Insomnia and depression are frequently encountered in patients during withdrawal from substances. While there are no approved medications for treating them, off-label attempts to address these phenomena with mirtazapine have shown some promising results. This case describes the use of mirtazapine as an aid in benzodiazepine withdrawal and its potential benefits in alleviating insomnia and depression in a 32-year-old man. It was found to ameliorate sleep myoclonus that was thought to be associated with his withdrawal syndrome. It is hoped this report will generate interest and stimulate further research in this area of psychopharmacology.
Matched MeSH terms: Mianserin/analogs & derivatives*; Mianserin/therapeutic use
Objective: To evaluate the prescription pattern of antidepressants in patients with medical co-morbidity from major psychiatric centres in Asia.
Methods: The Research on Asian Psychotropic Prescription Pattern for Antidepressants (REAP-AD 2013) collected data from 42 psychiatric centres in 10 Asian countries and regions. Antidepressant prescriptions of 2320 patients with various psychiatric disorders were evaluated. Of these, 370 patients who had specified medical co-morbidities formed the study cohort.
Results: Escitalopram (20%) and mirtazapine (20%) were the most commonly prescribed antidepressants in patients with medical co-morbidity followed by sertraline (16%), trazodone (15%), and paroxetine (12%). Overall, more than half (52%; 247/476) of prescriptions comprised selective serotonin reuptake inhibitors. Slightly less than two-thirds (63%; n = 233) of patients received at least 1 selective serotonin reuptake inhibitor. In addition, 79% of patients were prescribed only 1 antidepressant. The mean number of antidepressants used per patient was 1.25 (standard deviation, 0.56). There were subtle differences in the most preferred antidepressant across medical illnesses such as diabetes mellitus, liver dysfunction, acid peptic disease, and cerebrovascular disease. Differences were also seen in prescription patterns across different countries.
Conclusion: Although selective serotonin reuptake inhibitors formed the bulk of antidepressant
prescriptions in the presence of medical co-morbidity, mirtazapine was also commonly used in the presence of medical co-morbidities. Specified medical morbidities do influence the selection of antidepressants.
Key words: Antidepressive agents; Asia; Comorbidity
Matched MeSH terms: Mianserin/analogs & derivatives; Mianserin/therapeutic use
This is a 4 week, randomized, double-blind, placebo-controlled study to examine the effects of methylphenidate as add-on therapy to mirtazapine compared to placebo for treatment of depression in terminally ill cancer patients. It involved 88 terminally ill cancer patients from University of Malaya Medical Centre, Kuala Lumpur, Malaysia. They were randomized and treated with either methylphenidate or placebo as add on to mirtazapine. The change in Montgomery-Åsberg Depression Rating Scale (MADRS) score from baseline to day 3 was analyzed by linear regression. Changes of MADRS and Clinical Global Impression-Severity Scale (CGI-S) over 28 days were analyzed using mixed model repeated measures (MMRM). Secondary analysis of MADRS response rates, defined as 50% or more reduction from baseline score. A significantly larger reduction of Montgomery-Åsberg Depression Rating Scale (MADRS) score in the methylphenidate group was observed from day 3 (B=4.14; 95% CI=1.83-6.45). Response rate (defined as 50% or more reduction from baseline MADRS score) in the methylphenidate treated group was superior from day 14. Improvement in Clinical Global Impression-Severity Scale (CGI-S) was greater in the methylphenidate treated group from day 3 until day 28. The drop-out rates were 52.3% in the methylphenidate group and 59.1% in the placebo group (relative risk=0.86, 95%CI=0.54-1.37) due to cancer progression. Nervous system adverse events were more common in methylphenidate treated subjects (20.5% vs 9.1%, p=0.13). In conclusions, methylphenidate as add on therapy to mirtazapine demonstrated an earlier antidepressant response in terminally ill cancer patients, although at an increased risk of the nervous system side effects.
Matched MeSH terms: Mianserin/adverse effects; Mianserin/analogs & derivatives*; Mianserin/therapeutic use
Panic disorder (PD) being one of the most intensively investigated anxiety disorders is considered a heterogeneous psychiatric disease which has difficulties with early diagnosis. The disorder is recurrent and usually associated with low remission rates and high rates of relapse which may exacerbated social and quality of life, causes unnecessary cost and increased risk for complication and suicide. Current pharmacotherapy for PD are available but these drugs have slow therapeutic onset, several side effects and most patients do not fully respond to these standard pharmacological treatments. Ongoing investigations indicate the need for new and promising agents for the treatment of PD. This article will cover the importance of immediate and proper treatment, the gap in the current management of PD with special emphasis on pharmacotherapy, and evidence regarding the novel anti-panic drugs including the drugs in developments such as metabotropic glutamate (mGlu 2/3) agonist and levetiracetam. Preliminary results suggest the anti-panic properties and the efficacy of duloxetine, reboxetine, mirtazapine, nefazodone, risperidone and inositol as a monotherapy drug. Apart for their effectiveness, the aforementioned compounds were generally well tolerated compared to the standard available pharmacotherapy drugs, indicating their potential therapeutic usefulness for ambivalent and hypervigilance patient. Further strong clinical trials will provide an ample support to these novel compounds as an alternative monotherapy for PD treatment-resistant patient.
In recent years, more cases of manic switches on Mirtazapine have been reported. In this report, we discuss a case of manic switch in a gentleman who was treated as unipolar depression. A 66-year-old man presented to psychiatry 8 months following a nephrectomy for symptoms of depression. Treatment with Sertraline 50mg daily was initiated and titrated to 150mg, along with Zolpidem and Clonazepam to aid his sleep. Despite these medications he never achieved remission and continued to have persistent anxiety and insomnia. Due to suboptimal control, treatment was changed to Mirtazapine 15mg daily. At day 20 he showed symptoms of mania which included talkativeness, increased goal directed activities, reduced need for sleep and socially disinhibited behavior. Mirtazapine was discontinued, and treatment was changed to Sodium Valproate, optimized to 1000mg daily, augmented with Quetiapine 150mg daily. Remission was achieved after 4 months and he has remained asymptomatic for 2 months. This was his first episode of mania, and a diagnosis of Bipolar I disorder was made. In conclusion, antidepressant induced manic switches are common, they are relatively under-appreciated and under-reported, especially with the use of sleep-promoting antidepressants. All antidepressants should be considered to be a potential mediator of a switch in view of its pharmacological properties.
Objective: This systematic review is aimed to quantitatively summarise the
prevalence of sexual dysfunction among non-SSRI second generation
antidepressants namely agomelatine, bupropion, duloxetine, venlafaxine, and
mirtazapine.
Methods: Relevant studies published from inception till
December 2012 were identified by searching PubMed, OVID and Embase.
We included all literatures encompassing randomized controlled, cohort,
case-controlled and cross-sectional studies, which contained quantitative data
for prevalence on all aspects of sexual dysfunction in depressive patients who
were older than 18 years of age. Heterogeneity, publication bias and odds
ratio were assessed thoroughly.
Results: In the non-SSRI second generation
antidepressant group which consisted of 17,316 subjects, various studies
showed the range of sexual dysfunction prevalence between 0% and 67%.
Sexual dysfunction in patients who took non-SSRI second generation
antidepressants constituted a meta-analytical pooled prevalence of 15%, and
36% in those who took SSRIs. The combined relative risk of sexual
dysfunction in the non-SSRI second generation antidepressant group when
compared with SSRI was 0.57.
Conclusions: The pooled prevalence of sexual
dysfunction in non-SSRI second generation antidepressant is lower than in
SSRI antidepressants.