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Hassanein EHM, Althagafy HS, Baraka MA, Abd-Alhameed EK, Ibrahim IM. Pharmacological update of mirtazapine: a narrative literature review. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024; 397:2603-2619. [PMID: 37943296 PMCID: PMC11074035 DOI: 10.1007/s00210-023-02818-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 10/26/2023] [Indexed: 11/10/2023]
Abstract
Mirtazapine (MTZ) is an antidepressant drug with an exceptional pharmacological profile. It also has an excellent safety and tolerability profile. The present review provides a pharmacological update on MTZ and summarizes the research findings of MTZ's effects on different diseases. MTZ is hypothesized to have antidepressant effects because of the synergy between noradrenergic and serotonergic actions and is effective in treating major depressive disorder and depression associated with epilepsy, Alzheimer's disease, stroke, cardiovascular disease, and respiratory disease. In cancer patients, MTZ significantly reduced sadness, nausea, sleep disruption, and pain and improved quality of life. Also, it has promising effects on Parkinson's disease, schizophrenia, dysthymia, social anxiety disorder, alcohol dependency, posttraumatic stress disorder, panic disorder, pain syndromes, obsessive-compulsive disorder, and sleep disorders. Additionally, MTZ is potentially therapeutic in different situations associated with depression, such as liver, kidney, cardiovascular, respiratory, infertility, heavy metal-induced neurotoxicity, and pruritus. Potent antioxidative, anti-inflammatory, and anti-apoptotic bioactivities mediate these promising effects. These positive outcomes of the scientific investigations motivate more and more clinical trials for a golden exceptional antidepressant in different conditions.
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Affiliation(s)
- Emad H M Hassanein
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Al-Azhar University, Assiut Branch, Assiut, 71524, Egypt.
| | - Hanan S Althagafy
- Department of Biochemistry, Faculty of Science, University of Jeddah, Jeddah, Saudi Arabia
| | - Mohammad A Baraka
- Faculty of Pharmacy, Al-Azhar University, Assiut Branch, Assiut, 71524, Egypt
| | - Esraa K Abd-Alhameed
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Islam M Ibrahim
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
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Correia AS, Vale N. Antidepressants in Alzheimer's Disease: A Focus on the Role of Mirtazapine. Pharmaceuticals (Basel) 2021; 14:ph14090930. [PMID: 34577630 PMCID: PMC8467729 DOI: 10.3390/ph14090930] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 09/07/2021] [Accepted: 09/14/2021] [Indexed: 12/21/2022] Open
Abstract
Mirtazapine belongs to the category of antidepressants clinically used mainly in major depressive disorder but also used in obsessive-compulsive disorders, generalized anxiety, and sleep disturbances. This drug acts mainly by antagonizing the adrenergic α2, and the serotonergic 5-HT2 and 5-HT3 receptors. Neuropsychiatric symptoms, such as depression and agitation, are strongly associated with Alzheimer’s disease, reducing the life quality of these patients. Thus, it is crucial to control depression in Alzheimer’s patients. For this purpose, drugs such as mirtazapine are important in the control of anxiety, agitation, and other depressive symptoms in these patients. Indeed, despite some contradictory studies, evidence supports the role of mirtazapine in this regard. In this review, we will focus on depression in Alzheimer’s disease, highlighting the role of mirtazapine in this context.
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Affiliation(s)
- Ana Salomé Correia
- OncoPharma Research Group, Center for Health Technology and Services Research (CINTESIS), Rua Doutor Plácido da Costa, 4200-450 Porto, Portugal;
- Institute of Biomedical Sciences Abel Salazar (ICBAS), University of Porto, Rua de Jorge Viterbo Ferreira 228, 4050-313 Porto, Portugal
| | - Nuno Vale
- OncoPharma Research Group, Center for Health Technology and Services Research (CINTESIS), Rua Doutor Plácido da Costa, 4200-450 Porto, Portugal;
- Department of Community Medicine, Health Information and Decision (MEDCIDS), Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
- Correspondence:
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Melaragno AJ. Pharmacotherapy for Anxiety Disorders: From First-Line Options to Treatment Resistance. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2021; 19:145-160. [PMID: 34690578 PMCID: PMC8475920 DOI: 10.1176/appi.focus.20200048] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
In this review, the author examines the evidence for psychopharmacologic treatments among adults for generalized anxiety disorder, panic disorder, and social anxiety disorder derived from clinical trials. For each disorder, major categories of drugs are reviewed, and then the evidence-based medications in each category are discussed. The author reviews key safety and tolerability considerations for each of the medications or classes. Evidence-based dosing for most specific agents is displayed in a comprehensive reference table. Subsequently, the author synthesizes the available information to suggest a pragmatic stepwise approach to treatment that accounts for patient-specific factors. To inform the guidance, the author incorporates and refines perspectives from treatment guidelines already written by clinical professional organizations. The author also briefly reviews the relatively new quantitative systematic review methodology of network meta-analysis (NMA) and discusses how NMA may help guide pharmacologic treatment sequencing decisions in the future by way of ranking treatments according to effect size and the relative amount of study to which treatments have been subject. Caveats of NMA studies are briefly discussed, as are results of recent NMAs regarding the pharmacologic treatment of anxiety disorders.
