Depression medicine: Mirtazapine ?

[papzombie]

Hi all,

A psychiatrist has prescribed Mirtazapine (half of a pill of 7.5 mg per day) because she believes I have a depression (I don't have joy in my life). I wonder if this goes against my sleeping (I have too many awakenings during a night, to the point that a Somnologist has prescribed a CBT-I (cognitive behavioral therapy for insomnia) for me).

Anyone has some experience with it ?
Thanks,

[49er]

Hi all,

A psychiatrist has prescribed Mirtazepine (half of a pill of 7.5 mg per day) because she believes I have a depression (I don't have joy in my life). I wonder if this goes against my sleeping (I have too many awakenings during a night, to the point that a Somnologist has prescribed a CBT-I (cognitive behavioral therapy for insomnia) for me).

Anyone has some experience with it ?
Thanks,

Hi,

I took it for several years as part of a psych med cocktail for sleep. Unfortunately, it pooped out on me necessitating the addition of Doxepin. I have been off of meds for several years and knowing what I now know, I would have never touched them. But obviously, you have to decide what is best for you.

Taking the Remeron could confuse the issues with CBT-I especially since it would be hard to distinguish med start up effects with particular problems from CBT-I. Personally, I would give the CBT-I a chance to work before considering the Remeron. And if it works, you may find your depression greatly alleviated from better sleep which would increase your joy in life.

49er

[papzombie]

The psychiatrist also gave me 3 choices

- Remeron (Mirtazapine)
- Trazodone
- Quetiapine

To be honest, I am still looking to find more things to fix in my sleep, given my problems (quickly panic, quickly getting angry, anxiety disorder, hard to decide when the situation is a bit (just a bit) complicated, memory, concentration, ...), but the psychiatrist thinks that I am currently looking too much into sleeping disorders.

Am I biased too much into sleeping problems ? Or the fact that I post a question here guarantees that the answers are always sleep biased ?

Thanks

[49er]

The psychiatrist also gave me 3 choices

- Remeron (Mirtazapine)
- Trazodone
- Quetiapine

To be honest, I am still looking to find more things to fix in my sleep, given my problems (quickly panic, quickly getting angry, anxiety disorder, hard to decide when the situation is a bit (just a bit) complicated, memory, concentration, ...), but the psychiatrist thinks that I am currently looking too much into sleeping disorders.

Am I biased too much into sleeping problems ? Or the fact that I post a question here guarantees that the answers are always sleep biased ?

Thanks

To be honest papzombie, many psychiatrists don't exactly give bias free advice and think all problems are solvable by meds. Many of them still greatly underestimate the effect sleep problems have on mental health issues.

But the issue is what do you want to do and I think you just provided the answer above.

49er

[SpicedRum]

Hi there papzombie,

Am I correct in saying you've been prescribed half of a 7.5mg tablet a day? Do they intend for you to gradually increase the dose?

Therapeutic doses of Mirtazapine are up around the 30-45mg/day mark - so even if depression is the cause of your lack of enjoyment, I can't see how taking a tenth of the dose is going to make any impact on that.

For what its worth though, Mirtazapine can give people long, uninterrupted sleep. This is because, as well as acting on common antidepressant neurotransmitters such as serotonin, Mirtazapine also blocks histamine receptors in the brain, in exactly the same way as some cold and allergy medicines do, causing sedation. This sedating effect tends to be more prominent around the lower doses (7.5-15mg). At doses prescribed to treat depression (30-45mg) the stimulating effect of the increasing serotonin and noradrenaline levels, tends to outweigh the sedation caused by blocking histamine receptors.

So ironically, taking such a low dose may not directly improve symptoms of depression, but could help reduce your awakenings. It's probably best to take it about an hour before you go to sleep.

Hope this helps

[avi123]

Hi all,

A psychiatrist has prescribed Mirtazapine (half of a pill of 7.5 mg per day) because she believes I have a depression (I don't have joy in my life). I wonder if this goes against my sleeping (I have too many awakenings during a night, to the point that a Somnologist has prescribed a CBT-I (cognitive behavioral therapy for insomnia) for me).

Anyone has some experience with it ?
Thanks,

Question,

What are you asking, about the Drug or about the CBT? Does your psychiatrist hold an MD? And what about your Somnologist who prescribed CBT, what designation he/she holds? I would not take any of those prescriptions and just focus on improving my sleep. About CBT check here: http://adventures-in-hosehead-land.blog ... r-insomnia.

