Today’s clinical pearl comes from Nicholas Goodwin, DNP PMHNP who recently collaborated with Elite NP on our two new psychiatric based courses. In this blog, we discuss the role of Mirtazapine in the regulation of sleep and circadian rhythms.

Should Mirtazapine be used regularly as a sleep aid?

When it comes to treating insomnia, finding a medication that provides quick relief can be a challenge. Especially when the go-to remedies have failed or have not been tolerated well (i.e. Trazodone, hydroxyzine, melatonin etc). There are also some good reasons to avoid the potentially addictive sleep aids like zolpidem or benzodiazepines.

Mirtazapine is an antidepressant that can produce sedative effects, which can make for a good sleep agent. Before treating sleep issues or insomnia, providers should first address root causes of a patient’s insomnia. In my practice, I often see insomnia as a symptom of a mood disorder, rather than a disorder itself. But other common physical causes like sleep apnea, restless legs syndrome, and vasomotor symptoms should be screened and ruled out as well.  Sometimes, the insomnia is primary and does not seem to have any originating issue.

For people with depression and insomnia, Mirtazapine can be a great choice as it is both therapeutic and sedating at 15mg. A provider can treat a patient’s depression and insomnia with a single medication.  However, Mirtazapine has a significant number of side effects. Because of this, I suggest closely monitoring patients while prescribing this treatment regimen, and do not recommend it for a first line of treatment.

Benefits of Mirtazapine

Mirtazapine produces antidepressant effects at doses of 15mg +. Most guidelines put Mirtazapine as second or third line treatments for depression, but for the right client, first line may be considered. This medication also produces sedating effect at doses of 7.5+, but seem to remain sedating even at 45mg.

Mirtazapine is also a powerful antidepressant augmenter. A combination of venlafaxine and mirtazapine is coined “California rocket fuel”. This medication also has a lower risk of sexual side effects, and can even be completely neutral for sexual side effects in comparison to other SSRI/SNRIs. Mirtazapine can also function as an anti-nausea agent. This is ideal as nausea is a common side effect in psychiatric medication, which can be a deterrent for people interested in medication depression management.

This medication can treat akathisia and drug induced akathisia. Akathisia is a potentially dangerous and uncomfortable movement disorder (not at higher doses). It is also a potent appetite inducer for underweight clients, clients with anorexia, or clients experiencing appetite suppression from other medications.

Downsides of Mirtazapine

Mirtazapine may be too sedating. Unlike trazodone, Mirtazapine seems to be as sedating at every dose, which can sometimes be too much. I have had clients tell me they slept over 24 hours on it. The sedation can lessen with time, but may take weeks. Many clients are not ok with this.

This medication is also appetite inducing. This is often the first thing clients tell me: “I don’t want a medication that causes weight gain”. As far as meds that cause weight gain, Mirtazapine is close to the top. Weight gain can further increase the risk of metabolic syndrome and diabetes. Therefore, Mirtazapine is probably only an appropriate first line for some clients, and not usually for any non-mood disorder treatment (insomnia, nausea, akathisia) due to this risk.

Due to its potent antidepressant effect, especially in combination with another antidepressant, activation can be a risk as well. I used Mirtazapine in a client with severe depression in addition to venlafaxine. She felt great and stopped needing to sleep.  And went almost a full week with 0 sleep.  Which is the opposite of what I usually see. It subsided when she stopped, and no other manic symptoms were assessed. It should also be noted that Mirtazapine has the potential to cause suicidal ideation in patients under 24 years old.

How to dose

I always start at 15mg! 7.5mg can be effective for insomnia. However, this is not an effective antidepressant dose. I am mostly using Mirtazapine to treat depression with insomnia, and feel that unless other specific issues exist, the risk of Mirtazapine does not justify its use for insomnia treatment alone. A 30mg starting dose is tolerable, and is what some sources recommend. It has the potential to cause an increase in AM tiredness.

Key takeaways

Mirtazapine can help with insomnia. Due to the weight gain and suicidality risk, Mirtazapine is not considered first line unless other existing conditions that may benefit from it exist: depression, akathisia, anorexia, etc. With clients who have depression mixed with sleep disturbance, I still usually use an SSRI + a sleep aid before considering Mirtazapine. I have seen lots of people recover and remit due with the help of Mirtazapine, and this medication can be a great addition to your medical toolkit.

For a plethora of additional clinical pearls, check out the new “Clinical Psychiatry for the Nurse Practitioner Course”, or if you are interested in starting your very own mental health clinic, check out the other psych course “How to Open a Psychiatric Practice Course” which will walk the nurse practitioner through the steps of opening their very own psychiatric practice.