Cutting down from 15g mirtazapine after 12 years

[Coppernob]

Hi
I've been on mirtazapine for 12 years, coming down quite quickly from 45 to 30 to 15 mg, and have stayed on that dose because the psychiatristat at the hospital I was under said it was important as (at that time) a 70-year old to make sure I had plenty of sleep to avoid the dreaded dementia. The sleep has been the very good result I have had, as long as I sleep I feel physically well which is good for my mental health. But I have suffered in all that time with very low mood on waking in the morning, and it has been a trade-off between sleep and miserable mornings. Recently I had a very bad fall, broke my wrist, cracked my cheekbone and hurt my breast badly, as well as having concussion, and all this has made my morning depression much worse, I feel truly awful and just want to go back to sleep, which just makes everything even worse!

My question is, will I still get good sleep on 7.5mg, what kind of withdrawal symptoms might I get and is this a wise move after such a long time on this drug? Any help or personal experiences would be welcome. GP not much help on this. I'm also on 100mg of pregabalin a day.
Thanks
Chris

[panic_down_under]

I've been on mirtazapine for 12 years, coming down quite quickly from 45 to 30 to 15 mg

Why did your reduce the dose, Chris? It was no longer working?

The sleep has been the very good result I have had, as long as I sleep I feel physically well which is good for my mental health.

Inducing sleep is about all mirtazapine does. It is a powerful sedating antihistamine, not an antidepressant (AD). It is also very prone to pooping-out.

But I have suffered in all that time with very low mood on waking in the morning, and it has been a trade-off between sleep and miserable mornings.

As per above, mirtazapine is mostly a sedative, not an AD so doesn't address the underlying biology which manifests anxiety and/or depression the way an AD or therapy do.

My question is, will I still get good sleep on 7.5mg,

One of the curiosities of antihistamines is that they tend to be more sedating at low doses becoming less so as it increases. However, there is a lower limit to this which varies from person to person so 7.5mg may prove more sedating, or may no longer do anything.

what kind of withdrawal symptoms might I get

I can't say. It might be anywhere from none to relatively severe. Rebound insomnia might be the worst one. What was your experience when dropping from 45mg to 15mg?

and is this a wise move after such a long time on this drug?

If it were working well I'd say stay on mirtazapine, but I assume it no longer is. There is no point taking a med which isn't working well. A real antidepressant will probably be a better bet. If you go that route then, imo, it is likely better to start taking the new med and delaying weaning off mirtazapine until you're stabilized on an effective dose of the new one.

I'm also on 100mg of pregabalin a day.

For anxiety, or some other indication?

Like mirtazapine, pregabalin isn't a first line med for anxiety. Arguably, neither is even a second, or third line med. But the combination appears to be popular in the UK I assume because there are often fewer initial side-effects with mirtazapine and pregabalin was thought not to have the dependency issues of benzodiazepines which turns out isn't true.

Ian

PS: I'm giving one of the local surgeons some carving practice ahead of Christmas in about 12 hours which, all going well, will entail an overnight hospital stay so if you have followup questions my response may be delayed.

[Coppernob]

Thanks for the reply Ian. I hope your procedure went well!

I reduced the dose because the depression was lifting and I didn't need hefty meds any longer. My occasional bouts of depression and anxiety in my life have always had a trigger and I have recovered and been fine in between, always for several years. I have learned to cope, I think now I can head them off at the pass! It is, too, much more anxiety than true depression that I suffer from. The psychiatrist persuaded me to stay on the low dose of mirtazapine and pregabalin to hopefully avoid further episodes, which I suppose has worked.

The sedation was what I needed at the time, I was sleeping badly and that was making me ill and triggering more anxiety. The mirtazapine brought back my appetite too, which I had lost.

I had no adverse effects when dropping the dose before, because I still got good sleep. The only reason I am concerned now is because I have been on the drug for so long. I really need to lose these horrible mornings though which I attribute to the mirtazapine.

The pregabalin is for anxiety. I would love to ditch that too, but I think that's a hurdle for another day!

[panic_down_under]

I had no adverse effects when dropping the dose before, because I still got good sleep.

The last few milligrams can be the hardest to quit. Rather than simply stopping after a few weeks on 7.5mg I suggest halving the dose again to 3.75mg for two weeks and then stopping.

The only reason I am concerned now is because I have been on the drug for so long. I really need to lose these horrible mornings though which I attribute to the mirtazapine.

I'm not sure it is the mirtazapine. It has a half-life of 20-40 hours with plasma levels settling to a steady state after around 6-8 days and then not changing much between doses. It may be that mornings are when the disorder peaks which 15mg isn't able to contain.

The pregabalin is for anxiety. I would love to ditch that too, but I think that's a hurdle for another day!

Yes. It is never a good idea to make two med changes at the same time. Wait until you've been off mirtazapine for a few months.

[Coppernob]

Thank you for the advice. I will discuss with my GP.

Cheers, Chris