Tetracyclic antidepressant for anxiety?

[Vasa Lisa]

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Hi there -

Thoughts on Mirtazapine for anxiety? A quick google search says it is a tetracyclic antidepressant. Musings and insights appreciated. Links to research also appreciated - I have access to most online databases - but thought I would winnow the results by asking here first.

And gratitude for all of you MDs who are willing to do psych consults - there is such as shortage in my area.

Vasa Lisa

 

[nitemagi]

Most psychiatrists do not consider it first line. More often used for insomnia, or in the case of severe illness and weight loss the side effect profile (weight gain) is leveraged to help with other health issues.

 

[hamstergang]

Most psychiatrists do not consider it first line.

Is there a good reason for that?

 

[notdeadyet]

Is there a good reason for that?

Side effects and then efficacy.

 

[shan564]

Useful drug, but I usually only use it first-line if I need to stimulate somebody's appetite.

Otherwise, it's effective by itself and/or as an adjunct if an SSRI doesn't do the job.

As far as links to research - there are literally thousands of articles, so it's hard to know what to suggest and/or how to narrow it down just based on the idea of "anxiety." There are lots of different types of anxiety. I've met several psychiatrists who like to use it for people who have a ruminative-type anxiety, since its antihistamine effect also helps in the same way that vistaril does for some people. I don't like it as much for people that have autonomic-type anxiety, since it blocks alpha-2 receptors, which are involved in the natural slowing-down of the autonomic response.

Also, "tetracyclic antidepressants" are only grouped together from the standpoint of chemical structure. The different tetracyclics are quite different from each other, and people don't always agree on what falls under the umbrella of "tetracyclic."

 

[Vasa Lisa]

Thanks for your thoughts - interesting the connection with appetite - as this isn't a presenting concern - and insomnia is an issue - I need to get a ROI and find out more - but this gives me a start.

Bottom line - there is an improvement - talk therapy alone wasn't working.

 

[Jester25]

Thanks for your thoughts - interesting the connection with appetite - as this isn't a presenting concern - and insomnia is an issue - I need to get a ROI and find out more - but this gives me a start.

Bottom line - there is an improvement - talk therapy alone wasn't working.

I like to use Mirtazapine in failure to thrive patients, nauseated patients, and to help with insomnia. This makes it very useful for cancer and depression patients. From my previous readings, my understanding is that norepi does not help with anxiety and in fact can worsen anxiety. Mirtazapine as an alpha 2 antagonist works to increase both serotonin (through blockage of alpha 2 heteroreceptors) and norepi (though blockage of alpha 2 auto receptors). It also works on other receptors that can increase serotonin, norepi, and dopamine. It's sedating and weight gain properties come from potent H1 blockade at the lower doses, as the dose increases you get more of the activating elements of the medications. So if you are using it to help someone for sleep and appetite, 15 mg would be an ideal dose.

As far as anxiety. Elevating serotonin levels have been clearly established to show it helps with anxiety so that's why first line agents are the SSRIs. If patients don't do well with SSRIs for any reason (poor response, sexual dysfunction, etc), going out of the class to SNRIs and other antidepressants like Mirtazapine is commonly done.

 

[whopper]

Mirtazapine isn't cheap compared to the $4 generics. While it's not hundreds a month, it is around $50 and that does matter when you're dealing with a patient of a low SES without insurance.

Agree with the comments above such as Jester's. I hardly ever use it first-line unless the patient can't sleep, is underweight, and nauseated, it's a wonderful medication if it works. I also use it for California Rocket Fuel and yes I know the data supporting that should be more, but sometimes you got a treatment resistant case and you got to start somewhere on a method not tried before.

 

[shan564]

Thanks for your thoughts - interesting the connection with appetite - as this isn't a presenting concern - and insomnia is an issue - I need to get a ROI and find out more - but this gives me a start.

Bottom line - there is an improvement - talk therapy alone wasn't working.

This suggests that you're asking about your own care. You should really discuss that with your doctor, since we can't give specific advice without examining you personally. There are many reasons to choose many different treatments.

