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Abstract
Mirtazapine has often been prescribed as add-on treatment for schizophrenia in patients with suboptimal response to conventional treatments. In this review, we evaluate the existing evidence for efficacy and effectiveness of add-on mirtazapine in schizophrenia and reappraise the practical and theoretical aspects of mirtazapine-antipsychotic combinations. In randomized controlled trials (RCTs), mirtazapine demonstrated favourable effects on negative and cognitive (although plausibly not depressive) symptoms, with no risk of psychotic exacerbation. Mirtazapine also may have a desirable effect on antipsychotic-induced sexual dysfunction, but seems not to alleviate extrapyramidal symptoms, at least if combined with second-generation antipsychotics. It is noteworthy that all published RCTs have been underpowered and relatively short in duration. In the only large pragmatic effectiveness study that provided analyses by add-on antidepressant, only mirtazapine was associated with both decreased rate of hospital admissions and number of in-patient days. Mirtazapine hardly affects the pharmacokinetics of antipsychotics. However, possible pharmacodynamic interactions (sedation and metabolic offence) should be borne in mind. The observed desired clinical effects of mirtazapine may be due to its specific receptor-blocking properties. Alternative theoretical explanations include its possible neuroprotective effect. Further well-designed RCTs and real-world effectiveness studies are needed to determine whether add-on mirtazapine should be recommended for difficult-to-treat schizophrenia.
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Sagar M, Lindelof M, Boesen MS. [Serotonin syndrome shortly after the administration of low-dose mirtazapine]. Ugeskr Laeger 2020; 182:V01200020. [PMID: 32400384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Serotonin syndrome is a rare neuropsychiatric complication caused by serotonergic drugs. Symptoms include confusion, psychosis, tremor, palpitations, hyperthermia, and the neurological examination shows signs of central nervous system deficits. This is a case report of a 67-year-old woman, who developed serotonin syndrome in the form of delusions, tremor, cerebellar ataxia and upper neuron signs one day after administration of low-dose mirtazapine therapy. Complete symptom remission occurred one week after the discontinuation of mirtazapine.
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Abstract
BACKGROUND Fibromyalgia is a clinically defined chronic condition of unknown etiology characterised by chronic widespread pain, sleep disturbance, cognitive dysfunction, and fatigue. Many patients report high disability levels and poor quality of life. Drug therapy aims to reduce key symptoms, especially pain, and improve quality of life. The tetracyclic antidepressant, mirtazapine, may help by increasing serotonin and noradrenaline in the central nervous system (CNS). OBJECTIVES To assess the efficacy, tolerability and safety of the tetracyclic antidepressant, mirtazapine, compared with placebo or other active drug(s) in the treatment of fibromyalgia in adults. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, SCOPUS, the US National Institutes of Health, and the World Health Organization (WHO) International Clinical Trials Registry Platform for published and ongoing trials, and examined reference lists of reviewed articles, to 9 July 2018. SELECTION CRITERIA Randomised controlled trials (RCTs) of any formulation of mirtazapine against placebo, or any other active treatment of fibromyalgia, in adults. DATA COLLECTION AND ANALYSIS Two review authors independently extracted study characteristics, outcomes of efficacy, tolerability and safety, examined issues of study quality, and assessed risk of bias, resolving discrepancies by discussion. Primary outcomes were participant-reported pain relief (at least 50% or 30% pain reduction), Patient Global Impression of Change (PGIC; much or very much improved), safety (serious adverse events), and tolerability (adverse event withdrawal). Other outcomes were health-related quality of life (HRQoL) improved by 20% or more, fatigue, sleep problems, mean pain intensity, negative mood and particular adverse events. We used a random-effects model to calculate risk difference (RD), standardised mean difference (SMD), and numbers needed to treat. We assessed the evidence using GRADE and created a 'Summary of findings' table. MAIN RESULTS Three studies with 606 participants compared mirtazapine with placebo (but not other drugs) over seven to 13 weeks. Two studies were at unclear or high risk of bias in six or seven of eight domains. We judged the evidence for all outcomes to be low- or very low-quality because of poor study quality, indirectness, imprecision, risk of publication bias, and sometimes low numbers of events.There was no difference between mirtazapine and placebo for any primary outcome: participant-reported pain relief of 50% or greater (22% versus 16%; RD 0.05, 95% confidence interval (CI) -0.01 to 0.12; three studies with 591 participants; low-quality evidence); no data available for PGIC; only a single serious adverse event for evaluation of safety (RD -0.00, 95% CI -0.01 to 0.02; three studies with 606 participants; very low-quality evidence); and tolerability as frequency of dropouts due to adverse events (3% versus 2%; RD 0.00, 95% CI -0.02 to 0.03; three studies with 606 participants; low-quality evidence).Mirtazapine showed a clinically-relevant benefit compared to placebo for some secondary outcomes: participant-reported pain relief of 30% or greater (47% versus 34%; RD 0.13, 95% CI 0.05 to 0.21; number needed to treat for an additional beneficial outcome (NNTB) 8, 95% CI 5 to 20; three studies with 591 participants; low-quality evidence); participant-reported mean pain intensity (SMD -0.29, 95% CI -0.46 to -0.13; three studies with 591 participants; low-quality evidence); and participant-reported sleep problems (SMD -0.23, 95% CI -0.39 to -0.06; three studies with 573 participants; low-quality evidence). There was no benefit for improvement of participant-reported improvement of HRQoL of 20% or greater (58% versus 50%; RD 0.08, 95% CI -0.01 to 0.16; three studies with 586 participants; low-quality evidence); participant-reported fatigue (SMD -0.02, 95% CI -0.19 to 0.16; two studies with 533 participants; low-quality evidence); participant-reported negative mood (SMD -0.67, 95% CI -1.44 to 0.10; three studies with 588 participants; low-quality evidence); or withdrawals due to lack of efficacy (1.5% versus 0.1%; RD 0.01, 95% CI -0.01 to 0.02; three studies with 605 participants; very low-quality evidence).There was no difference between mirtazapine and placebo for participants reporting any adverse event (76% versus 59%; RD 0.12, 95 CI -0.01 to 0.26; three studies with 606 participants; low-quality evidence). There was a clinically-relevant harm with mirtazapine compared to placebo: in the number of participants with somnolence (42% versus 14%; RD 0.24, 95% CI 0.18 to 0.30; number needed to treat for an additional harmful outcome (NNTH) 5, 95% CI 3 to 6; three studies with 606 participants; low-quality evidence); weight gain (19% versus 1%; RD 0.17, 95% CI 0.11 to 0.23; NNTH 6, 95% CI 5 to 10; three studies with 606 participants; low-quality evidence); and elevated alanine aminotransferase (13% versus 2%; RD 0.13, 95% CI 0.04 to 0.22; NNTH 8, 95% CI 5 to 25; two studies with 566 participants; low-quality evidence). AUTHORS' CONCLUSIONS Studies demonstrated no benefit of mirtazapine over placebo for pain relief of 50% or greater, PGIC, improvement of HRQoL of 20% or greater, or reduction of fatigue or negative mood. Clinically-relevant benefits were shown for pain relief of 30% or greater, reduction of mean pain intensity, and sleep problems. Somnolence, weight gain, and elevated alanine aminotransferase were more frequent with mirtazapine than placebo. The quality of evidence was low or very low, with two of three studies of questionable quality and issues over indirectness and risk of publication bias. On balance, any potential benefits of mirtazapine in fibromyalgia were outweighed by its potential harms, though, a small minority of people with fibromyalgia might experience substantial symptom relief without clinically-relevant adverse events.
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Affiliation(s)
- Patrick Welsch
- Health Care Center for Pain Medicine and Mental Health, Saarbrücken, Germany
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Abstract
BACKGROUND Many individuals who have a diagnosis of schizophrenia experience a range of distressing and debilitating symptoms. These can include positive symptoms (such as delusions, hallucinations, disorganised speech), cognitive symptoms (such as trouble focusing or paying attention or using information to make decisions), and negative symptoms (such as diminished emotional expression, avolition, alogia, and anhedonia). Antipsychotic drugs are often only partially effective, particularly in treating negative symptoms, indicating the need for additional treatment. Mirtazapine is an antidepressant drug that when taken in addition to an antipsychotic may offer some benefit for negative symptoms. OBJECTIVES To systematically assess the effects of mirtazapine as adjunct treatment for people with schizophrenia. SEARCH METHODS The Information Specialist of Cochrane Schizophrenia searched the Cochrane Schizophrenia Group's Study-Based Register of Trials (including registries of clinical trials) up to May 2018. SELECTION CRITERIA All randomised-controlled trials (RCTs) with useable data focusing on mirtazapine adjunct for people with schizophrenia. DATA COLLECTION AND ANALYSIS We extracted data independently. For binary outcomes, we calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat (ITT) basis. For continuous data, we estimated the mean difference (MD) between groups and its 95% CI. We employed a fixed-effect model for analyses. For included studies we assessed risk of bias and created 'Summary of findings' table using GRADE. MAIN RESULTS We included nine RCTs with a total of 310 participants. All studies compared mirtazapine adjunct with placebo adjunct and were of short-term duration. We considered five studies to have a high risk of bias for either incomplete outcome data, selective reporting, or other bias.Our main outcomes of interest were clinically important change in mental state (negative and positive symptoms), leaving the study early for any reason, clinically important change in global state, clinically important change in quality of life, number of days in hospital and incidence of serious adverse events.One trial defined a reduction in the Scale for the Assessment of Negative Symptoms (SANS) overall score from baseline of at least 20% as no important response for negative symptoms. There was no evidence of a clear difference between the two treatments with similar numbers of participants from each group showing no important response to treatment (RR 0.81, 95% CI 0.57 to 1.14, 1 RCT, n = 20, very low-quality evidence).Clinically important change in positive symptoms was not reported, however, clinically important change in overall mental state was reported by two trials and data for this outcome showed a favourable effect for mirtazapine (RR 0.69, 95% CI 0.51 to 0.92; I2 = 75%, 2 RCTs, n = 77, very low-quality evidence). There was no evidence of a clear difference for numbers of participants leaving the study early (RR 1.03, 95% CI 0.64 to 1.66, 9 RCTs, n = 310, moderate-quality evidence), and no evidence of a clear difference in global state Clinical Global Impressions Scale (CGI) severity scores (MD -0.10, 95% CI -0.68 to 0.48, 1 RCT, n = 39, very low-quality evidence). A favourable effect for mirtazapine adjunct was found for the outcome clinically important change in akathisia (RR 0.33, 95% CI 0.20 to 0.52, 2 RCTs, n = 86, low-quality evidence; I2 = 61%I). No data were reported for quality life or number of days in hospital.In addition to the main outcomes of interest, there was evidence relating to adverse events that the mirtazapine adjunct groups were associated with an increased risk of weight gain (RR 3.19, 95% CI 1.17 to 8.65, 4 RCTs, n = 127) and sedation/drowsiness (RR 1.64, 95% CI 1.01 to 2.68, 7 RCTs, n = 223). AUTHORS' CONCLUSIONS The available evidence is primarily of very low quality and indicates that mirtazapine adjunct is not clearly associated with an effect for negative symptoms, but there is some indication of a positive effect on overall mental state and akathisia. No effect was found for global state or leaving the study early and data were not available for quality of life or service use. Due to limitations of the quality and applicability of the evidence it is not possible to make any firm conclusions, the role of mirtazapine adjunct in routine clinical practice remains unclear. This underscores the need for new high-quality evidence to further evaluate mirtazapine adjunct for schizophrenia.