[Goofproof]

Hi all,

A psychiatrist has prescribed Mirtazapine (half of a pill of 7.5 mg per day) because she believes I have a depression (I don't have joy in my life). I wonder if this goes against my sleeping (I have too many awakenings during a night, to the point that a Somnologist has prescribed a CBT-I (cognitive behavioral therapy for insomnia) for me).

Anyone has some experience with it ?
Thanks,

I didn't know they had a pill that gave someone "Joy in Life", I'll take a bottle, and please send me a bottle of "Eternal Youth" also, I have coupons. Make them large bottles. Jim


















'

[robysue]

Papzombie,

A good question is whether your psychiatrist and sleep doctor are willing to talk to each other about your problems. The combination of continuing sleep problems while on CPAP and possible depression mean that you may very well have two conditions that strongly influence each other:

Insomnia and fractured sleep can lead to a worsening of mood problems, including depression but it's also true that depression can cause or increase insomnia and fractured sleep.

Tackling both the possible depression and the insomnia problems at the same time may be necessary for you to really make progress in solving either problem.

You write:

A psychiatrist has prescribed Mirtazapine (half of a pill of 7.5 mg per day) because she believes I have a depression

and

The psychiatrist also gave me 3 choices

- Remeron (Mirtazapine)
- Trazodone
- Quetiapine

Mirtazapine is an antidepressant and it is usually "ramped" up from a starting dose to a therapeutic/maintenance dose over several weeks. Did the psychiatrist explain whether she wants you to ramp up the dosage over a several week period? Mirtazapine does seem to be effective at helping insomnia in people with depression and it apparently helps with excess nighttime wakes in particular in patients with depression and sleep maintenance insomnia. Mirtazapine is also apparently prescribed off-label for treating insomnia by some doctors. (https://www.sleepio.com/articles/sleep- ... and-sleep/)

Trazodone is an antidepressant that is frequently prescribed off label for insomnia. When used to treat depression, trazodone is titrated up from an initial dose to a therapeutic one over a week or two.

Quetiapine is an atypical antipsychotic and its on-label uses include treating schizophrenia or bipolar disorder. Low doses of quetiapine are apparently commonly used off label to treat insomnia, but there is some question as to the safety of this practice (https://www.ncbi.nlm.nih.gov/pubmed/22510671) Since the psychiatrist suspects that you have depression rather than bipolar disorder, a good question to ask the psychiatrist is why she believes quetiapine is an appropriate drug for you to be taking.

The upshot is that all three drugs are used off label to treat insomnia, and hence they may be worth a trial. It would be a good idea to run the idea by your sleep specialist before starting any of these drugs in my opinion.

It is also worth pointing out that CBT-I does not necessarily rule out the use of sleep medication---whether it be something prescribed on or off label for treating insomnia. In my own case, the PA who directed my official CBT-I back in 2011 prescribed a low dose of Ambien for me to take on an "as needed" basis to prevent me from having too many genuinely sleepless nights in a row. However, mirtazapine, trazodone, and quetiapine are all designed to be taken every day at the same time. And not taking them as directed can mess things up even more. So again it comes back to the need to run the idea of taking any one of these three medicines as a drug for treating the insomnia by the sleep doctor.

But it also comes down to whether you need or want to try one of these drugs as a way of treating the depression. The mirtazapine or trazodone might be useful in helping with both the depression and the insomnia. But only you can make the decision of whether you believe your depression is severe enough to warrant taking medication for it. It is worth talking to the psychiatrist about how long she thinks you might need to be on medication and how difficult it can be to wean yourself off the medication at some point in the future.

Finally you write:

To be honest, I am still looking to find more things to fix in my sleep, given my problems (quickly panic, quickly getting angry, anxiety disorder, hard to decide when the situation is a bit (just a bit) complicated, memory, concentration, ...), but the psychiatrist thinks that I am currently looking too much into sleeping disorders.

Am I biased too much into sleeping problems ? Or the fact that I post a question here guarantees that the answers are always sleep biased ?

I think you are dealing with a Gordian knot of problems. You are hoping that if you can somehow fix the sleep problems, then everything else will start to get better. But given the large constellation of interrelated problems, it may be impossible to fix the sleep problems without doing something to also fix some of the other problems that are undoubtably aggravating the sleep problems.

