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Am Fam Physician. 2001;63(3):444-445

to the editor: I am responding to the recently published review by Drs. Gurvich and Cunningham,1 “Appropriate Use of Psychotropic Drugs in Nursing Homes.” I believe that the data presented regarding the clinical efficacy and side effect profile of the newer antidepressant mirtazapine (Remeron) may be potentially misleading.

The number of safe and effective medications with approved labeling for the treatment of depression has increased significantly during the past 10 years. The brief mention of mirtazapine in the review by Gurvich and Cunningham1 is understandable in light of the number of new agents they needed to discuss. However, their discussion of this extensively used noradrenergic and specific serotonergic antidepressant (NaSSA) appears to suggest a more troublesome toxicity profile that conflicts with what I have seen in clinical trials and in practice.

The authors state that research on the use of this drug in the geriatric population has been limited. However, many randomized, double-blind, controlled trials and clinical reports support the use of mirtazapine as a first-line agent for the treatment of depression in these and other patient types; these studies include two that were specifically directed at the elderly population.24 Tolerability of mirtazapine was examined in elderly persons by Montgomery,5 who found no difference in tolerance between patients older than 65 years and younger patients taking mirtazapine.

Drs. Gurvich and Cunningham1 raised concerns that mirtazapine might cause anticholinergic effects caused by weak muscarinic blockade; however, a retrospective database review of safety by Montgomery5 revealed that mirtazapine has virtually no adverse anticholinergic effects (editor's note: data published in a journal supplement sponsored by the manufacturer of mirtazapine). The authors also state that mirtazapine can cause orthostatic hypotension caused by weak alpha-adrenergic blockade. However, in clinical trials, orthostatic hypotension occurred less in mirtazapine-treated patients than in placebo-treated patients.6

In conclusion, from my review of the literature and from my clinical experience: (1) mirtazapine is effective in the treatment of depression; (2) side effects of mirtazapine, such as somnolence and increased appetite, can be beneficial in the depressed elderly patient who is not sleeping or eating, especially in the long-term care setting and (3) orthostatic hypotension has not been demonstrated to be more clinically significant with mirtazapine than with other new antidepressants.

in reply: Selecting an appropriate antidepressant for any given patient is a complicated process and is dependent on the prescriber's clinical experience and the patient's ability to tolerate the drug. Mirtazapine is clearly better tolerated than tricyclic agents and is appropriate for some geriatric patients. Mirtazapine may be especially helpful in those who need a sedating agent or in patients who need to gain weight. An increase in appetite was reported in 17 percent of patients taking mirtazapine.1 Some dizziness and anticholinergic side effects, however, were reported in clinical trials. We believe that prescribers need to be aware of the possibility of these side effects so that they can factor them into their clinical decision making.

Email letter submissions to afplet@aafp.org. Letters should be fewer than 400 words and limited to six references, one table or figure, and three authors. Letters submitted for publication in AFP must not be submitted to any other publication. Letters may be edited to meet style and space requirements.

This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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