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Abstract
BACKGROUND Insomnia disorder is a subjective condition of unsatisfactory sleep (e.g. sleep onset, maintenance, early waking, impairment of daytime functioning). Insomnia disorder impairs quality of life and is associated with an increased risk of physical and mental health problems including anxiety, depression, drug and alcohol abuse, and increased health service use. hypnotic medications (e.g. benzodiazepines and 'Z' drugs) are licensed for sleep promotion, but can induce tolerance and dependence, although many people remain on long-term treatment. Antidepressant use for insomnia is widespread, but none is licensed for insomnia and the evidence for their efficacy is unclear. This use of unlicensed medications may be driven by concern over longer-term use of hypnotics and the limited availability of psychological treatments. OBJECTIVES To assess the effectiveness, safety and tolerability of antidepressants for insomnia in adults. SEARCH METHODS This review incorporated the results of searches to July 2015 conducted on electronic bibliographic databases: the Cochrane Central Register of Controlled Trials (CENTRAL, 2015, Issue 6), MEDLINE (1950 to 2015), Embase (1980 to 2015) and PsycINFO (1806 to 2015). We updated the searches to December 2017, but these results have not yet been incorporated into the review. SELECTION CRITERIA Randomised controlled trials (RCTs) of adults (aged 18 years or older) with a primary diagnosis of insomnia and all participant types including people with comorbidities. Any antidepressant as monotherapy at any dose whether compared with placebo, other medications for insomnia (e.g. benzodiazepines and 'Z' drugs), a different antidepressant, waiting list control or treatment as usual. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for eligibility and extracted data using a data extraction form. A third review author resolved disagreements on inclusion or data extraction. MAIN RESULTS The search identified 23 RCTs (2806 participants).Selective serotonin reuptake inhibitors (SSRIs) compared with placebo: three studies (135 participants) compared SSRIs with placebo. Combining results was not possible. Two paroxetine studies showed significant improvements in subjective sleep measures at six (60 participants, P = 0.03) and 12 weeks (27 participants, P < 0.001). There was no difference in the fluoxetine study (low quality evidence).There were either no adverse events or they were not reported (very low quality evidence).Tricyclic antidepressants (TCA) compared with placebo: six studies (812 participants) compared TCA with placebo; five used doxepin and one used trimipramine. We found no studies of amitriptyline. Four studies (518 participants) could be pooled, showing a moderate improvement in subjective sleep quality over placebo (standardised mean difference (SMD) -0.39, 95% confidence interval (CI) -0.56 to -0.21) (moderate quality evidence). Moderate quality evidence suggested that TCAs possibly improved sleep efficiency (mean difference (MD) 6.29 percentage points, 95% CI 3.17 to 9.41; 4 studies; 510 participants) and increased sleep time (MD 22.88 minutes, 95% CI 13.17 to 32.59; 4 studies; 510 participants). There may have been little or no impact on sleep latency (MD -4.27 minutes, 95% CI -9.01 to 0.48; 4 studies; 510 participants).There may have been little or no difference in adverse events between TCAs and placebo (risk ratio (RR) 1.02, 95% CI 0.86 to 1.21; 6 studies; 812 participants) (low quality evidence).'Other' antidepressants with placebo: eight studies compared other antidepressants with placebo (one used mianserin and seven used trazodone). Three studies (370 participants) of trazodone could be pooled, indicating a moderate improvement in subjective sleep outcomes over placebo (SMD -0.34, 95% CI -0.66 to -0.02). Two studies of trazodone measured polysomnography and found little or no difference in sleep efficiency (MD 1.38 percentage points, 95% CI -2.87 to 5.63; 169 participants) (low quality evidence).There was low quality evidence from two studies of more adverse effects with trazodone than placebo (i.e. morning grogginess, increased dry mouth and thirst). AUTHORS' CONCLUSIONS We identified relatively few, mostly small studies with short-term follow-up and design limitations. The effects of SSRIs compared with placebo are uncertain with too few studies to draw clear conclusions. There may be a small improvement in sleep quality with short-term use of low-dose doxepin and trazodone compared with placebo. The tolerability and safety of antidepressants for insomnia is uncertain due to limited reporting of adverse events. There was no evidence for amitriptyline (despite common use in clinical practice) or for long-term antidepressant use for insomnia. High-quality trials of antidepressants for insomnia are needed.
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Affiliation(s)
- Hazel Everitt
- University of SouthamptonPrimary Care and Population Sciences, Faculty of MedicineAldermoor Health CentreAldermoor CloseSouthamptonUKSO16 5ST
| | - David S Baldwin
- University of SouthamptonUniversity Department of Psychiatry, Faculty of MedicineSouthamptonUK
| | - Beth Stuart
- University of SouthamptonPrimary Care and Population Sciences, Faculty of MedicineAldermoor Health CentreAldermoor CloseSouthamptonUKSO16 5ST
| | - Gosia Lipinska
- University of Cape TownUCT Sleep Sciences, Department of PsychologyCape TownSouth Africa
| | - Andrew Mayers
- Bournemouth UniversityDepartment of Psychology, Faculty of Science and TechnologyPoole House, Talbot CampusFern BarrowPooleUKBH12 5BB
| | - Andrea L Malizia
- The Burden Centre, Frenchay hospitalDepartment of NeurosurgeryBristolUKBS16 1LE
| | - Christopher CF Manson
- Faculty of Medicine, University of SouthamptonUniversity Department of PsychiatryAcademic Centre, College Keep 4‐12 Terminus TerraceSouthamptonUKSO14 3DT
| | - Sue Wilson
- Imperial College LondonCentre for Neuropsychopharmacology, Division of Brain SciencesBurlington Danes BuildingHammersmith Hospital campusLondonUKW12 0NN
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Sandahl H, Jennum P, Baandrup L, Poschmann IS, Carlsson J. Treatment of sleep disturbances in trauma-affected refugees: Study protocol for a randomised controlled trial. Trials 2017; 18:520. [PMID: 29110681 PMCID: PMC5674222 DOI: 10.1186/s13063-017-2260-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 10/13/2017] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Sleep disturbances are often referred to as a hallmark and as core symptoms of post-traumatic stress disorder (PTSD). Untreated sleep disturbances can contribute to the maintenance and exacerbation of PTSD symptoms, which may diminish treatment response and constitute a risk factor for poor treatment outcome. Controlled trials on treatment of sleep disturbances in refugees suffering from PTSD are scarce. The present study aims to examine sleep-enhancing treatment in refugees with PTSD. We aim to assess if add-on treatment with mianserin and/or Imagery Rehearsal Therapy (IRT) to treatment as usual (TAU) for PTSD improves sleep disturbances. We will study the relation between sleep disturbances, PTSD symptoms, psychosocial functioning and quality of life. METHODS The study is a randomised controlled superiority trial with a 2 × 2 factorial design. The study will include 230 trauma-affected refugees. The patients are randomised into four groups. All four groups receive TAU - an interdisciplinary treatment approach covering a period of 6-8 months with pharmacological treatment, physiotherapy, psychoeducation and manual-based cognitive behavioural therapy within a framework of weekly sessions with a physician, physiotherapist or psychologist. One group receives solely TAU, serving as a control group, while the three remaining groups are active-treatment groups receiving add-on treatment with either mianserin, IRT or a combination of both. Treatment outcome is evaluated using self-administered rating scales, observer ratings and actigraph measurements at baseline, during treatment and post treatment. The primary outcome is subjective sleep quality using the Pittsburgh Sleep Quality Index. Secondary outcome measures are objective sleep length, nightmares, PTSD severity, symptoms of depression and anxiety, pain, quality of life and psychosocial functioning. DISCUSSION This trial will be the first randomised controlled trial to examine sleep-enhancing treatment in trauma-affected refugees, as well as the first trial to investigate the effect of IRT and mianserin in this population. Therefore, this trial may optimise treatment recommendations for sleep disturbances in trauma-affected refugees. Based on our findings, we expect to discuss the effect of treatment, focussing on sleep disturbances. Furthermore, the results will provide new information regarding the association between sleep disturbances, PTSD symptoms, psychosocial functioning and quality of life in trauma-affected refugees. TRIAL REGISTRATION EudraCT registration under the name 'Treatment of sleep disturbances in trauma-affected refugees - a randomised controlled trial', registration number: 2015-004153-40 , registered on 13 November 2015. ClinicalTrials.gov, ID: NCT02761161. Registered on 27 April 2016.