To put it another way: The psychiatrist is treating you for the panic and anxiety disorders and the anger problems could well be one way your depression may be manifesting itself. Depression is also known to cause problems with memory and concentration. And depression can cause sleep problems. But you also have sleep apnea and while CPAP has fixed the OSA in terms of preventing the apneas, your sleep has not improved as expected. In other words, if the only reason your sleep was bad was the OSA, then you probably would be sleeping better by now. So the question boils down to this: Is the insomnia being caused by the anxiety and depression and then worsening the concentration, memory, and anger issues? Or is the insomnia the root cause of the depression, anxiety, and anger? My guess is that the answer is not an "either-or" answer. My guess is that you might have some basic insomnia issues that are independent of the anxiety and depression, but that you also have some insomnia issues that are directly caused by the anxiety and depression.

And so I do think you need to realize that you may indeed be focusing too much of the "blame" for your daytime problems on the insomnia and that you need to consider the idea that some of the insomnia problems may indeed be caused by the depression and anxiety problems the psychiatrist is treating you for.

My advice would be this:

Make an appointment with the sleep doc to talk to him/her about the medication(s) the psychiatrist has recommended. Ask the sleep doc for some insight into whether s/he has any experience with any of these medications being used as sleep medications. Ask the sleep doc for advice: Would the sleep doc recommend any of these medications given your particular medical history in terms of what the sleep doc knows of your OSA, your CPAP therapy, and your on-going problems with too many arousals/awakenings at night. Ask whether it's worthwhile to do CBT-I while taking medication suggested by your psychiatrist.

Then make an appointment with the psychiatrist to talk about what you've learned from the sleep doctor. If you are leery about taking medication for your depression, talk about your misgivings, but don't couch the misgivings solely in terms of your sleep issues. Also bring up the anxiety and panic issues, as well as the anger issues and the concentration and memory issues. Ask whether the psychiatrist believes taking mirtazapine or trazodone might help with those issues and if so, why. And talk about the overall plan: How long does the psychiatrist think you might need to take the medication and how difficult will it be to wean you off the medication when it is no longer needed. And if you are very leery of taking any medication for the depression and/or anxiety, then also ask the psychiatrist about CBT for depression and anxiety. Sometimes CBT is enough to take the edge off these things so that you can once again concentrate and not feel so miserable during the daytime.

After all of that, take the time to seriously evaluate everything both doctors have told you about what they think about your situation. Evaluate what you are and are not willing to do in terms of non-drug therapy for the depression, anxiety, anger, and insomnia issues. And evaluate just how how good or bad your current quality of life is in terms of all of these problems and not just the insomnia. And then make an informed decision.

[49er]

robysue,

I don't disagree that depression can cause insomnia and fracture sleep but why not see if the CBT-I improves things first especially since it sounds like that is what papzombie would like to do?

Regarding Trazadone, that is rarely prescribed for depression. And as SpicedRum rightfully pointed out, Remeron, when used to treat depression, is precribed at alot higher dose, which would negate its effect as a sedating medication.

I vehemently disagree that Quetiapine, an antipsychotic is worth a trial. These drugs have horrible side effects, even at lower doses.

I supposed if someone tried everything on this earth to resolve insomnia and was unable to and their mental health was in severe decline, than maybe it would be worth a shot. But to suggest this at the beginning stages of things, makes me doubt the competence of the prescribing psychiatrist. And to suggest it for depression has me shaking my head big time.

Good advice about asking the psychiatrist how difficult she thinks it would be to wean off the drugs. If the psychiatrist thinks there won't be any problems, I would look for another provider. Way too many of them minimize these issues and as a result, that is why people end up on AD withdrawal boards.

49er

[robysue]

robysue,

I don't disagree that depression can cause insomnia and fracture sleep but why not see if the CBT-I improves things first especially since it sounds like that is what papzombie would like to do?

It is reasonable. If that is want papzombie really wants to do.

But CBT-I is also something that I think may or may not be enough. We don't know. And that's the real point that I'm trying to make: Papzombie needs to make sure that both docs know what the other is saying to do. It's not clear if Papzombie asked the psychiatrist about CBT-I.

Regarding Trazadone, that is rarely prescribed for depression. And as SpicedRum rightfully pointed out, Remeron, when used to treat depression, is precribed at alot higher dose, which would negate its effect as a sedating medication.

