How much time to give mirtazapine?

[spiral]

I've been on mirtazapine 15mg for 5 weeks. And then on 30mg for just over 3 weeks.
I'm still feeling very anxious (although nowhere near as bad at the start). I'm still too panicky to drive and although I'm well enough to work I just don't find anything enjoyable so my free time is a waste.
I'd like to hear people's experiences on mirtazapine, do I just need to give it more time or should I be booking a drs appointment to ask about switching to something else?
I previously had success with citalopram but can't go back on that due to family medical issues that have arisen since.

[panic_down_under]

I've been on mirtazapine 15mg for 5 weeks. And then on 30mg for just over 3 weeks.
I'm still feeling very anxious (although nowhere near as bad at the start).

Mirtazapine is more a sedating antihistamine than antidepressant and a positive response can begin within 2-3 weeks, though it may take 4-8 weeks to reach its full potential.


I previously had success with citalopram but can't go back on that due to family medical issues that have arisen since.

Cardiovascular issues?

If citalopram worked well there is a good chance that another SSRI such as sertraline (Zoloft), or fluoxetine (Prozac) will too should the mirtazapine not work for you.

[spiral]

Thanks for the reply.
Yes cardiovascular issues, the doctor says I could go back on citalopram and have regular ecgs but given I'm anxious about my health a different AD would be better.
I've managed to get an appointment today so spoken to the doctor. Given that I've not improved much in the in the 8 weeks and I'm not completely happy with side effects (change in appetite and lack of energy to exercise) I'm going to switch to fluoxitine.
Shame as I've enjoyed the fact mirtazapine has fixed my insomnia and that it doesn't have as annoying side effects as citalopram did.

[panic_down_under]

Thanks for the reply.
Yes cardiovascular issues, the doctor says I could go back on citalopram and have regular ecgs but given I'm anxious about my health a different AD would be better.

While there is now considerable data showing citalopram and escitalopram are not as risky as has been claimed, given the health anxiety switching to fluoxetine is probably the better option


I'm not completely happy with side effects (change in appetite and lack of energy to exercise)

You experienced the mirtazapine carbohydrate cravings? It is a side-effect that few avoid, unfortunately. Some find alpha-lipoic acid supplements moderate both the craving and sedation.


Shame as I've enjoyed the fact mirtazapine has fixed my insomnia and that it doesn't have as annoying side effects as citalopram did.

You could ask your GP if you can take a low mirtazapine dose for insomnia when needed. Doses of 3.75-7.5mg tend to be more sedating than higher ones.

[spiral]

It's not necessarily cravings as such but it's definitely affected my appetite in a negative way. I'm still struggling to eat my meals but I'm sure I could manage unlimited biscuits, chocolate, can't etc. I thought it would just increase my overall appetite but sadly only increases it for junk food.
My main problem is I feel too lethargic to exercise and that could be psychological but it's not normally a problem I have.

Yeah that sounds like a good idea with low dosage for insomnia. When I was on citalopram it did fix my insomnia so hopefully once the fluoxitine kicks in I will go back to sleeping normally.

Thanks for the advice.

[lorenwilson]

Any update?

[spiral]

I've reduced to 15mg from 30mg for a week, and have started fluoxetine this morning. Have another week of mirtazapine before coming off completely.
Feeling very anxious but no worse really than I was on 30mg. I am much more tired though.
Fingers crossed that fluoxetine has more of an effect than the mirtazapine has...

[spiral]

Feeling so anxious that I've not gone in to work today :-(

[panic_down_under]

I am much more tired though.

One of the weirdish thinks about antihistamines is they can be more sedating at the lower doses. Though it could also be the fluoxetine alone or in combination with mirtazapine. Fluoxetine is usually on the stimulating side, but it can be sedating for some. It all depends on how it meshes with your physiology.


Fingers crossed that fluoxetine has more of an effect than the mirtazapine has...

