Mirtazapine alternatives? Feeling terrible

[dunant173]

I've posted this post in a reply to Mirtazapine post but wondered if anyone could share any thoughts or experiences as I'm getting desperate.

Most of my life I've been on SSRIs for various anxiety/depression episodes and they control it for a while and then they stop being effective. I have had counselling and CBT, too, so I've gone down that route - I think I am unfortunately just 'wired' this way. Depression runs in both sides of my family.

Recently, after suffering more with anxiety, my GP suggested I try Mirtazapine instead of another SSRI (I have tried most, to be fair). So, before Christmas, I cross-tapered from Escitalopram (10mg, then 5mg) to Mirtazapine (15mg). When I was taking both, I felt pretty good. When I stopped taking the Escitalopram, I started experiencing sudden dizziness - I wasn't sure if that was from coming off of Escitalopram or from side effects starting Mirtazapine. Occasionally, I will get a really violent dizzy spell for a couple of seconds and then be fine again so I am not concerned about it really.

However, I am having a terrible time with my mental health. Soon after I went 100% on mirtazapine, I noticed the intrusive thoughts I was experiencing on Escitalopram trying to nudge their way into my consciousness again. Just brief things and I put them down to post-Christmas fatigue, etc. But they have got gradually worse and distressing. Changing from Escitalopram to Mirt was to try to stop these thoughts but by God when they hit it's bad. Today has been horrendous.

I mentioned this to my GP two weeks ago on a phone consult to review the meds. He sounded totally disinterested and said, "Well, you could just stop taking Mirt because you've not been on it for long" - but offered no other solution. Like he'd just given up treating me. When I said I wasn't necessarily saying I wanted to stop it (my sleep has been excellent on it and I have had more energy in the day - though this might be from stopping the Escitalopram) he then said I could just "experiment" with halving the Mirt to 7.5mg to see if that worked better and then told me to book another review when I felt like it and that was that!

The next day I had a massive panic attack. I was upset because I was on new meds and felt I had no medical back-up there. I ended up calling an online GP service for a second opinion. The GP was kind and told me that the dosage I was on for Mirt (15mg) was the equivalent of being on 5mg of Escitalopram and that it was likely that I needed an increase. My GP the previous day refused that - said he didn't think we should go up. So the phone GP said I could try a little longer to see if things level out because it's hard to know at the moment if I am still getting withdrawal effects from the Escitalopram or side effects from the Mirt. But he was pretty sure I'd need to go up to 30mg.

I am just so exhausted. I am getting really terrible anxiety and then depression and am struggling to cope now - veering between such dreadful anxiety that I feel I cannot go on and get urges to hurt myself and then crushing depression that makes me feel I can't bear the sadness of life. I've eventually submitted an e-consult request and am supposed to be speaking to my GP at some point today but am scared I'll face the disinterest I experienced last time - made me feel like a hypochondriac or a nuisance. I don't want to feel this way - if I could be drug-free and happy I would obviously take that!

Has anyone experienced this on this medication? Have any other meds been better? I wish I could speak to a psychiatrist to try to get to the bottom of this - I think my father had bioplar disorder though it was never officially diagnosed, and I wonder if I am the same. I just don't understand why things continue being difficult and meds and counselling haven't worked. Paying for private psychiatry just isn't an option, financially.

I am not an expert by any means but I have been on Mirtazapine for many years, I did increase my dose a few months ago due to not doing well due to Covid, house move and cat dying. The increase to 30 mgs has really helped me

Sounds to me like withdrawal from the SSRI I would think and maybe the Mirtazapine needs more time or increase in dose

I take 30mgs at night now. I have never tried an SSRI though

From research, Mirtazapine is a long acting drug and takes a good 12 weeks to build up in your system to have a therapeutic effect

My dh couldn’t get on with it at all, just made him put on so much weight and he wanted to sleep all the time (he has severe depression and bioplar episodes). They switched him to Citalopram and that’s been much better for him, although he needs it at a fairly hefty dose 40mg. He’s been on that around 5 years now and it’s been life changing for him. He’s was previously on Sertraline and Prozac but felt they made him too hyper and anxious. Citalopram seems to calm him down. He expects (and wants) to be on it for life.

Thank you for your replies. I am sorry to hear about your recent stressors. Like you, I have recently had a build-up of events that haven't helped - health scares, Long Covid, cat dying and then lost my job. I guess it's not surprising that I get down but it's the overwhelming nature of what I am experiencing - I just can't bear it. I will see what the Dr says whenever he calls. I really wish this had stayed being helpful as at first I felt so much better but now I feel absolutely terrible.

I admit that the weight gain worries me, too. I worked hard to lose 17kg and am fitter now and eat well but I've put on 3kg which has upset me as I am not eating more and exercise every day.
I took Citalopram in the past and Sertraline. The latter for postnatal depression. I seem to go on these SSRIs and get on OK and then get used to them and then it's a search for another one. But, apart from the sleeping side of things, I don't think the Mirt. is really helping me at all. It's such a shame as I felt really good when I was cross-tapering.
I am glad your husband has found something that works - it's a Godsend.