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Affiliation(s)
- Andrew J Melaragno
- Division of Medical Psychiatry, Brigham and Women's Hospital, Boston; Department of Psychiatry Harvard Medical School, Boston
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Zulfarina MS, Syarifah-Noratiqah SB, Nazrun SA, Sharif R, Naina-Mohamed I. Pharmacological Therapy in Panic Disorder: Current Guidelines and Novel Drugs Discovery for Treatment-resistant Patient. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2019; 17:145-154. [PMID: 30905115 PMCID: PMC6478076 DOI: 10.9758/cpn.2019.17.2.145] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/11/2018] [Accepted: 10/12/2018] [Indexed: 12/26/2022]
Abstract
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.
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Affiliation(s)
- Mohamed S Zulfarina
- Pharmacoepidemiology and Drug Safety Unit, Department of Pharmacology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Syed-Badrul Syarifah-Noratiqah
- Pharmacoepidemiology and Drug Safety Unit, Department of Pharmacology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Shuid A Nazrun
- Pharmacoepidemiology and Drug Safety Unit, Department of Pharmacology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Razinah Sharif
- Program of Nutritional Sciences, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Isa Naina-Mohamed
- Pharmacoepidemiology and Drug Safety Unit, Department of Pharmacology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
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Alam A, Voronovich Z, Carley JA. A review of therapeutic uses of mirtazapine in psychiatric and medical conditions. Prim Care Companion CNS Disord 2013; 15:13r01525. [PMID: 24511451 DOI: 10.4088/pcc.13r01525] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Accepted: 07/09/2013] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE To review the literature examining the use of mirtazapine with an emphasis on its therapeutic benefits for psychiatric patients with comorbid medical conditions. DATA SOURCES MEDLINE, PsycINFO, Global Health, and AGRICOLA were searched using the terms mirtazapine OR Remeron. Limits were English language, human, year 1980-2012, treatment and prevention, and therapy. STUDY SELECTION Two hundred ninety-three articles were identified. DATA EXTRACTION Identified articles were reviewed with a focus on indications and therapeutic benefits in patients with medical comorbidities. RESULTS Mirtazapine is an effective antidepressant with unique mechanisms of action. It is characterized by a relatively rapid onset of action, high response and remission rates, a favorable side-effect profile, and several unique therapeutic benefits over other antidepressants. Mirtazapine has also shown promise in treating some medical disorders, including neurologic conditions, and ameliorating some of the associated debilitating symptoms of weight loss, insomnia, and postoperative nausea and vomiting. CONCLUSIONS Mirtazapine offers clinicians multiple therapeutic advantages especially when treating patients with comorbid medical illness.
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Affiliation(s)
- Abdulkader Alam
- Departments of Psychiatry and Medicine (Dr Alam), University of Pittsburgh School of Medicine (Ms Voronovich), Pittsburgh, Pennsylvania; and University of Alabama School of Medicine, Birmingham (Dr Carley)
| | - Zoya Voronovich
- Departments of Psychiatry and Medicine (Dr Alam), University of Pittsburgh School of Medicine (Ms Voronovich), Pittsburgh, Pennsylvania; and University of Alabama School of Medicine, Birmingham (Dr Carley)
| | - Joseph A Carley
- Departments of Psychiatry and Medicine (Dr Alam), University of Pittsburgh School of Medicine (Ms Voronovich), Pittsburgh, Pennsylvania; and University of Alabama School of Medicine, Birmingham (Dr Carley)
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Abstract
Exposure of the general population to a 1:4 lifetime risk of disabling anxiety has inspired generations of fundamental and clinical psychopharmacologists, from the era of the earliest benzodiazepines (BZ) to that of the selective serotonin reuptake inhibitors (SSRIs) and related compounds, eg, the serotonin and norepinephrine reuptake inhibitors (SNRIs). This comprehensive practical review summarizes current therapeutic research across the spectrum of individual disorders: generalized anxiety disorder (GAD), panic disorder (PD) and agoraphobia (social anxiety disorder), compulsive disorder (OCD), phobic disorder (including social phobia), and posttraumatic stress disorder (PTSD). Specific diagnosis is a precondition to successful therapy: despite substantial overlap, each disorder responds preferentially to specific pharmacotherapy. Comorbidity with depression is common; hence the success of the SSRIs, which were originally designed to treat depression. Assessment (multidomain measures versus individual end points) remains problematic, as-frequently-do efficacy and tolerability The ideal anxiolytic remains the Holy Grail of worldwide psychopharmacologic research.