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Affiliation(s)
- Hinuga Sandahl
- Competence Centre for Transcultural Psychiatry, Mental Health Centre Ballerup, Mental Health Services of the Capital Region of Denmark, Ballerup, Denmark
| | - Poul Jennum
- Danish Center for Sleep Medicine, Department of Clinical Neurophysiology, Rigshospitalet – Glostrup, Copenhagen University Hospital, Nordre Ringvej 57, 2600 Glostrup, Denmark
| | - Lone Baandrup
- Mental Health Centre Ballerup, Mental Health Services of the Capital Region of Denmark, Ballerup, Denmark
| | - Ida Sophie Poschmann
- Competence Centre for Transcultural Psychiatry, Mental Health Centre Ballerup, Mental Health Services of the Capital Region of Denmark, Ballerup, Denmark
| | - Jessica Carlsson
- Competence Centre for Transcultural Psychiatry, Mental Health Centre Ballerup, Mental Health Services of the Capital Region of Denmark, Ballerup, Denmark
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Cipriani A, Zhou X, Del Giovane C, Hetrick SE, Qin B, Whittington C, Coghill D, Zhang Y, Hazell P, Leucht S, Cuijpers P, Pu J, Cohen D, Ravindran AV, Liu Y, Michael KD, Yang L, Liu L, Xie P. Comparative efficacy and tolerability of antidepressants for major depressive disorder in children and adolescents: a network meta-analysis. Lancet 2016; 388:881-90. [PMID: 27289172 DOI: 10.1016/s0140-6736(16)30385-3] [Citation(s) in RCA: 388] [Impact Index Per Article: 48.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Major depressive disorder is one of the most common mental disorders in children and adolescents. However, whether to use pharmacological interventions in this population and which drug should be preferred are still matters of controversy. Consequently, we aimed to compare and rank antidepressants and placebo for major depressive disorder in young people. METHODS We did a network meta-analysis to identify both direct and indirect evidence from relevant trials. We searched PubMed, the Cochrane Library, Web of Science, Embase, CINAHL, PsycINFO, LiLACS, regulatory agencies' websites, and international registers for published and unpublished, double-blind randomised controlled trials up to May 31, 2015, for the acute treatment of major depressive disorder in children and adolescents. We included trials of amitriptyline, citalopram, clomipramine, desipramine, duloxetine, escitalopram, fluoxetine, imipramine, mirtazapine, nefazodone, nortriptyline, paroxetine, sertraline, and venlafaxine. Trials recruiting participants with treatment-resistant depression, treatment duration of less than 4 weeks, or an overall sample size of less than ten patients were excluded. We extracted the relevant information from the published reports with a predefined data extraction sheet, and assessed the risk of bias with the Cochrane risk of bias tool. The primary outcomes were efficacy (change in depressive symptoms) and tolerability (discontinuations due to adverse events). We did pair-wise meta-analyses using the random-effects model and then did a random-effects network meta-analysis within a Bayesian framework. We assessed the quality of evidence contributing to each network estimate using the GRADE framework. This study is registered with PROSPERO, number CRD42015016023. FINDINGS We deemed 34 trials eligible, including 5260 participants and 14 antidepressant treatments. The quality of evidence was rated as very low in most comparisons. For efficacy, only fluoxetine was statistically significantly more effective than placebo (standardised mean difference -0·51, 95% credible interval [CrI] -0·99 to -0·03). In terms of tolerability, fluoxetine was also better than duloxetine (odds ratio [OR] 0·31, 95% CrI 0·13 to 0·95) and imipramine (0·23, 0·04 to 0·78). Patients given imipramine, venlafaxine, and duloxetine had more discontinuations due to adverse events than did those given placebo (5·49, 1·96 to 20·86; 3·19, 1·01 to 18·70; and 2·80, 1·20 to 9·42, respectively). In terms of heterogeneity, the global I(2) values were 33·21% for efficacy and 0% for tolerability. INTERPRETATION When considering the risk-benefit profile of antidepressants in the acute treatment of major depressive disorder, these drugs do not seem to offer a clear advantage for children and adolescents. Fluoxetine is probably the best option to consider when a pharmacological treatment is indicated. FUNDING National Basic Research Program of China (973 Program).
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Affiliation(s)
| | - Xinyu Zhou
- Department of Neurology and Psychiatry, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China; Institute of Neuroscience and the Collaborative Innovation Center for Brain Science, Chongqing Medical University, Chongqing, China
| | - Cinzia Del Giovane
- Department of Diagnostic, Clinical and Public Health Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Sarah E Hetrick
- Orygen, The National Centre of Excellence in Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Bin Qin
- Department of Neurology and Psychiatry, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China; Institute of Neuroscience and the Collaborative Innovation Center for Brain Science, Chongqing Medical University, Chongqing, China
| | | | - David Coghill
- Division of Neuroscience, School of Medicine, University of Dundee, Dundee, UK; Department of Paediatrics, and Department of Psychiatry, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Yuqing Zhang
- Department of Neurology and Psychiatry, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China; Institute of Neuroscience and the Collaborative Innovation Center for Brain Science, Chongqing Medical University, Chongqing, China
| | - Philip Hazell
- Discipline of Psychiatry, Sydney Medical School, Concord West, NSW, Australia
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, Technische Universität München, Munich, Germany
| | - Pim Cuijpers
- Department of Clinical, Neuro- and Developmental Psychology, VU University Amsterdam, Amsterdam, Netherlands
| | - Juncai Pu
- Department of Neurology and Psychiatry, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China; Institute of Neuroscience and the Collaborative Innovation Center for Brain Science, Chongqing Medical University, Chongqing, China
| | - David Cohen
- Department of Child and Adolescent Psychiatry, Hôpital Pitié-Salpétrière, Institut des Systèmes Intelligents et Robotiques, Université Pierre et Marie Curie, Paris, France
| | - Arun V Ravindran
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Yiyun Liu
- Department of Neurology and Psychiatry, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China; Institute of Neuroscience and the Collaborative Innovation Center for Brain Science, Chongqing Medical University, Chongqing, China
| | - Kurt D Michael
- Department of Psychology, Appalachian State University, Boone, NC, USA
| | - Lining Yang
- Department of Neurology and Psychiatry, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China; Institute of Neuroscience and the Collaborative Innovation Center for Brain Science, Chongqing Medical University, Chongqing, China
| | - Lanxiang Liu
- Department of Neurology and Psychiatry, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China; Institute of Neuroscience and the Collaborative Innovation Center for Brain Science, Chongqing Medical University, Chongqing, China
| | - Peng Xie
- Department of Neurology and Psychiatry, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China; Institute of Neuroscience and the Collaborative Innovation Center for Brain Science, Chongqing Medical University, Chongqing, China; South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.
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DeBellis RJ, Schaefer OP, Liquori M, Volturo GA. Linezolid-Associated Serotonin Syndrome After Concomitant Treatment With Citalopram and Mirtazepine in a Critically Ill Bone Marrow Transplant Recipient. J Intensive Care Med 2016; 20:351-3. [PMID: 16280409 DOI: 10.1177/0885066605280825] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Linezolid was initially discovered as an antidepressant because of its effect on blocking intracellular metabolism of serotonin, norepinephrine, and other biogenic amines. As time passed, it was realized that linezolid possessed antibacterial activity, and linezolid has been developed and marketed as such. In medicine we are quick to categorize drugs into specific classes as a mechanism to recall indication and use. By classifying linezolid as an antibacterial, it is common to forget about its antidepressant roots. A case report involving linezolid with citalopram and mirtazepine in the precipitation of serotonin syndrome in a critically ill bone marrow transplant patient is described in this article.
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Affiliation(s)
- Ronald J DeBellis
- Massachusetts College of Pharmacy and Health Sciences-Worcester, MA, USA.
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Gambi F, De Berardis D, Sepede G, Campanella D, Galliani N, Carano A, La Rovere L, Salini G, Penna L, Cicconetti A, Spinella S, Quartesan R, Salerno RM, Ferro FM. Effect of Mirtazapine on Thyroid Hormones in Adult Patients with Major Depression. Int J Immunopathol Pharmacol 2016; 18:737-44. [PMID: 16388723 DOI: 10.1177/039463200501800417] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Hypothalamic pituitary thyroid (HPT) axis abnormalities and alterations in major depression are reported in literature. The aim of our study was to evaluate the effect of mirtazapine on thyroid hormones after 6 months of therapy in a sample of adult outpatients with Major Depression (MD). 17 adult outpatients (7 men, 10 women) with MD according to DSM-IV criteria, were included in the study. All participants had to have met criteria for a major depressive episode with a score of at least 15 on the Hamilton Depression Rating Scale (HAM-D). Fasting venous blood samples were obtained for determination of serum Thyroid Stimulating Hrmone (TSH), Free T3 (FT3) and Free T4 (FT4) concentrations both at baseline and after 6 months of therapy. HAM-D scores decreased significantly from the first day of treatment to the end of the treatment period (p<0.001) and twelve patients (70.6%) were classified as responders. A significant increase in FT3 concentrations was found between baseline and the end of treatment period (P=0.015) whereas FT4 concentrations decreased (P=0.046). No significant changes were found in TSH levels. Higher FT4 concentrations at baseline predicted higher HAM-D scorers both at baseline and at the end of the treatment period. Furthermore, higher FT3 concentrations at endpoint were found to be predictors of lower HAM-D scores. Long-term treatment with mirtazapine increases FT3 levels and decreases FT4 maybe involving the deiodination process of T4 into T3.
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Affiliation(s)
- F Gambi
- Department of Oncology and Neurosciences, Institute of Psychiatry, University G. d' Annunzio, Chieti, Italy.
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Jiang SM, Jia L, Liu J, Shi MM, Xu MZ. Beneficial effects of antidepressant mirtazapine in functional dyspepsia patients with weight loss. World J Gastroenterol 2016; 22:5260-5266. [PMID: 27298569 PMCID: PMC4893473 DOI: 10.3748/wjg.v22.i22.5260] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 04/06/2016] [Accepted: 04/15/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To explore the effects and mechanism of action of antidepressant mirtazapine in functional dyspepsia (FD) patients with weight loss.
METHODS: Sixty depressive FD patients with weight loss were randomly divided into a mirtazapine group (MG), a paroxetine group (PG) or a conventional therapy group (CG) for an 8-wk clinical trial. Adverse effects and treatment response were recorded. The Nepean Dyspepsia Index-symptom (NDSI) checklist and the 17-item Hamilton Rating Scale of Depression (HAMD-17) were used to evaluate dyspepsia and depressive symptoms, respectively. The body composition analyzer was used to measure body weight and fat. Serum hormone levels were measured by ELISA.