So sorry if you already mentioned in your post, my concentration is crap, but why can’t you just keep taking them both if that worked for you? I find mirtazapine is a life saver for me but not on its own, I need Effexor in the morning to balance it out. On its own it makes me sleep but does nothing for my mood at all other than from not having insomnia anymore.
I do actually have an unusual presentation of bipolar disorder that was misdiagnosed as depression at first. Look up the symptoms of dysphoria/ mixed state bipolar/ cyclothymia and see if any of that sounds familiar then go back to the gp (a different one if at all possible, your current one sounds terrible).
It’s very common to be on more than one medication anyway. It’s called a “cocktail”.
I used to be on a very small dose of an antipsychotic as well and it worked very well for intrusive thoughts/ racing thoughts.
Do you know that when you go up on mirtazapine you can lose the sedative effect (so it may not help with sleep anymore)?
fwiw I think it’s a good medication. It has a bad reputation for the weight gain but I think once your mood is stable it is possible to manage the weight gain on it.
Unfortunately most GPs don’t really know what they’re doing once the go to SSRIs aren’t working but it’s so difficult to get in front of a psychiatrist these days. I really hope you get sorted x

yes, I agree, re-reading your post, why cannot you try both meds at the same time if it was helping? My GP has mentioned in the past about the possibility of adding another smaller dose of something extra if needed in future

I really sympathise OP, it's so hard to find the correct treatment when the usual ' go toos ' don't work for you. I agree that most gps opt for ssris, which for some of us really don't work and cause more anxiety and agitation. I'm one of these people. I'm currently on mirtazapine at 30mg and have been taking for nearly four months now and I've had a very weird journey on them. At first they worked really well for sleep but did nothing to tackle the racing thoughts and anxiety. But around week 3 I started to feel great, as if a magic eraser had wiped all my feelings of depression, insomnia and anxiety and I honestly felt amazing! Come week 7 the anxiety and racing thoughts and heart palpitations were back - this lasted for a month and I was ready to give up. Then the depression took hold, I literally couldn't stop crying and every negative, horrible event in my life played on a loop in my mind and I was extremely low. this brings me to now at the nearly 4 month point where the depression and anxiety lifted three weeks ago- not depressed, not overwhelmed with anxiety, just numb which is far preferable to the low moods. I don't feel great or happy but the feelings are dialled down and I feel more removed from the anxiety. My sleeps unfortunately gone to shit again though. It's a very odd drug and Tbh I'm not sure this is the usual trajectory of how an antidepressant should work. Like you, I question whether I have a mood disorder such as bipolar and need another type of medication to level me out. But it's all guess work because psychiatrists need to diagnose that and not a gp and it's impossibly to see one without going private. I do feel for you and hope it gives some comfort that there are others out here going through the same thing.

Thank you for your reply - I will look up the condition you mention and see if it could fit.

I wish I could take Lexapro/Mirtazapine as I felt good on that but my GP doesn't seem keen and did not offer it as a possible way forward so I thought it wasn't allowed (serotonin syndrome). He did mention introducing Venlafaxine if the increased dosage doesn't work but I tried that once in the past and felt awful on it so I definitely do not want to do that. @TheGiantMillipede thanks for your comment - explanation here as to why I am not on both - I would definitely consider it but it wasn't offered.

I am hoping I won't gain too much weight - have been eating normally and exercising every day so fingers crossed that won't be too much of an issue. At the moment I would take feeling better over anything else.

Gosh, I am so sorry to read this. What an awful time you have had on this. TBH I feel terrible today - I know it's early days for going up but I am having a very physical reaction to my anxiety, bordering on wanting to self-harm, which is not me. I am terrified to be alone too with my thoughts. I cannot see myself sticking this out - I would rather have the anxiety and depression at normal levels on an SSRI than this. It's hell. The only saving grace is the sleep - I had forgotten how long I had gone without sleeping well - but if I wake up and feel this desperate I cannot continue. I really hope you find the solution; it's awful that such serious moods etc are treated so lightly, as if doling out candy!

When mirtazapine didn't work for me I was given duloextine which helped a lot.

Is that an SNRI? I tried Venlafaxine years ago and it made me very jittery and ended up coming off of that. I feel useless - nothing seems to work.

Mirtazapine made my sister fat and miserable so she switched back to sirtraline and lost loads of weight and was so much happier.

I was on sertraline for years 200mg but didn't like how 'numbing' it was as it cancelled all emotions completely. I had 18months off then a difficult work environment, double and sudden bereavement plus lots more sent the anxiety and depression off again. I've just started Trazadone at a low dose - have you thought about this option. So far, I've tolerated it reasonably well. Really good luck, it's horrid to struggle like this.

I am sorry to hear you have been having such a hard time. I've had a series of difficult life events over the past two years and I think they just got on top of me. I was already taking escitalopram to deal with them but it wasn't working well and an increase to 15mg from 10mg made me feel worse. I tried sertraline 22 years ago after the birth of my daughter (PND) and I can't quite remember how it made me feel. I took it for about a year, had counselling, and stopped. Nothing miraculous but not like this at least. It must be weird having that numb effect though. I haven't been offered or told about Trazadone - thanks for the tip. I hope you feel better soon! I hate this - it's bad enough feeling bad but to feel worse is just awful.

Yes I think it is an snri, but I'm not sure that means you'd have bad side effects with it? I went through quite a few SSRIs before and only had noticeable side effects with two and problematic side effects with mirtazipine only. Mirtazapine also helped but duloxetine has helped me much more.

I take it for anxiety & depression - both were severe but gradually improved. Also propranolol for anxiety which helps a lot.

Have you tried both escitalopram and citalopram?