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Affiliation(s)
- Giovanni B Cassano
- Department of Psychiatry, Neurobiology, Pharmacology, and Biotechnology, University of Pisa, Pisa, Italy
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Freire RC, Hallak JE, Crippa JA, Nardi AE. New treatment options for panic disorder: clinical trials from 2000 to 2010. Expert Opin Pharmacother 2011; 12:1419-28. [DOI: 10.1517/14656566.2011.562200] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Croom KF, Perry CM, Plosker GL. Mirtazapine: a review of its use in major depression and other psychiatric disorders. CNS Drugs 2009; 23:427-52. [PMID: 19453203 DOI: 10.2165/00023210-200923050-00006] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Mirtazapine (Remeron, Zispin) is a noradrenergic and specific serotonergic antidepressant (NaSSA) that is approved in many counties for use in the treatment of major depression. Monotherapy with mirtazapine 15-45 mg/day leads to rapid and sustained improvements in depressive symptoms in patients with major depression, including the elderly. It is as effective as other antidepressants and may have a more rapid onset of action than selective serotonin reuptake inhibitors (SSRIs). Furthermore, it may also have a higher sustained remission rate than amitriptyline. Preliminary data suggest that mirtazapine may also be effective in the treatment of anxiety disorders (including post-traumatic stress disorder, panic disorder and social anxiety disorder), obsessive-compulsive disorder, undifferentiated somatoform disorder and, as add-on therapy, in schizophrenia, although large, well designed trials are needed to confirm these findings. Mirtazapine is generally well tolerated in patients with depression. In conclusion, mirtazapine is an effective antidepressant for the treatment of major depression and also has the potential to be of use in other psychiatric indications.
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Fox CB, Treadway AK, Blaszczyk AT, Sleeper RB. Megestrol acetate and mirtazapine for the treatment of unplanned weight loss in the elderly. Pharmacotherapy 2009; 29:383-97. [PMID: 19323618 DOI: 10.1592/phco.29.4.383] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
A rising concern among clinicians is treatment of unplanned weight loss in the elderly, especially given the predicted growth of this population over the next few decades. Unexpected weight loss in the geriatric patient worsens overall health outcomes. A variety of pharmacotherapeutic options are available for treatment; however, evidence underlying their use is limited, and none has gained approval from the United States Food and Drug Administration for this indication. At present, no guidelines support the choice of one agent over another. Although several drug interventions have been employed for this problem, megestrol acetate and mirtazapine are becoming increasingly used for appetite stimulation. These drugs represent two feasible options for geriatric patients because of their generally favorable adverse-effect profiles and few drug interactions, but they are often misused. In a comprehensive search of the MEDLINE and International Pharmaceutical Abstracts databases, we identified all published reports on the use of megestrol acetate or mirtazapine for the treatment of weight loss and on any adverse events associated with these drugs. Special emphasis was placed on trials performed in an elderly population. Results were conflicting, most likely because of differing study designs and small numbers of patients. Megestrol acetate and mirtazapine appear to be effective for appetite stimulation and weight gain in some settings. However, applicability of the data to elderly individuals is unclear, and adverse events reported in a few of the trials and in case reports were not benign. Therefore, the use of megestrol acetate or mirtazapine for weight loss should be thoroughly evaluated on an individual basis. Pharmacotherapy should be used only after all underlying causes of weight loss are assessed and treated.