Both relevant. However it's also relevant that Papzombie has not told us whether or not the psychiatrist just wants papzombie to take the small dose (as an insomnina aid perhaps) without ramping up to a dose high enough to treat depression. Knowing more about what the psychiatrist intends would be useful

I vehemently disagree that Quetiapine, an antipsychotic is worth a trial. These drugs have horrible side effects, even at lower doses.

I supposed if someone tried everything on this earth to resolve insomnia and was unable to and their mental health was in severe decline, than maybe it would be worth a shot. But to suggest this at the beginning stages of things, makes me doubt the competence of the prescribing psychiatrist. And to suggest it for depression has me shaking my head big time.

If you read what I wrote carefully, I pointed out that recommending Quetipapine didn't make much sense to me either. Again, I recommended a long chat with the psychiatrist about why she is suggesting Quetipapine as an alternative. As to whether this is enough to question the competence of the psychiatrist, I'm not sure, but I agree that it's an early flag.

Good advice about asking the psychiatrist how difficult she thinks it would be to wean off the drugs. If the psychiatrist thinks there won't be any problems, I would look for another provider. Way too many of them minimize these issues and as a result, that is why people end up on AD withdrawal boards.

Yes. I agree completely. And that's why I brought it up. While I think that too many psychiatrists fail to mention weaning off antidepressants and antipsychotics, I also think that most patients fail to bring the question up with their psychiatrists in the first place.

In other words, 49er, I think you and I agree on more than not.

[Uncle_Bob]

I didn't know they had a pill that gave someone "Joy in Life"

Viagra

[Omne]

One thing to keep in mind is that Mirtazapine is also prescribed to increase appetites in chemo patients. Weight gain is a common side effect- about 17% IIRC.

[library lady]

I do have some experience with Mirtazapine... my doctor prescribed it for me at 15mg several years prior to my OSA diagnosis as a sleep aid, although it is an antidepressant. 15mg turned out to be too much for me, it made me feel funny in some way. I don't remember the details(7.5mg). That was a better dose for me, and to some extent it helped my sleep, though in the long run CPAP has proven to be better. I no longer take that med.

[papzombie]

Thank you all for your input, sorry that I am a bit late in responding to this.

Mirtazapine of 3.25 mg per day was prescribed, because (from my memory) the psychiatrist thinks it helps both my depression and sleep.

The sleep doctor presribed CBT-I, and this psychiatrist has asked my sleep doctor before giving me those 3 choices, I don't remember she said who prescribed the Quetiapine.

About weather or not I should try CBT-I before taking the meds, this psychiatrist told me that "I should not have a high expectation on CBT-I, because it's only about using the bed for sleep and sex, and go to bed on time, ....". But upon hearing that I thought she did not know enough about CBT-I.

I will have a phone talk with this psychiatrist tomorrow, and I will ask her "How long does the psychiatrist think I might need to take the medication and how difficult will it be to wean me off the medication when it is no longer needed".

Also I'll ask the sleep doctor which of the 3 meds he suggests.

I hope that I don't miss any important advice from you.

Thanks

[Therapist]

A psychiatrist has prescribed Mirtazapine (half of a pill of 7.5 mg per day) because she believes I have a depression (I don't have joy in my life).

I've never experienced depression, but I have many friends who have. Some of these took drugs, others did not. From everything I observed, this recommendation from Chicago Granny would be the route I would take if depression befell me:

In dealing with insomnia do you,

- Practice good sleep hygiene (Google it and read several sources)
- Eat a good diet
- Have a regular, moderate exercise program
- Try to avoid daytime naps
- Practice total abstinence of caffeine including sources like chocolate (sigh)
- Review all medicines, vitamins and supplements you are taking to make sure none are interfering with sleep
- Use the bedroom for sleeping (and sex) only, and make sure the bedroom and bed are comfortable.
- Learn to appropriately handle emotional stress in your life
- Do not listen to your breathing or the sound of the machine as you are falling asleep.
- Distract your mind by thinking of a pleasant, relaxing activity that you enjoy. Thinking of sitting under an umbrella on a quiet beach with a warm gentle breeze works for me.
- Use CPAP software, such as the free SleepyHead, to make sure your therapy is optimized
- If you still don't feel or sleep well, make sure you have regular medical checkups to confirm there are no other medical problems

CG

That's granny's recommendation for insomnia, but it is also an excellent treatment for mild to moderate depression and anxiety.

Sorry, Granny, I have seen you post this many times and hope you don't mind that I lifted it.