 

[michaelrack]

I like to use Mirtazapine in failure to thrive patients, nauseated patients, and to help with insomnia. This makes it very useful for cancer and depression patients. From my previous readings, my understanding is that norepi does not help with anxiety and in fact can worsen anxiety. Mirtazapine as an alpha 2 antagonist works to increase both serotonin (through blockage of alpha 2 heteroreceptors) and norepi (though blockage of alpha 2 auto receptors). It also works on other receptors that can increase serotonin, norepi, and dopamine. It's sedating and weight gain properties come from potent H1 blockade at the lower doses, as the dose increases you get more of the activating elements of the medications. So if you are using it to help someone for sleep and appetite, 15 mg would be an ideal dose.

As far as anxiety. Elevating serotonin levels have been clearly established to show it helps with anxiety so that's why first line agents are the SSRIs.

I agree that pure noradrenergic agents are not good for anxiety, but there is some good evidence for "balanced" antidepressants- that increase serotonin and norepinephrine- in anxiety. When you get to the OCD end of the anxiety spectrum, I like highly serotonergic agents. For GAD, balanced agents such as many of the TCA's or Effexor (higher doses) work pretty well. Of course, it's fine to start off with an SSRI when treating anxiety d/o's

 

[Jester25]

I agree that pure noradrenergic agents are not good for anxiety, but there is some good evidence for "balanced" antidepressants- that increase serotonin and norepinephrine- in anxiety. When you get to the OCD end of the anxiety spectrum, I like highly serotonergic agents. For GAD, balanced agents such as many of the TCA's or Effexor (higher doses) work pretty well. Of course, it's fine to start off with an SSRI when treating anxiety d/o's

I am not sure about this. I think SNRIs work for anxiety due to the serotonin, not the norepi. If norepi is improving someone's anxiety, it is likely their ADHD. Physiologically it doesn't make sense for norepi to improve anxiety. I would love to read a study comparing SSRIs vs SNRIs for anxiety thou, I haven't seen one. I've read studies in a book I read about anxiety comparing SSRIs/ SNRIs vs. NRIs. The NRIs predictably were not helpful.

 

[michaelrack]

I am not sure about this. I think SNRIs work for anxiety due to the serotonin, not the norepi. If norepi is improving someone's anxiety, it is likely their ADHD. Physiologically it doesn't make sense for norepi to improve anxiety. I would love to read a study comparing SSRIs vs SNRIs for anxiety thou, I haven't seen one. I've read studies in a book I read about anxiety comparing SSRIs/ SNRIs vs. NRIs. The NRIs predictably were not helpful.

http://www.ncbi.nlm.nih.gov/pubmed/16633143 reboxetine as effective as fluvoxamine for ptsd

http://www.ncbi.nlm.nih.gov/pubmed/14971862 This one is more relevant- imipramine vs sertraline for panic

http://www.ncbi.nlm.nih.gov/pubmed/11838623 reboxetine for panic

http://www.ncbi.nlm.nih.gov/pubmed/9160622 in this study imipramine was more effective than fluvoxamine in panic

On the other hand, this study found that the effect of impipramine on panic was more attributable to imipramine rather than N-desmethylimipramine (desipramine) plasma levels- supporting a serotonergic hypothesis: http://www.ncbi.nlm.nih.gov/pubmed/2643933

I stick by my opinion that a balanced (serotonergic/noradrenergic) approach works for non-OCD anxiety disorders, but the evidence is not conclusive and a pure serotnergic approach is certainly reasonable (and is currently first line).

 

[Jester25]

http://www.ncbi.nlm.nih.gov/pubmed/16633143 reboxetine as effective as fluvoxamine for ptsd

http://www.ncbi.nlm.nih.gov/pubmed/14971862 This one is more relevant- imipramine vs sertraline for panic

http://www.ncbi.nlm.nih.gov/pubmed/11838623 reboxetine for panic

http://www.ncbi.nlm.nih.gov/pubmed/9160622 in this study imipramine was more effective than fluvoxamine in panic

On the other hand, this study found that the effect of impipramine on panic was more attributable to imipramine rather than N-desmethylimipramine (desipramine) plasma levels- supporting a serotonergic hypothesis: http://www.ncbi.nlm.nih.gov/pubmed/2643933

I stick by my opinion that a balanced (serotonergic/noradrenergic) approach works for non-OCD anxiety disorders, but the evidence is not conclusive and a pure serotnergic approach is certainly reasonable (and is currently first line).

Thanks for the links, I will give it a read sometime this weekend.