth and constipation which are manageable.

[PixieP]

Thank you for the replies. I think I may take 30mg / 22.5mg on alternate days for a couple of weeks rather than jump straight to 30mg as I'm concerned about even more increased anxiety (my symptoms never diminish at their worst and before December I lived in a near permanent state of panic all day, every day for 2 months).
If I have no success with this I will take your advice panic down under and ask for something else. I'm not prepared to go to 45mg if 30mg does nothing.
Out of interest, has anyone tried pregabalin? I know it's expensive and GPs aren't keen to prescribe it for that reason but there seem to be good results from it.
I've had talking therapy and CBT but as there's no specific cause for my anxiety I didn't find it much help. I've been going to work but purely because the alternative is being alone at home all day. I just feel crap all day there instead but at least there's people to talk to!
Thank you all for the support :hugs:

[panic_down_under]

Out of interest, has anyone tried pregabalin? I know it's expensive and GPs aren't keen to prescribe it for that reason but there seem to be good results from it.

Imho, this is a third tier anxiety med. It seems to work okay for some, but not for most. I believe antidepressants are the better long term bet.


I've had talking therapy and CBT but as there's no specific cause for my anxiety I didn't find it much help.

CBT shouldn't be able finding a cause, or causes. Knowing what triggered an anxiety disorder (or depression) doesn't change anything. What you should be getting from therapy is learning ways to deal with your anxious thoughts and addressing specific issues created by them.

[PixieP]

I think my issue is I know that undue stress caused by work and an injury that left me unable to exercise was the trigger for the anxiety this time around. However, now things have resolved themselves but the anxiety is still there or rather the physical symptoms are. So I'm living in a permanent state of extreme agitation and it's the fear of this (the feelings are so intense there is no let up) that's keeping it all going. Acceptance is great in theory. It so very hard in practice when all I want is to feel normal again (and that to me means yes thee will always be stress in my life but I just deal with it). The CBT I had didn't really help as the only negative thought I was having was "I hate this feeling and want to be me again". Difficult to challenge as I have no avoidance or safety behaviours (doing everything I normally would) just awful physical feelings the whole time. I just wonder whether another course with a different counsellor might be beneficial? I'm sick of being a medication guinea pig!

---------- Post added at 14:41 ---------- Previous post was at 14:39 ----------

I'm also starting to wonder whether it might all be related to the onset of menopause and just my hormones are all over the place. I might ask the GP to test for this next time I see her.

[panic_down_under]

However, now things have resolved themselves but the anxiety is still there or rather the physical symptoms are.

Yes, because anxiety disorders (and also depression) soon take on a 'life' of their own independent of their trigger. Removing the stressor then changes nothing.


I'm also starting to wonder whether it might all be related to the onset of menopause and just my hormones are all over the place.

It may well be. Women are much more susceptible to developing most of the anxiety disorders (also depression) than men and hormones seem to be the main reason for this. However, treating the hormonal issues will not necessarily resolve the anxiety.