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Affiliation(s)
- Carol B Fox
- Department of Pharmacy Practice, Geriatrics Division, School of Pharmacy, Texas Tech University Health Sciences Center, Abilene, Texas, USA
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Abstract
BACKGROUND Mirtazapine is an antidepressant first approved in the Netherlands in 1994 for the treatment of major depressive disorder. However, evidence suggests its effectiveness in a variety of other psychiatric disorders and non-psychiatric medical conditions. OBJECTIVE The present paper reviews the published literature on the off-label indications of Mirtazapine. METHODS A search of the relevant literature from MEDLINE, PsycLIT and EMBASE databases, included in the Science Citation Index and available up to March 2006, was conducted using the terms mirtazapine, case-reports, open-label trials and randomized controlled trials. Only articles referring to conditions other than major depression were included in this present review. RESULTS Off-label use of mirtazapine has been reported in panic disorder, post-traumatic stress disorder, generalized anxiety disorder, social phobia, obsessive-compulsive disorder, dysthymia, menopausal depression, poststroke depression, depression as a result of infection with human immunodeficiency virus, elderly depression, Methylenedioxymethamphetamine (MDMA)-induced depression, hot flashes, alcohol and other substance use disorders, sleep disorders, sexual disorders, tension-type headaches, cancer pain, fibromyalgia, schizophrenia and other less frequent conditions. CONCLUSIONS So far, data on the off-label usefulness of mirtazapine are limited and mainly based on observations from case reports or open-label studies. However, positive cues suggest that confirmation of these preliminary data with randomized controlled trials may give sufficient evidence to warrant the use of mirtazapine in a broad range of disorders.
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Affiliation(s)
- Luis San
- 1Department of Psychiatry, Hospital de San Rafael, Barcelona, Spain
| | - Belen Arranz
- 1Department of Psychiatry, Hospital de San Rafael, Barcelona, Spain
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Szegedi A, Schwertfeger N. Mirtazapine: a review of its clinical efficacy and tolerability. Expert Opin Pharmacother 2005; 6:631-41. [PMID: 15934889 DOI: 10.1517/14656566.6.4.631] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Armin Szegedi
- Department of Psychiatry, Charité-University Medicine Berlin, Campus Benjamin Franklin, Eschenallee 3, D-14050 Berlin, Germany.
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Montañés-Rada F, De Lucas-Taracena MT, Sánchez-Romero S. Mirtazapine versus paroxetine in panic disorder: an open study. Int J Psychiatry Clin Pract 2005; 9:87-93. [PMID: 24930788 DOI: 10.1080/13651500510018248] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Introduction Open studies suggest that mirtazapine has efficacy in panic disorder treatment. We designed an open study that evaluates changes induced by mirtazapine compared with paroxetine in panic disorder. Methodology Patients 18-65 years old consecutively referred to a psychiatry liaison service with panic disorder (DSM-IV criteria) were offered either mirtazapine or paroxetine treatment. Results There were statistically significant reductions from baseline to week 3 and from week 3 to 8 for mirtazapine and paroxetine groups for: number of panic attacks, Beck Anxiety or Depression Inventory (BAI, BDI) Clinical Global Impresion (CGI) of panic disorder severity and CGI of panic disorder response (these variables were evaluated by the patient, the clinician or a blind evaluator). Responders at week 3 (BAI decrease of 50%) were 83% for the mirtazapine group and 84% for the paroxetine group. Responders at week 8 (number of panic attacks equal to 0) were 77% for the mirtazapine group and 73% for the paroxetine group Statistically significant differences between mirtazapine and paroxetine were found for number of panic attacks at weeks 3 and 8 and BAI at week 3, suggesting a faster response for mirtazapine. Responders at week 8 maintained a no recurrence figure of 95% at follow-up 6 months later. Panic disorder either with or without comorbid depression improved in both groups of treatment. Discussion Our study supports the hypothesis that mirtazapine has efficacy in the treatment of panic disorder either with or without comorbid depression.