RESULTS: (1) After 2 wk of treatment, NDSI scores were significantly lower for the MG than for the PG and CG; (2) After 4 or 8 wk of treatment, HAMD-17 scores were significantly lower for the MG and PG than for the CG; (3) After 8 wk of treatment, patients in the MG experienced a weight gain of 3.58 ± 1.57 kg, which was significantly higher than that observed for patients in the PG and CG. Body fat increased by 2.77 ± 0.14 kg, the body fat ratio rose by 4%, and the visceral fat area increased by 7.56 ± 2.25 cm2; and (4) For the MG, serum hormone levels of ghrelin, neuropeptide Y (NPY), motilin (MTL) and gastrin (GAS) were significantly upregulated; in contrast, those of leptin, 5-hydroxytryptamine (5-HT) and cholecystokinin (CCK) were significantly downregulated.
CONCLUSION: Mirtazapine not only alleviates symptoms associated with dyspepsia and depression linked to FD in patients with weight loss but also significantly increases body weight (mainly the visceral fat in body fat). The likely mechanism of mirtazapine action is regulation of brain-gut or gastrointestinal hormone levels.
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Tallon D, Wiles N, Campbell J, Chew-Graham C, Dickens C, Macleod U, Peters TJ, Lewis G, Anderson IM, Gilbody S, Hollingworth W, Davies S, Kessler D. Mirtazapine added to selective serotonin reuptake inhibitors for treatment-resistant depression in primary care (MIR trial): study protocol for a randomised controlled trial. Trials 2016; 17:66. [PMID: 26842107 PMCID: PMC5526304 DOI: 10.1186/s13063-016-1199-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 01/26/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND People with depression are usually managed in primary care and antidepressants are often the first-line treatment, but only one third of patients respond fully to a single antidepressant. This paper describes the protocol for a randomised controlled trial (MIR) to investigate the extent to which the addition of the antidepressant mirtazapine is effective in reducing the symptoms of depression compared with placebo in patients who are still depressed after they have been treated with a selective serotonin reuptake inhibitor (SSRI) or serotonin and noradrenaline reuptake inhibitor (SNRI) for at least 6 weeks in primary care. METHODS/DESIGN MIR is a two-parallel group, multi-centre, pragmatic, placebo controlled, randomised trial with allocation at the level of the individual. Eligible participants are those who: are aged 18 years or older; are currently taking an SSRI/SNRI antidepressant (for at least 6 weeks at an adequate dose); score ≥ 14 on the Beck Depression Inventory (BDI-II); have adhered to their medication; and meet ICD-10 criteria for depression (assessed using the Clinical Interview Schedule-Revised version). Participants who give written, informed consent, will be randomised to receive either oral mirtazapine or matched placebo, starting at 15 mg daily for 2 weeks and increasing to 30 mg daily thereafter, for up to 12 months (to be taken in addition to their usual antidepressant). Participants, their GPs, and the research team will all be blind to the allocation. The primary outcome will be depression symptoms at 12 weeks post randomisation, measured as a continuous variable using the BDI-II. Secondary outcomes (measured at 12, 24 and 52 weeks) include: response (reduction in depressive symptoms (BDI-II score) of at least 50% compared to baseline); remission of depression symptoms (BDI-II <10); change in anxiety symptoms; adverse effects; quality of life; adherence to antidepressant medication; health and social care use, time off work and cost-effectiveness. All outcomes will be analysed on an intention-to-treat basis. A qualitative study will explore patients' views and experiences of either taking two antidepressants, or an antidepressant and a placebo; and GPs' views on prescribing a second antidepressant in this patient group. DISCUSSION The MIR trial will provide evidence on the clinical and cost-effectiveness of mirtazapine as an adjunct to SSRI/SNRI antidepressants for patients in primary care who have not responded to monotherapy. TRIAL REGISTRATION EudraCT Number: 2012-000090-23 (Registered January 2012); ISRCTN06653773 (Registered September 2012).
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Affiliation(s)
- Debbie Tallon
- School of Social and Community Medicine, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN UK
| | - Nicola Wiles
- School of Social and Community Medicine, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN UK
| | - John Campbell
- University of Exeter Medical School, St Luke’s Campus, Smeall Building, Magdalen Road, Exeter, EX1 2LU UK
| | - Carolyn Chew-Graham
- Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG UK
| | - Chris Dickens
- University of Exeter Medical School, Room 1.04, College House, St Luke’s Campus, Heavitree Road, Exeter, EX1 2LU UK
| | - Una Macleod
- Hull York Medical School, University of Hull, Kingston upon Hull, HU6 7RX UK
| | - Tim J. Peters
- School of Clinical Sciences, 69 St Michael’s Hill, Bristol, BS2 8DZ UK
| | - Glyn Lewis
- University College London, Maple House, 149 Tottenham Court Rd, London, W1T 7NF UK
| | - Ian M. Anderson
- Neuroscience and Psychiatry Unit, The University of Manchester, Room G809, Stopford Building, Oxford Road, Manchester, M13 9PT UK
| | - Simon Gilbody
- Mental Health Research Group, Department of Health Sciences and Hull York Medical School, Alcuin College C Block, University of York, YO10 5DD Heslington, UK
| | - William Hollingworth
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Simon Davies
- Centre for Addiction and Mental Health, Room 6318, 80 Workman Way, Toronto, ON Canada
| | - David Kessler
- School of Social and Community Medicine, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN UK
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Wu CS, Tong SH, Ong CT, Sung SF. Serotonin Syndrome Induced by Combined Use of Mirtazapine and Olanzapine Complicated with Rhabdomyolysis, Acute Renal Failure, and Acute Pulmonary Edema-A Case Report. Acta Neurol Taiwan 2015; 24:117-121. [PMID: 27333965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
PURPOSE Serotonin syndrome is a potentially life-threatening complication of serotonergic agents. Although mirtazapine is a relatively safe antidepressant and has a comparatively low incidence of side effects, it still could induce serotonin syndrome. CASE REPORT We described a 34-year-old man with schizophrenic disorder who presented with acute consciousness disturbance, extremely high fever, rigidity, and spontaneous clonus in lower limbs. Two days before entry, oral mirtazapine was added to his regular medication of olanzapine. The serotonin-related symptoms resolved soon after withdrawal of mirtazapine and olanzapine combined with treatment with intravenous benzodiazepine and oral cyproheptadine. However, the clinical course was complicated by rhabdomyolysis, acute renal failure, and acute pulmonary edema. After receiving mechanical ventilation, hemodialysis, and appropriate supportive treatment, his general condition recovered and he was discharged without any neurological sequelae. CONCLUSION With the increasing use of serotonergic agents, awareness of serotonin syndrome is important. Early diagnosis and timely discontinuation of the offending agent(s) are imperative to prevent morbidity and mortality.
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Affiliation(s)
- Chi-Shun Wu
- Division of Neurology, Department of Internal Medicine
| | - Show-Hwa Tong
- Department of Pharmacy, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Taiwan
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Dömötör J, Clemens B. [FOCAL MOTOR SEIZURES AND STATUS EPILEPTICUS PROVOKED BY MIRTAZAPINE]. Ideggyogy Sz 2015; 68:286-288. [PMID: 26380424 DOI: 10.18071/isz.68.0286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
The seizure-provoking effect of the tetracyclic antidepressant mirtazapine is not a well-known adverse effect of the drug. The authors report on a 39-year-old non-epileptic patient who had been treated for depression with the usual daily dose of mirtazapine. Having increased the daily dose of the drug from 30 to 45 milligrams he experienced a few clonic seizures of the right lower limb. This symptom and insomnia erroneously intended the patient to further increase the daily dose of mirtazapine, which immediately resulted in the evolution of focal clonic status epilepticus in the same limb. After admission, this condition was recorded by video-EEG and abolished by intravenous administration of levetiracetam after the intravenous clonazepam had been ineffective. Discontinuation of mirtazapine and administration of carbamazepine resulted in completely seizure-free state that persisted even after carbamazepine treatment was terminated. The clinical and laboratory data indicate the seizure-provoking effect of mirtazapine in the reported case.
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Affiliation(s)
- Nancy C Winters
- Division of Child and Adolescent Psychiatry, Oregon Health & Sciences, University School of Medicine, Portland, USA
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Krhut J, Gärtner M. [Urinary incontinence induced by the antidepressants - case report]. Ceska Gynekol 2015; 80:65-68. [PMID: 25723082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
AIM Case study of the patient with urinary incontinence induced by the antidepressant mirtazapin and the review of the related literature. DESIGN Case Report. SETTING Department of Urology, University Hospital Ostrava-Poruba. CASE REPORT A case of 55-years old patiens, who was reffered to the surgical treatment of the urinary incontinence. We found a major discrepancies during the evaluation that led us to suspect that this is not a common uncomplicated case of stress urinary incontinence. Based on the detailed history we identified the antidepressant mirtazapine as a likely causal factor. After discontinuing mirtazapin patient has achieved full control of the continence. CONCLUSION Given that antidepressants affects adrenergic and dopaminergic regulatory mechanisms in the central nervous system, they may affect the lower urinary tract function. This work presents a case report where the disclosure of the less common cause of incontinence saved the patientoriginally proposed surgical treatment and allowed the effective restoration of the continence. We emphasize the need to consider the potential interaction of antidepressants with lower urinary tract function in daily practice.
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Nishimura H, Kawakami M. [A Case with the Increased PT-INR after the Addition of Mirtazapine to Warfarin Therapy]. Seishin Shinkeigaku Zasshi 2015; 117:820-825. [PMID: 26827407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To report a case of warfarinization involving a patient who developed nasal bleeding and an elevated prothrombin time-international normalized ratio (PT-INR) after taking 15 mg of mirtazapine. CASE SUMMARY A 70-year-old Japanese man with anxiety and irritation was admitted to the ER of our hospital with nasal bleeding. His medical history included atrial fibrillation, treated with warfarin at 3.0 mg a day, hypertension, and diabetus mellitus. He had also been taking mirtazapine at 15 mg. He experienced nasal bleeding 4 days after the initiation of therapy with mirtazapine. His PT-INR markedly elevated from 1.21 before therapy to 7.93 after therapy. Both mirtazapine and warfarin were immediately discontinued by his cardiologist. One week later, PT-INR had normalized (1.00) and the nasal bleeding had resolved. DISCUSSION The metabolism of warfarin involves several cytochrome P450 isoenzymes, including CYP1A2, CYP2C9, CYP2C19, and CYP3A4. Mirtazapine is metabolized primarily by CYP2D6 and CYP3A4, with lesser contributions by CYP1A2. A competitive enzyme inhibition may occur, with CYP3A4 metabolizing the two drugs. No drug interaction was seen with his other medications. CONCLUSION The coadministration of mirtazapine and warfarin can result in an increase in the anticoagulant effect of warfarin. This case shows the need to closely monitor potential drug interactions in the elderly, especially those taking mirtazapine and warfarin.
