Mirtazapine (Remeron)
Antidepressant (norepinephrine/serotonin receptor antagonist at alpha-2, 5-HT2, 5-HT3; in low dose is histamine antagonist promoting sleep)
- Major Depression3
- Hypnotic safe elderly (and deepens sleep)3
- OCD3
- Anorexia3
- Methamphetamine1
- Anxious Depression
- Anti-nausea
- Insomnia
Features
Dosing
7.5-15 mg qhs for sleep, 30-45 mg qhs for depression (maximum benefit usually at 30 mg).
INTERACTIONS: Raise by 2-3x if using with carbamazepine.
Management
Reduces cravings in meth/amph (?cocaine) abuse. Reduces side effects of SSRIs, but does not augment antidepressants (except in anxious depression).
Good for anxious depression and geriatrics. Deepens sleep quality.
Treats nausea and itch. Treats akathisia in doses below 30mg/night, but can cause it above that.
TOLERABILITY: fatigue, weight gain (30%).
RISKS: Very rare decreased platelet count.
EMR Text
Depression
Mirtazapine use based on FDA approval in depression.
Mirtazapine side effects reviewed with patient.
Insomnia
Mirtazapine use based on trials in insomnia, where it deepened sleep quality.
Mirtazapine side effects reviewed with patient.
OCD
Mirtazapine use based on a randomized controlled trial in OCD where it augmented SSRIs (Mowla A et al, Int Clin Psychopharmacol 2023;38(1):4-8).
Mirtazapine side effects reviewed with patient.
Anorexia
Mirtazapine use based on a uncontrolled studies in anorexia nervosa (Hrdlicka M et al, Eur Child Adolesc Psychiatry 2008;17(3):187-9).
Mirtazapine side effects reviewed with patient.
Methamphetamine
Mirtazapine use based on a large randomized, phase III trial in methamphetamine use disorder where it reduced cravings, withdrawal symptoms, and drug use (McKetin R et al, JAMA Psychiatry 2026 Apr 1:e260159).
Mirtazapine side effects reviewed with patient.