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Berigan TR. Panic Attacks During Escalation of Mirtazapine. PRIMARY CARE COMPANION TO THE JOURNAL OF CLINICAL PSYCHIATRY 2004; 5:93. [PMID: 15156239 PMCID: PMC353045 DOI: 10.4088/pcc.v05n0208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Sarchiapone M, Amore M, De Risio S, Carli V, Faia V, Poterzio F, Balista C, Camardese G, Ferrari G. Mirtazapine in the treatment of panic disorder: an open-label trial. Int Clin Psychopharmacol 2003; 18:35-8. [PMID: 12490773 DOI: 10.1097/00004850-200301000-00006] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The aim of this open label trial was to evaluate mirtazapine tolerability and effectiveness in controlling symptomatology of patients with panic disorder. Forty-five patients with panic disorder, with or without agoraphobia, 11 of them with a comorbid diagnosis of major depression, were included. Patients were assessed with a structured psychiatric interview and their symptomatology evaluated with specific psychometric scales. Three study participants dropped out due to adverse events. Mirtazapine was administered at an established dose of 30 mg daily for 3 months. Patients were assessed at weeks 2 and 4, and then at monthly intervals. All psychometric measures showed statistically significant reductions in total scores at the rated time points, with a pronounced decline in number and intensity of panic attacks and anticipatory anxiety throughout the study. Mirtazapine was well tolerated as signified by the low discontinuation rate (6.3%), and all patients showed a significant symptomatic improvement. The improvement did not appear to be linked to the concurrent presence of a depressive illness.
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Affiliation(s)
- M Sarchiapone
- Institute of Psychiatry, Catholic University of Sacred Heart, Rome, Italy
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Abstract
Panic disorder occurs less frequently in the elderly than in younger adults and rarely starts for the first time in old age. Panic attacks that begin in late life should prompt the clinician to conduct a careful search for a depressive disorder, physical illness or drugs that could be contributing to their presence. When panic attacks do occur in the elderly, the symptoms are qualitatively similar to those experienced by younger people. The elderly, however, may have fewer and less severe symptoms and exhibit less avoidant behaviour. As panic disorder is typically a chronic or recurrent condition, its management requires a long-term approach. With the exception of one descriptive pilot study, there have been no randomised controlled trials of the treatment of panic disorder in later life. Therefore, recommendations regarding the management of this disorder in the elderly must be extrapolated from research pertaining to younger patients. Selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, monoamine oxidase inhibitors, benzodiazepines and cognitive behavioural therapy are efficacious treatments for panic disorder. There are no consistent differences in efficacy between classes of medications or between pharmacotherapy and cognitive behavioural therapy. Furthermore, there are no reliable predictors of response to one type of treatment compared with another. Treatment selection, therefore, depends on an individual assessment of the risks and benefits of each type of treatment (taking into account comorbid psychiatric and physical conditions), patient preference, cost and the availability of therapists skilled in cognitive behavioural techniques. As a general rule, antidepressant medication is preferable to a benzodiazepine as a first-line treatment for panic disorder in the elderly, especially given the high level of comorbidity between panic disorder and depressive disorders. Of the antidepressants, an SSRI is recommended as the initial choice of treatment in older patients. Anxious patients frequently misattribute somatic symptoms of anxiety to adverse effects of medication. Adherence with treatment, therefore, can be enhanced by starting antidepressant medication at a low dosage so as to avoid initial exacerbation of anxiety (but then gradually increasing the dosage to the therapeutic range), frequent follow-up during the first few weeks of treatment, discussion about potential adverse effects and addressing any other concerns the patient may have about taking medication. Given the delayed onset of action of antidepressant medication, the short-term use of adjunctive lorazepam in the first few weeks of treatment may be helpful in selected patients.
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Affiliation(s)
- Alastair J Flint
- Departments of Psychiatry, University Health Network and University of Toronto, Toronto, Ontario, Canada.
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Slaap BR, Boshuisen ML, van Roon AM, den Boer JA. Heart rate variability as predictor of nonresponse to mirtazapine in panic disorder: a preliminary study. Int Clin Psychopharmacol 2002; 17:69-74. [PMID: 11892720 DOI: 10.1097/00004850-200203000-00005] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Using spectral analysis of heart rate, several studies have shown that panic disorder patients are characterized by a reduced heart rate variability (HRV), indicative of abnormalities in autonomous nervous system (ANS) function. We recently reported that patients with panic disorder, who did not respond to pharmacotherapy, were characterized at baseline by a higher heart rate. In this study, ANS functioning is investigated as a possible predictor of nonresponse to pharmacotherapy. Twenty-eight medication-free panic disorder patients entered a 12-week open-label treatment study with mirtazapine. Five-minute HRV recordings were obtained before treatment and were analysed using spectral analysis. The data of 17 patients could be used. The total spectrum and low frequency power of responders to mirtazapine were significantly higher than those of nonresponders. Our findings suggest that nonresponders to short-term mirtazapine treatment are characterized at baseline by a lowered output of the ANS. The results are preliminary in view of the small sample studied.
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Affiliation(s)
- B R Slaap
- Department of Psychiatry, Academic Hospital Groningen, The Netherlands
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