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Uguz F, Sahingoz M, Gungor B, Aksoy F, Askin R. Weight gain and associated factors in patients using newer antidepressant drugs. Gen Hosp Psychiatry 2015; 37:46-8. [PMID: 25467076 DOI: 10.1016/j.genhosppsych.2014.10.011] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 10/25/2014] [Accepted: 10/27/2014] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The aim of the present study was to examine weight gain and its association with clinical and sociodemographic characteristics in patients using newer antidepressants. METHODS The study had a cross-sectional design. A total of 362 consecutive psychiatric patients taking antidepressant drugs for 6 to 36 months were included in the study. RESULTS The prevalence rate of weight gain was 55.2%; 40.6% of the patients had a weight gain of 7% or more compared to the baseline. Overall, antidepressant use was significantly related to increased body weight. Specifically, citalopram, escitalopram, sertraline, paroxetine, venlafaxine, duloxetine and mirtazapine, but not fluoxetine, were associated with significant weight gain. Multivariate logistic regression analysis indicated that lower education status, lower body mass index at the onset of antidepressant use and family history of obesity were independent predictors of weight gain ≥7% compared to the baseline. CONCLUSIONS The study results suggest that patients who take newer antidepressants might have significant problems related to body weight.
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Affiliation(s)
- Faruk Uguz
- Department of Psychiatry, University of Necmettin Erbakan, Meram Faculty of Medicine, Konya, Turkey.
| | - Mine Sahingoz
- Department of Psychiatry, University of Necmettin Erbakan, Meram Faculty of Medicine, Konya, Turkey.
| | - Buket Gungor
- Department of Psychiatry, Sevket Yilmaz Research and Training Hospital, Bursa, Turkey.
| | - Fadime Aksoy
- Department of Psychiatry, University of Necmettin Erbakan, Meram Faculty of Medicine, Konya, Turkey.
| | - Rustem Askin
- Department of Psychiatry, Sevket Yilmaz Research and Training Hospital, Bursa, Turkey.
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Alampay MM, Haigney MC, Flanagan MC, Perito RM, Love KM, Grammer GG. Transcranial magnetic stimulation as an antidepressant alternative in a patient with Brugada syndrome and recurrent syncope. Mayo Clin Proc 2014; 89:1584-7. [PMID: 25444490 DOI: 10.1016/j.mayocp.2014.08.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 07/18/2014] [Accepted: 08/26/2014] [Indexed: 11/26/2022]
Abstract
Brugada syndrome (BrS) is a common occult cause of sudden cardiac arrest in otherwise healthy-appearing adults. The pathognomonic electrocardiographic pattern may be unmasked only by certain medications, many of which are unknown. We report a case of a depressed but otherwise healthy man with an asymptomatic right bundle branch block on electrocardiography who experienced antidepressant-induced BrS and ultimately recovered with transcranial magnetic stimulation (TMS). After an initial trial of nortriptyline, the patient's depressive symptoms improved; however, he experienced a syncopal event and was subsequently diagnosed as having BrS. Cross titration to bupropion, which had not previously been known to exacerbate BrS, was followed by another cardiac event. As a result, the patient was referred for TMS as a substitute for pharmacotherapy. After 31 TMS sessions over 8 weeks, the patient demonstrated significant improvement by subjective report and objective reduction in his Patient Health Questionnaire-9 scores from 10 (moderate) to 1 (minimal). Transcranial magnetic stimulation is a Food and Drug Administration-approved nonpharmacologic treatment for depression. Given the potential lethality of BrS with known and unknown psychopharmacologic agents, providers should consider TMS as first-line therapy in this patient population. Bupropion should be added to the list of agents known to exacerbate this disease.
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Affiliation(s)
- Miguel M Alampay
- Department of Psychiatry, Walter Reed National Military Medical Center, Bethesda, MD.
| | - Mark C Haigney
- Department of Medicine-Cardiology, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Michael C Flanagan
- Department of Cardiology, Fort Belvoir Community Hospital, Fort Belvoir, VA
| | - Robert M Perito
- Department of Psychiatry, Walter Reed National Military Medical Center, Bethesda, MD
| | - Kathleen M Love
- Department of Cardiology, Naval Hospital, Camp Pendleton, CA
| | - Geoffrey G Grammer
- Department of Research, National Intrepid Center of Excellence, Bethesda, MD
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Abstract
Though there is ample evidence for the association between selective serotonin reuptake inhibitors and hyponatremia, evidence for the relationship between mirtazapine and hyponatremia is scarce. We present a case of mirtazapine-induced hyponatremia in an adult patient, which was dose related.
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Affiliation(s)
- Abhishek Ghosh
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aditya Hegde
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sandeep Grover
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Mirtazapine: rhabdomyolysis. Prescrire Int 2014; 23:129. [PMID: 24926518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Rajpurohit N, Aryal SR, Khan MA, Stys AT, Stys TP. Propafenone associated severe central nervous system and cardiovascular toxicity due to mirtazapine: a case of severe drug interaction. S D Med 2014; 67:137-139. [PMID: 24791374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
We describe a rare case of severe drug-drug interaction between propafenone and mirtazapine leading to propafenone toxicity. A 69-year-old Caucasian male taking propafenone for atrial fibrillation was prescribed mirtazapine for insomnia. Subsequent to the first dose of mirtazapine the patient experienced seizures, bradycardia and prolonged QRS as well as QTc intervals on EKG. The patient was admitted to the ICU and recovered after supportive management. Propafenone is an established class IC antiarrhythmic drug commonly used in the treatment of atrial fibrillation. It is metabolized through the CYP4502D6 pathway. Five to 10 percent of Caucasians are poor metabolizers. Mirtazapine is a commonly prescribed antidepressant drug, which is also metabolized through and may modulate the CYP4502D6 pathway leading to altered metabolism of propafenone and possible adverse effects. In this case, toxicity was reversed once the offending drugs were discontinued. An extensive review of the literature revealed this to be the first described case of drug interaction between propafenone and mirtazapine.
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Buggenhout S, Vandenberghe J, Sienaert P. [Electroconvulsion therapy for neuroleptic malignant syndrome]. Tijdschr Psychiatr 2014; 56:612-615. [PMID: 25222100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
A 64-year-old man, diagnosed with recurrent depression, developed a neuroleptic malignant syndrome (nms) during treatment with olanzapine and mirtazapine. Psychotropic drugs were discontinued. Supportive therapy in an intensive care setting was initiated and electroconvulsive therapy (ect) was administered, after which the patient recovered. This case report discusses the place of ect in the treatment of nms.
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Munzer A, Sack U, Mergl R, Schönherr J, Petersein C, Bartsch S, Kirkby KC, Bauer K, Himmerich H. Impact of antidepressants on cytokine production of depressed patients in vitro. Toxins (Basel) 2013; 5:2227-40. [PMID: 24257035 PMCID: PMC3847723 DOI: 10.3390/toxins5112227] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Revised: 11/08/2013] [Accepted: 11/12/2013] [Indexed: 12/14/2022] Open
Abstract
The interplay between immune and nervous systems plays a pivotal role in the pathophysiology of depression. In depressive episodes, patients show increased production of pro-inflammatory cytokines such as interleukin (IL)-1β and tumor necrosis factor (TNF)-α. There is limited information on the effect of antidepressant drugs on cytokines, most studies report on a limited sample of cytokines and none have reported effects on IL-22. We systematically investigated the effect of three antidepressant drugs, citalopram, escitalopram and mirtazapine, on secretion of cytokines IL-1β, IL-2, IL-4, IL-6, IL-17, IL-22 and TNF-α in a whole blood assay in vitro, using murine anti-human CD3 monoclonal antibody OKT3, and 5C3 monoclonal antibody against CD40, to stimulate T and B cells respectively. Citalopram increased production of IL-1β, IL-6, TNF-α and IL-22. Mirtazapine increased IL-1β, TNF-α and IL-22. Escitalopram decreased IL-17 levels. The influence of antidepressants on IL-2 and IL-4 levels was not significant for all three drugs. Compared to escitalopram, citalopram led to higher levels of IL-1β, IL-6, IL-17 and IL-22; and mirtazapine to higher levels of IL-1β, IL-17, IL-22 and TNF-α. Mirtazapine and citalopram increased IL-22 production. The differing profile of cytokine production may relate to differences in therapeutic effects, risk of relapse and side effects.
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Affiliation(s)
- Alexander Munzer
- Department of Psychiatry, University of Leipzig, Semmelweisstr. 10, 04103 Leipzig, Germany; E-Mails: (A.M.); (R.M.); (J.S); (C.P.); (S.B.)
| | - Ulrich Sack
- Institute of Immunology, University of Leipzig, Johannisallee 30, 04103 Leipzig, Germany; E-Mails: (U.S.); (K.B.)
| | - Roland Mergl
- Department of Psychiatry, University of Leipzig, Semmelweisstr. 10, 04103 Leipzig, Germany; E-Mails: (A.M.); (R.M.); (J.S); (C.P.); (S.B.)
| | - Jeremias Schönherr
- Department of Psychiatry, University of Leipzig, Semmelweisstr. 10, 04103 Leipzig, Germany; E-Mails: (A.M.); (R.M.); (J.S); (C.P.); (S.B.)
| | - Charlotte Petersein
- Department of Psychiatry, University of Leipzig, Semmelweisstr. 10, 04103 Leipzig, Germany; E-Mails: (A.M.); (R.M.); (J.S); (C.P.); (S.B.)
| | - Stefanie Bartsch
- Department of Psychiatry, University of Leipzig, Semmelweisstr. 10, 04103 Leipzig, Germany; E-Mails: (A.M.); (R.M.); (J.S); (C.P.); (S.B.)
| | - Kenneth C. Kirkby
- Department of Psychiatry, University of Tasmania, Hobart, Tasmania, Australia; E-Mail:
| | - Katrin Bauer
- Institute of Immunology, University of Leipzig, Johannisallee 30, 04103 Leipzig, Germany; E-Mails: (U.S.); (K.B.)
| | - Hubertus Himmerich
- Department of Psychiatry, University of Leipzig, Semmelweisstr. 10, 04103 Leipzig, Germany; E-Mails: (A.M.); (R.M.); (J.S); (C.P.); (S.B.)
