Bit of reassurance needed?

[CP353]

Hi there,

Not sure if this is the best place to ask, as not really mirt specific, but here goes...

I'm new to mirtazapine, been taking it for about 2 weeks following coming off citalopram (long story!), following a long period of anxiety (even longer story). Up to now, it's actually been great - anxiety much reduced, sleeping well, eating much better...However, I was at the hairdresser last night, and felt the anxiety almost clunk in. Tried to relax over the evening, and slept well, but this morning I'm still wound up. Really struggling to feel like eating, and feeling down.

I think I just need a bit of reassurance that setbacks are normal, and don't mean that the drugs don't work and I'm heading back to the bad times. Does anyone else have experience with, I guess, just handling bad days? It's been very busy in work after the Xmas holidays, and perhaps I've been trying to do too much.

I do struggle with all or nothing thinking - either everything is ABSOLUTELY FINE, or I'm quitting my job and moving back in with my parents. I don't seem to have space for 'yeah, you felt bad today, but it'll ease up and you'll feel better tomorrow'.

Gosh this stuff is so hard!

[panic_down_under]

I'm new to mirtazapine, been taking it for about 2 weeks

...Up to now, it's actually been great - anxiety much reduced, sleeping well, eating much better...However, I was at the hairdresser last night, and felt the anxiety almost clunk in. Tried to relax over the evening, and slept well, but this morning I'm still wound up. Really struggling to feel like eating, and feeling down.

As I mentioned previously, mirtazapine is only a powerful sedating antihistamine, not an antidepressant (AD). Hence the improved sleep. It can also induce very intense carbohydrate cravings with weight gain being a frequent side-effect.


I think I just need a bit of reassurance that setbacks are normal, and don't mean that the drugs don't work and I'm heading back to the bad times. Does anyone else have experience with, I guess, just handling bad days? It's been very busy in work after the Xmas holidays, and perhaps I've been trying to do too much.

Bad days can happen with any anxiety and depression med and higher than usual work stress won't help. Plus, I'm guessing you're only taking 15mg/day which is the usual starting dose. Most need 30-45mg to get good results.


Gosh this stuff is so hard!

Anxiety disorders (and depression) are often a long time in the making and don't surrender easily. :weep: But they can be bought to heel provided you keep working at it.

[ServerError]

If mirtazapine is not a true antidepressant, why is it described everywhere as an antidepressant? And why is prescribed to treat depression? Do you have an opinion on its effectiveness in treating depression and anxiety? I ask because I'm taking it and my doctor was convinced it would be the right one for me (I'm less convinced).

[panic_down_under]

If mirtazapine is not a true antidepressant, why is it described everywhere as an antidepressant? And why is prescribed to treat depression?

Marketing. There is no fixed criterion for what can be called an antidepressant (or what can be a SSRI, or SNRI). If a pharmaceutical company wants to call their med an antidepressant it can even if the data says otherwise. Doxepin is another sedating antihistamine which has long been promoted as an AD despite having poor outcomes.

True ADs work by stimulating the growth of new brain cells in the hippocampal regions of the brain. There is no evidence that either mirtazapine, or doxepin do this, afaik.

Another marker for AD effectiveness is reuptake inhibition of one or more of the neurotransmitters serotonin, noradrenaline (aka norepinephrine) and dopamine. Neither mirtazapine or doxepin do this.

Mirtazapine is the second of two 'antidepressants' to be marketed by Organon Pharmaceuticals. The first was mianserin which causes a brief flurry of positive reviews in the medical literature and then sales dropped through the floor as psychiatrists realised the hype didn't match the outcomes they were seeing in patients. Mirtazapine was a rework of mianserin with Organon claiming it has a greater effect on receptors and transporters than mianserin. However, mirtazapine is in fact less potent (see below).

As a guide, SSRIs have a binding affinity of <=2 Ki to the serotonin reuptake transporter molecules (SERT) with paroxetine being the most potent SSRI at 0.08 (https://en.wikipedia.org/wiki/Pharmacology_of_antidepressants#Receptor_affinity) Ki. The most potent noradrenaline reuptake inhibitor, desipramine, has a binding affinity of 0.83 Ki on noradrenaline transporters (NAT) (Ki = the concentration of the drug needed to block 50% of the target receptors, or transporters, so the lower the value the more potent the inhibition).

Mirtazapine has affinity values of SERT: 10,000 Ki, NAT: 4,600 Ki , but 0.14 Ki on histamine H1 receptors which makes it a more potent antihistamine than meds sold as antihistamines (as examples, desloratadine, is 0.4 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3667286/) Ki and fexofenadine 10.0 Ki)!

The values for mianserin are SERT: 4,000 Ki, NAT: 71 Ki and H1: 1.0 Ki

Doxepin is more potent, SERT: 68 Ki, NAT: 29.5 Ki, but it is a slightly less effective H1 blocker at 0.24 Ki.


Do you have an opinion on its effectiveness in treating depression and anxiety?

I don't rate it for depression, though occasionally it will pull the very depressed, bordering on catatonic back from the brink for a while and its sedating properties can be all some with anxiety need. However, I don't rate it as a first, or second line med for either anxiety, or depression. That said, some do well on it so...

I suggest you have a scroll through some of the posts in this sub forum to get a broader picture of others' experiences.