It should do, but it may take a while to kick-in. Fluoxetine has by far the longest half-life of all the ADs and its active metabolite, which does a lot of the heavy lifting, has an even longer half-life, up to 16 days. While this has several advantages the downside is the med can take quite a while to work. :sad:

[spiral]

I think the tiredness is from the reduced dose or mirtazepine as it started before I started the fluoxetine. I'm only on day 2 of Fluoxetine so only two tablets taken so far.
I have scared myself that it won't work by spending too much time googling...
I am worrying that the Fluoxetine will be too stimulating and therefore will make me more anxious rather than less. As I read somewhere that Fluoxetine increased noradrenalin in rats in a study... And I am worried that the reason that Mirtazapine didn't work as it was increasing my noradrenaline.
I know I shouldn't google but it seems like a compulsion...
Even if I am being rational and ignoring the rat study I am worrying that the fluoxetine will give me insomnia as I do tend toward insomnia and feel I have only been sleeping recently because of the mirtazapine .

[panic_down_under]

I have scared myself that it won't work by spending too much time googling...

Googling is counterproductive. Especially when you don't understand what you're reading.


I am worrying that the Fluoxetine will be too stimulating and therefore will make me more anxious rather than less. As I read somewhere that Fluoxetine increased noradrenalin in rats in a study...

Are you referring to Bymaster FP (https://link.springer.com/article/10.1007/s00213-001-0986-x), 2002? If so, yes, they found fluoxetine increased noradrenaline, aka norepinephrine in the extracellular fluid, not within the cells. Also, the study only examined what happens with acute administration, i.e. a single dose. It also found, as you'd expect, that there was an increase in serotonin, aka 5-HT. That happens with all SSRIs and other serotonergic ADs and is the cause of many of the initial side-effects. But with chronic dosing serotonin levels drop back to well below pretreatment levels. See, for example Caccia S (https://pubmed.ncbi.nlm.nih.gov/1381817/), 1992. Because of the long fluoxetine half-life brain serotonin levels take weeks to rebound to pretreatment levels after the med is discontinued (Trouvin JH (https://pubmed.ncbi.nlm.nih.gov/7683363/), 1993)

I haven't been able to find a study which tested noradrenaline levels after chronic fluoxetine administration, but I'd be surprised if they also didn't drop significantly after a few weeks. This is what happens with noradrenaline reuptake inhibitors such as desipramine, (Zangen A (http://www.sciencedirect.com/science/article/pii/S0006899399012147), 1999).


And I am worried that the reason that Mirtazapine didn't work as it was increasing my noradrenaline.

How do you know that mirtazapine was raising your brain noradrenaline levels? Stress itself greatly increases it too and also brain serotonin levels. It is one of the proofs that anxiety disorders and depression are not caused by insufficient brain serotonin, or noradrenaline.


I know I shouldn't google but it seems like a compulsion...

You're not helping yourself by doing so. Just the opposite it seems.


I am worrying that the fluoxetine will give me insomnia as I do tend toward insomnia and feel I have only been sleeping recently because of the mirtazapine .

It may do, but how does crossing bridges before you get to them help? If it happens then it can be treated. Small doses of mirtazapine being one of the remedies.

[spiral]

Thanks for all of these points.
Basically all of what I said was stuff I "learnt" on Reddit. I'm assuming that that is the study but I've forgotten the names. I only read the abstract as you needed a login so I accepted the interpretations on Reddit.
I need to stay off Reddit it's even worse than Google.

I think crossing bridges before I get to them is how I've got myself into this state in the first place.

[spiral]

I don't know how to quote your post but in response to "How do you know that mirtazapine was raising your brain noradrenaline levels?"

It was NHS website that sparked it all of as it says this about mirtazapine:
It works by increasing the activity of mood-enhancing chemicals called noradrenaline and serotonin in your brain.

In any case however it works I need to follow your advice and stop googling as I don't have the time or inclination to read everything in enough detail to understand it properly.
I just need to be patient and see if fluoxetine works and if not try something else.
Patience isn't my strong suit...

[panic_down_under]

I need to stay off Reddit it's even worse than Google.

Indeed.


It was NHS website that sparked it all of as it says this about mirtazapine:
It works by increasing the activity of mood-enhancing chemicals called noradrenaline and serotonin in your brain.

The website is wrong. The 'chemical imbalance' hypothesis as being the cause of anxiety disorders and depression was dismissed almost as soon as it was proposed, but it has become a zombie myth which refuses to die in large part because it's a simpler concept for doctors and pharmaceutical companies to 'sell' to patients than the real cause. My 'Serotonin - The 'chemical imbalance myth (http://www.nomorepanic.co.uk/showthread.php?t=193671)' post explains why it's doesn't stack up.

[spiral]

Great post, thanks.