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Bognár Z, Vonyik G, Gazdag G. [Antidepressant treatment associated hyponatremia -- case report]. Neuropsychopharmacol Hung 2013; 15:177-80. [PMID: 24108183 DOI: pmid/24108183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hyponatremia is a potential side-effect of antidepressants that was observed most frequently in connection with compounds acting on the serotonin system. Risk of hyponatremia was found to be higher in the elderly. Authors report a case of a 65-year old male patient who was treated with venlafaxine-mirtazapine combination for recurrent depression. Severe hyponatremia, requiring intensive care, emerged in connection with the treatment. The authors emphasize the importance of the regular checking of serum sodium levels during antidepressant treatment, especially in elderly patients.
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Affiliation(s)
- Zsófia Bognár
- Egyesített Szent István és Szent László Kórház-Rendelőintézet, Szent László Kórház, IV. Belgyógyászati osztály, Budapest, Hungary.
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Kjaersgaard MIS, Parner ET, Vestergaard M, Sørensen MJ, Olsen J, Christensen J, Bech BH, Pedersen LH. Prenatal antidepressant exposure and risk of spontaneous abortion - a population-based study. PLoS One 2013; 8:e72095. [PMID: 24015208 PMCID: PMC3756033 DOI: 10.1371/journal.pone.0072095] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Accepted: 07/08/2013] [Indexed: 11/19/2022] Open
Abstract
PURPOSE To estimate the risk of spontaneous abortion after use of antidepressant medication during pregnancy. METHODS From the Danish Medical Birth Registry and the Danish National Hospital Registry, we identified all pregnancies leading to in- or outpatient contacts in Denmark from February 1997 to December 2008. The Danish Registry of Medicinal Product Statistics provided information on the women's prescriptions for antidepressants during pregnancy. We obtained information on women who were diagnosed with depression from the Danish Psychiatric Central Registry. Adjusted relative risks (aRR) of spontaneous abortion were estimated according to exposure to antidepressants or maternal depression using binomial regression. RESULTS Of the 1,005,319 pregnancies (547,300 women) identified, 114,721 (11.4%) ended in a spontaneous abortion. We identified 22,061 pregnancies exposed to antidepressants and 1,843 with a diagnosis of depression with no antidepressant use, of which 2,637 (12.0%) and 205 (11.1%) ended in a spontaneous abortion, respectively. Antidepressant exposure was associated with an aRR of 1.14 (95% confidence interval (CI) 1.10-1.18) for spontaneous abortion compared with no exposure to antidepressants. Among women with a diagnosis of depression, the aRR for spontaneous abortion after any antidepressant exposure was 1.00 (95% CI 0.80-1.24). No individual selective serotonin reuptake inhibitor (SSRI) was associated with spontaneous abortions. In unadjusted analyses, we found that mirtazapine, venlafaxine, and duloxetine were associated with spontaneous abortions among women with depression but we had no information on potential differences in disease severity and only few pregnancies were exposed in the population. CONCLUSION We identified a slightly increased risk of spontaneous abortion associated with the use of antidepressants during pregnancy. However, among women with a diagnosis of depression, antidepressants in general or individual SSRI in particular were not associated with spontaneous abortions. Further studies are warranted on the newer non-SSRI antidepressants, as we had insufficient data to adjust for important confounding factors.
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Affiliation(s)
| | - Erik Thorlund Parner
- Department of Public Health, Section for Biostatistics, Aarhus University, Aarhus, Denmark
| | - Mogens Vestergaard
- Research Unit for General Practice, Aarhus University, Aarhus, Denmark
- Department of Public Health, Section for General Practice, Aarhus University, Aarhus, Denmark
| | - Merete Juul Sørensen
- Regional Center for Child and Adolescent Psychiatry, Aarhus University Hospital, Risskov, Denmark
| | - Jørn Olsen
- Department of Public Health, Section for Epidemiology, Aarhus University, Aarhus, Denmark
| | - Jakob Christensen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Pharmacology, Aarhus University, Aarhus, Denmark
| | - Bodil Hammer Bech
- Department of Public Health, Section for Epidemiology, Aarhus University, Aarhus, Denmark
| | - Lars Henning Pedersen
- Department of Public Health, Section for Epidemiology, Aarhus University, Aarhus, Denmark
- Department of Obstetrics and Gynecology, Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
- * E-mail:
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Kohmura K, Iwamoto K, Aleksic B, Sasada K, Kawano N, Katayama H, Noda Y, Noda A, Iidaka T, Ozaki N. Effects of sedative antidepressants on prefrontal cortex activity during verbal fluency task in healthy subjects: a near-infrared spectroscopy study. Psychopharmacology (Berl) 2013; 226:75-81. [PMID: 23052571 DOI: 10.1007/s00213-012-2885-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Accepted: 09/15/2012] [Indexed: 11/29/2022]
Abstract
RATIONALE Japanese researchers have recently conducted studies using near-infrared spectroscopy (NIRS) to help diagnose psychiatric disorders based on changes in brain activity. However, the influence of psychotropic drugs on NIRS measurements has not been clarified. OBJECTIVE To assess the effects of sedative antidepressants on prefrontal cortex activity in healthy subjects using NIRS in a double-blinded, placebo-controlled, crossover trial. METHODS Nineteen healthy males received nocturnal doses of mirtazapine 15 mg, trazodone 25 mg, or placebo for eight consecutive days in rotation, with a washout period of more than 1 week between each rotation. Subjects performed a verbal fluency task during NIRS on a total of seven occasions during the study period: more than a week prior to receiving the first dose of the first medication; and on days 2 and 9 of each rotation. The number of words correctly generated during the task (behavioral performance) was also recorded. Stanford Sleepiness Scale (SSS) scores were determined each day. RESULTS Mirtazapine 15 mg significantly increased oxyhemoglobin (oxy-Hb) concentration change in NIRS on day 9, compared to trazodone 25 mg and placebo. Mirtazapine 15 mg significantly increased SSS on day 2, compared to the other conditions. No significant differences in behavioral performance were observed. CONCLUSIONS Administration of mirtazapine for eight consecutive days affected oxy-Hb changes on NIRS. This result indicates that researchers should consider how certain types of antidepressant could influence brain function when the brain activity of patients with psychiatric disorders is assessed.
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Affiliation(s)
- Kunihiro Kohmura
- Department of Psychiatry, Graduate School of Medicine, Nagoya University, 65 Tsurumai, Showa, Nagoya, Aichi, Japan
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Knud Larsen J. [Mirtazapine versus other antidepressive agents for depression]. Ugeskr Laeger 2012; 174:2864-2866. [PMID: 23153468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
A Cochrane analysis compared efficacy and side effects of mirtazapine with other antidepressants. After six weeks of treatment no reliable difference of efficacy between mirtazapine, selective serotonin reuptake inhibitors (SSRI), noradrenaline reuptake inhibitors or tricyclic antidepressants was found. The side effects like increased sleep and weight gain were compared by treatment with mirtazapine and treatment with SSRI antidepressants. The very fact of the sleep effect and the fast onset of action have probably increased the effect size compared with SSRI antidepressants. The results of the Cochrane analysis cannot for certain be generalized to inpatients, as other studies have found tricyclic antidepressants to be especially effective.
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Uguz F, Sahingoz M, Kose SA, Ozbebit O, Sengul C, Selvi Y, Sengul CB, Ayhan MG, Dagistanli A, Askin R. Antidepressants and menstruation disorders in women: a cross-sectional study in three centers. Gen Hosp Psychiatry 2012; 34:529-33. [PMID: 22534402 DOI: 10.1016/j.genhosppsych.2012.03.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Revised: 03/19/2012] [Accepted: 03/20/2012] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The relationship between menstruation disorders and antidepressant drugs usage in women remains unclear. In this study, we aimed to investigate the incidence rate of antidepressant-related menstruation disorders and to examine whether or not antidepressant use is associated with menstrual disorders in women. METHODS The study sample was gathered from three centers and four hospitals. A total of 1432 women who met the criteria of inclusion were included in the study. The sample was divided into two groups: the antidepressant group (n=793) and the control group (n=639). The menstruation disorders were established with reports from the study participants on the basis of related gynecological descriptions. RESULTS The prevalence of menstrual disorders was significantly higher in the antidepressant group (24.6%) than the control group (12.2%). The incidence of antidepressant-induced menstruation disorder was 14.5%. The antidepressants most associated with menstrual disorders were paroxetine, venlafaxine, sertraline and their combination with mirtazapine. Overall, the incidence rate was similar in women receiving selective serotonin reuptake inhibitors and serotonin noradrenaline reuptake inhibitors. CONCLUSIONS The results of the present study suggest that menstruation disorders are frequently observed in women taking antidepressants and that it appears to be associated with antidepressant use at least in some women.
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Affiliation(s)
- Faruk Uguz
- Department of Psychiatry, Meram Faculty of Medicine, Konya University, Konya, Turkey.
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Schmidt FM, Tennert C, Teupser D, Himmerich H. [Optimizing antidepressant pharmacotherapy in a case of inflammatory bowel disease and major depression]. Psychiatr Prax 2012; 39:239-242. [PMID: 22689282 DOI: 10.1055/s-0032-1305013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVE In the framework of a case report on a patient suffering from major depression and inflammatory bowel disease we address the pharmacotherapeutical options in case of subtherapeutic mirtazapine levels. METHODS We applied therapeutic drug monitoring (TDM) and cytochrome P450 2D6 genotyping, and switched to an orodispersible tablet. RESULTS AND CONCLUSION Thus, mirtazapine plasma levels could be raised and clinical improvement of the depressive symptoms was achieved.
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MESH Headings
- Alleles
- Anti-Inflammatory Agents/administration & dosage
- Anti-Inflammatory Agents/adverse effects
- Antidepressive Agents, Tricyclic/adverse effects
- Antidepressive Agents, Tricyclic/pharmacokinetics
- Antidepressive Agents, Tricyclic/therapeutic use
- Colitis, Ulcerative/blood
- Colitis, Ulcerative/diagnosis
- Colitis, Ulcerative/psychology
- Combined Modality Therapy
- Cytochrome P-450 CYP2D6/genetics
- Depressive Disorder, Major/blood
- Depressive Disorder, Major/diagnosis
- Depressive Disorder, Major/drug therapy
- Depressive Disorder, Major/psychology
- Dose-Response Relationship, Drug
- Genetic Carrier Screening
- Humans
- Liver/enzymology
- Male
- Mesalamine/adverse effects
- Mesalamine/therapeutic use
- Metabolic Clearance Rate/genetics
- Mianserin/adverse effects
- Mianserin/analogs & derivatives
- Mianserin/pharmacokinetics
- Mianserin/therapeutic use
- Middle Aged
- Mirtazapine
- Patient Admission
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Affiliation(s)
- Frank Martin Schmidt
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Universitätsklinikum Leipzig.
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Christoffersen RK, Vestergård LD, Høimark L, Vesterby A. [Eosinophilic myocarditis and sudden unexpected death in a younger patient treated with antipsychotics]. Ugeskr Laeger 2011; 173:2799-2800. [PMID: 22040663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
A 36 year-old man suffering from schizophrenia was found dead in his apartment. Forensic autopsy was performed due to sudden unexpected death but did not yield the cause of death. Histological examination of the heart showed eosinophilic myocarditis (EM) while forensic chemistry showed a raised level of aripripazol. We discuss the risk of sudden cardiac death in patients receiving antipsychotic drugs and the possible connection between raised drug levels and EM, and we emphasise the importance of autopsy and hope for better means in the future of finding patients at risk.
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Banerjee S, Hellier J, Dewey M, Romeo R, Ballard C, Baldwin R, Bentham P, Fox C, Holmes C, Katona C, Knapp M, Lawton C, Lindesay J, Livingston G, McCrae N, Moniz-Cook E, Murray J, Nurock S, Orrell M, O'Brien J, Poppe M, Thomas A, Walwyn R, Wilson K, Burns A. Sertraline or mirtazapine for depression in dementia (HTA-SADD): a randomised, multicentre, double-blind, placebo-controlled trial. Lancet 2011; 378:403-11. [PMID: 21764118 DOI: 10.1016/s0140-6736(11)60830-1] [Citation(s) in RCA: 301] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Depression is common in dementia but the evidence base for appropriate drug treatment is sparse and equivocal. We aimed to assess efficacy and safety of two of the most commonly prescribed drugs, sertraline and mirtazapine, compared with placebo. METHODS We undertook the parallel-group, double-blind, placebo-controlled, Health Technology Assessment Study of the Use of Antidepressants for Depression in Dementia (HTA-SADD) trial in participants from old-age psychiatry services in nine centres in England. Participants were eligible if they had probable or possible Alzheimer's disease, depression (lasting ≥4 weeks), and a Cornell scale for depression in dementia (CSDD) score of 8 or more. Participants were ineligible if they were clinically critical (eg, suicide risk), contraindicated to study drugs, on antidepressants, in another trial, or had no carer. The clinical trials unit at King's College London (UK) randomly allocated participants with a computer-generated block randomisation sequence, stratified by centre, with varying block sizes, in a 1:1:1 ratio to receive sertraline (target dose 150 mg per day), mirtazapine (45 mg), or placebo (control group), all with standard care. The primary outcome was reduction in depression (CSDD score) at 13 weeks (outcomes to 39 weeks were also assessed), assessed with a mixed linear-regression model adjusted for baseline CSDD, time, and treatment centre. This study is registered, number ISRCTN88882979 and EudraCT 2006-000105-38. FINDINGS Decreases in depression scores at 13 weeks did not differ between 111 controls and 107 participants allocated to receive sertraline (mean difference 1·17, 95% CI -0·23 to 2·58; p=0·10) or mirtazapine (0·01, -1·37 to 1·38; p=0·99), or between participants in the mirtazapine and sertraline groups (1·16, -0·25 to 2·57; p=0·11); these findings persisted to 39 weeks. Fewer controls had adverse reactions (29 of 111 [26%]) than did participants in the sertraline group (46 of 107, 43%; p=0·010) or mirtazapine group (44 of 108, 41%; p=0·031), and fewer serious adverse events rated as severe (p=0·003). Five patients in every group died by week 39. INTERPRETATION Because of the absence of benefit compared with placebo and increased risk of adverse events, the present practice of use of these antidepressants, with usual care, for first-line treatment of depression in Alzheimer's disease should be reconsidered. FUNDING UK National Institute of Health Research HTA Programme.
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Affiliation(s)
- Sube Banerjee
- Institute of Psychiatry, Health Services and Population Research Department, King's College London, London, UK.
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Affiliation(s)
- Julien Dubois
- Université de Toulouse, Centre de Recherche Cerveau et Cognition, Université Paul Sabatier, Toulouse, France.
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Kim JE, Yoon SJ, Kim J, Jung JY, Jeong HS, Cho HB, Shin E, Lyoo IK, Kim TS. Efficacy and tolerability of mirtazapine in treating major depressive disorder with anxiety symptoms: an 8-week open-label randomised paroxetine-controlled trial. Int J Clin Pract 2011; 65:323-9. [PMID: 21314870 DOI: 10.1111/j.1742-1241.2010.02624.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
AIMS Prominent anxiety symptoms are related to poor clinical course and outcome in major depressive disorder (MDD). The aim of this randomised, open-label, controlled study is to compare the efficacy and tolerability of mirtazapine in the form of orally disintegrating tablets against paroxetine in treating MDD patients with anxiety symptoms. METHODS A total of 60 MDD patients with a score above 18 on the Hamilton Anxiety Rating Scale (HARS) were randomly assigned to 8 weeks of fixed dosing treatment with mirtazapine (15-30 mg/day) and paroxetine (10-20 mg/day). Efficacy was primarily assessed with the HARS and with the 17-item Hamilton Depression Rating Scale (HDRS) at weeks 1, 2, 4 and 8 after treatment. Tolerability was assessed from adverse events. RESULTS The generalised estimating equations (GEE) models showed that the rates of improvement in HDRS scores from baseline to week 8 were similar between mirtazapine and paroxetine groups. However, patients with mirtazapine exhibited earlier improvement in HARS scores at weeks 1 and 2. Week-by-week GEE models showed that these significant differences in improvement of HARS scores between the two treatment groups were detectable from the first evaluation after the treatment (week 1) and maintained through week 2. There was no difference in the overall frequency of adverse events experienced between the two treatment groups. The most common adverse event in the mirtazapine group was somnolence (n = 8), whereas that in the paroxetine group was gastrointestinal discomfort (n = 9). CONCLUSIONS Mirtazapine and paroxetine were equally effective and well tolerated for the depressive symptoms in MDD patients with the high level of anxiety symptoms. Mirtazapine was, however, more effective in reducing the anxiety symptoms than paroxetine in the early weeks of treatment, suggesting that mirtazapine may have an earlier-onset action for the anxiety symptoms in MDD patients.
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Affiliation(s)
- J E Kim
- Department of Psychiatry, Seoul National University College of Medicine, Seoul, South Korea
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Butler MC, Di Battista M, Warden M. Sertraline-induced serotonin syndrome followed by mirtazapine reaction. Prog Neuropsychopharmacol Biol Psychiatry 2010; 34:1128-9. [PMID: 20430060 DOI: 10.1016/j.pnpbp.2010.04.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2010] [Revised: 04/16/2010] [Accepted: 04/16/2010] [Indexed: 12/01/2022]
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Deuschle M, Angermeier T, Westphal S, Lederbogen F, Gilles M, Frankhauser P, Schilling C, Onken V, Weber-Hamann B, Kopf D. Venlafaxine, but not mirtazapine lowers retinol-binding protein 4 serum concentrations in nondiabetic depressed patients. Psychother Psychosom 2010; 79:123-5. [PMID: 20090399 DOI: 10.1159/000276374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/18/2009] [Indexed: 11/19/2022]
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Manakova E, Hubickova L, Kostalova J, Zemanova Z. Embryotoxicity of mirtazapine: a study using Chick Embryotoxicity Screening Test. Neuro Endocrinol Lett 2010; 31 Suppl 2:8-10. [PMID: 21187830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/17/2010] [Accepted: 11/16/2010] [Indexed: 05/30/2023]
Abstract
OBJECTIVE Mirtazapine is a new antidepressant used in last years, however experience with it during pregnancy is unsatisfactory on the present. Its wide therapeutic range and only little proved side effects may be an advantage for treatment during pregnancy. Aim of our study was to contribute to the knowledge on possible risks. MATERIALS AND METHODS For embryotoxicity testing we used an alternative method - CHEST, that used chicken embryos as experimental model. Fertilized eggs of outbred Grey Leghorn stock (AVČR farm Koleč) were treated on embryonic day (ED) 4 by Mirtazapine, incubated till 9ED, when they were weighed and examined. Summing the proportions of dead and malformed embryos, the beginning of the embryotoxicity dose range was estimated. RESULTS Mirtazapine solved in 15% DMSO in water revealed low embryotoxicity corresponding data from preclinical studies. If 100% DMSO was used as a solvent, the dose 0.05 μg/3 μL resulted in 57% mortality (LD50). Typical malformations were microphtalmia and malformation (shortening) of limbs on left side, which is a place of contact the embryonic body with maximal Mirtazapine concentration. Approximation of doses in chick embryos to mammals is complicated by low solubility of mirtazapine. CONCLUSIONS If the embryotoxic dose was close to LD50, risk at therapeutical doses will be probably low. Mirtazapine according to results of testing and cases published in literature is relatively safe for pregnant women, only higher rate of abortions was demonstrated, however more information is needed to exclude all potential risks.
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Affiliation(s)
- Eva Manakova
- 3rd Faculty of Medicine, Department of Histology and Embryology, Charles University, Prague, Czech Republic.
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Bertram L, Liss Y, Grözinger M. Neopterin and C-reactive protein in the course of Stevens-Johnson syndrome: report of a case. Acta Derm Venereol 2009; 89:285-7. [PMID: 19479127 DOI: 10.2340/00015555-0631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We describe a patient originally suffering from a depressive syndrome who developed Stevens-Johnson syndrome after 12 days of treatment with lamotrigine. The clinical symptoms and the inflammation parameters neopterin and C-reactive protein were documented. Neopterin values showed a good correlation with the course of the disease, which, to the best of our knowledge, has not been reported previously. C-reactive protein followed the neopterin curve with a delay of 4 days. Since neopterin is a widely available parameter it should be considered as a routine measurement in this type of hyperergic reaction. It might help to identify the beginning, the maximum and the regression of the disease in order to support therapeutic decisions.
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Affiliation(s)
- Linda Bertram
- Department of Anaesthesiology/Department of Palliative Medicine, RWTH Aachen University, Pauwelsstrasse 30, USA.
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Rihmer Z, Purebl G. [Mirtazapine--pharmacologic action and clinical advantages]. Neuropsychopharmacol Hung 2009; 11:35-40. [PMID: 19731817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Mirtazapine is an effective antidepressant with unique and special mechanism of action characterized by high response and remission rates, relatively early onest of action and favourable side-effect profile. The present paper reviews some special points of the clinical use of mirtazapine, which is on the market in Hungary for almost 10 years, including its sleep-improving and anxiolytic effets. This review will also touch the management of the most commonly occuring side-effects.
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Affiliation(s)
- Zoltán Rihmer
- Semmelweis Egyetem, Klinikai es Kutatási Mentá lhigiéné s Osztály, Budapest.
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Danileviciūte V, Sveikata A, Adomaitiene V, Gumbrevicius G, Fokas V, Sveikatiene R. Efficacy, tolerability, and preference of mirtazapine orally disintegrating tablets in depressed patients: a 17-week naturalistic study in Lithuania. Medicina (Kaunas) 2009; 45:778-784. [PMID: 19996664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Mirtazapine is an established antidepressant with well-documented efficacy demonstrated in controlled clinical trials. However, the gap between the results obtained in controlled clinical trials and everyday clinical practice exists. Therefore, the importance of naturalistic studies in psychiatry is becoming recognized. The aim of present naturalistic study was to acquire data on efficacy, safety, and preference of mirtazapine orally disintegrating tablets during a 17-week treatment of depression. This prospective, open-label, multicenter study in patients with mild to severe depression was conducted at 47 mental health centers of Lithuania by 78 psychiatrists. Patients were initially given 15 mg or 30 mg of mirtazapine orally disintegrating tablets; the maximum allowed dose was 45 mg per day. The primary efficacy measure was the total score on the Hamilton Depression Rating Scale-17 (HAMD-17), the Clinical Global Impression-Severity (CGI-S), and Clinical Global Impression-Improvement (CGI-I) scales. Tolerability was primarily measured by assessing the incidence of treatment-emergent adverse events. Patients were evaluated at baseline, at weeks 1, 5, 9, 13, and 17. A total of 779 patients (595 women [76.4%] with a mean [SD] age of 50.2 [13.65] and 184 men [23.6%] with a mean [SD] age of 52.4 [14.6] years) were enrolled into the study; 687 (88.2%) patients completed the study. The mean (SD) daily dose of mirtazapine orally disintegrating tablets was 29.0 (3.8) mg. The mean total (SD) HAMD-17 score improved significantly from 25.7 (4.6) to 7.3 (4.3) (P<0.005). At each visit, the mean HAMD-17 score was significantly lower than that at the preceding visit. At week 17, remission (HAMD-17 score < or =7) was observed in 436 (56%) patients. The mean (SD) CGI-S score improved significantly from 4.9 (1.0) at baseline to 1.5 (0.6) at endpoint (P<0.001). According to the CGI-I assessments, 621 patients (89.4%) improved and improved very much. The vast majority of patients (80%) preferred the new formulation of mirtazapine - mirtazapine orally disintegrating tablet. Treatment-emergent adverse events occurred in 106 patients (13.6%). The most frequent adverse events were weight gain, sedation, dizziness, and dry mouth. In this study conducted in Lithuania with depressed patients, a significant improvement was shown in all efficacy measures. In addition, mirtazapine orally disintegrating tablet was a well-tolerated and preferable formulation for the treatment of depressed patients.
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Affiliation(s)
- Vita Danileviciūte
- Department of Theoretical and Clinical Pharmacology, Kaunas University of Medicine, A. Mickeviciaus 9, 44307 Kaunas, Lithuania
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Waring WS, Good AM, Bateman DN. Lack of significant toxicity after mirtazapine overdose: A five-year review of cases admitted to a regional toxicology unit. Clin Toxicol (Phila) 2008; 45:45-50. [PMID: 17357381 DOI: 10.1080/15563650601005837] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Mirtazapine is a comparatively new antidepressant that selectively blocks central alpha2-adrenergic autoreceptors and postsynaptic 5-HT2 and 5-HT3 receptors, causing reduced neuronal norepinephrine and serotonin reuptake. The prevalence of mirtazapine prescribing has steadily risen; however, comparatively little information is available regarding the clinical features associated with mirtazapine overdose. AIMS To characterize the toxic features that result from mirtazapine overdose. METHODS We performed a retrospective case analysis of patients admitted to the Toxicology Unit of the Royal Infirmary of Edinburgh between January 2000 and December 2004 after stated mirtazapine overdose. Casenotes were examined for clinical, laboratory, and electrocardiographic safety data. RESULTS There were 117 mirtazapine cases where the median (interquartile range) stated dose ingested was 450 mg (240-785 mg). Conscious level was reduced in 27.2% of patients and there was a higher incidence of tachycardia (30.4%) than predicted from normal reference range values (p < 0.001). There was no evidence of any other significant clinical, laboratory, or electrocardiographic abnormality. CONCLUSIONS Severe toxic features could be attributed to other co-ingested drugs or alcohol. The adverse clinical effects attributable to mirtazapine overdose appeared mild and predictable. Mirtazapine overdose appears to be associated with fewer features of severe toxicity than previously reported for other antidepressants.
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Affiliation(s)
- W Stephen Waring
- Scottish Poisons Information Bureau, Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom.
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Chen ZX, Wang HQ, Jin WD. [Selective serotonin reuptake inhibitor is more likely to induce sexual dysfunction than mirtazapine in treating depression]. Zhonghua Nan Ke Xue 2008; 14:896-899. [PMID: 19157098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVE To compare the incidences of sexual dysfunction induced by mirtazapine and SSRI in the treatment of patients with depression. METHODS Using key-word retrieval from the compact disks of the Chinese biological medicine (CBM) data base, we analyzed the rates of sexual dysfunction from the published clinical control trials on depression treated with mirtazapine and SSRI by applying the fixed effects model (FEM) of evidence-based medicine (EBM). RESULTS Among 1108 cases in 14 studies, there were 5 cases of mirtazapine-induced and 106 cases of SSRI-induced sexual dysfunction, accounting for 0.90% and 19.2% respectively, OR = 0.07 (95% CI: 0.04-0.14), Z = 8.03, P < 0.01. CONCLUSION SSRI is far more likely to induce sexual dysfunction than mirtazapine in the treatment of depression.
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Affiliation(s)
- Zheng-xin Chen
- Department of Psychiatry, Zhejiang Province Mental Health Center, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang 310012, China
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Sokolover N, Merlob P, Klinger G. Neonatal recurrent prolonged hypothermia associated with maternal mirtazapine treatment during pregnancy. Can J Clin Pharmacol 2008; 15:e188-e190. [PMID: 18515920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
We present a case of recurrent hypothermia in concordant monozygotic twins born to a mirtazapine treated mother. The twins were born at 35 weeks gestation at birth weights of 2426 g and 2355 g. Both twins presented with recurrent hypothermia continuing until day 10 of life. Possible etiologies of hypothermia were excluded. The degree of prematurity and the weight of the twins were not consistent with prolonged thermal instability. The twins' mother was treated with mirtazapine during the entire pregnancy. Due to its serotonin and alpha 2 receptors antagonism mirtazapine is known to influence thermoregulation in adult humans and other mammals. We suggest that maternal mirtazapine treatment during pregnancy was associated with recurrent hypothermia in both identical twins.
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Affiliation(s)
- Nir Sokolover
- Neonatal Intensive Care, Schneider Children's Medical Center of Israel, Petah Tiqva, Israel
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Mrakotsky C, Masek B, Biederman J, Raches D, Hsin O, Forbes P, de Moor C, DeMaso DR, Gonzalez-Heydrich J. Prospective open-label pilot trial of mirtazapine in children and adolescents with social phobia. J Anxiety Disord 2008; 22:88-97. [PMID: 17419001 DOI: 10.1016/j.janxdis.2007.01.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2006] [Revised: 12/22/2006] [Accepted: 01/26/2007] [Indexed: 11/30/2022]
Abstract
Mirtazapine is indicated for major depression and used for anxiety in adults; however, little is known about its application in pediatric populations. This is an 8-week open-label pilot study of mirtazapine in children with social phobia age 8-17 years. Primary outcomes were symptom improvement based on clinician rating and self-report, as well as tolerability based on rates of discontinuation due to adverse effects. Fifty-six percent (10/18) responded to treatment, 17% (3/18) achieved full remission. Social phobia symptoms improved significantly during the first 2 weeks of treatment, as did comorbid symptoms of depression and anxiety. Eleven patients (61%) did not complete all 8 weeks of treatment; four patients (22%) discontinued due to adverse effects including fatigue and irritability. The others discontinued due to study burden (28%), insufficient response (6%), or to pursue herbal treatment (6%). Significant weight gain was observed. Larger controlled trials are needed to further evaluate efficacy and safety.
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Affiliation(s)
- Christine Mrakotsky
- Department of Psychiatry, Children's Hospital Boston, 300 Longwood Avenue, Fegan 8, Boston, MA 02115, United States
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