5 weeks on mirtazapine, up and down

Nigel, you are an angel to me, you have me reassurance before at 3 weeks when i was having a wobble, thank you so much for responding to me, i was feeling like it was failing because mirtazapine is supposed to work quicker than SSris? i had such a horrible experience with sertraline where i had side effects for 12 weeks, and no relief, despite other ssris working for me in the past, thats its made me think nothing is going to work now - just so spaced out much of the time it scares me, and im reaching for my lorazepam more than i would like - still no more than 1-2mgs a day, but there are days like today when i really need it, though last week i was much better, its difficult to find success stories on here, so your words mean everything xxxxxx

Hi Nigel,

I really hope you can help. I had an anxiety relapse in May 22 that I tried to get over using my usual regimen of Venlfaxine 75mg. I have been using Venlafaxine 75mg when needed for 10-11 years without much incident, where I could increase to Venlafaxine 75mg when anxiety episodes happened and reduce to a therapeutic level of 37.5 when they abated (generally after 8 weeks). This last episode didn't follow that pattern, and I have now been through, and I have since been on the rollercoaster of trying to find the right combo.

I have been on Venlafaxine 112.mg and Mirtazapine 30mg for eight weeks. This initially led to a remarkable recovery where I have been relatively anxiety free (80-90%) for this time. This week has seen a return to pre Mirtazapine symptoms (jitteryness, racing thoughts, brain fog). Its not helping sleep much nor is to giving me the carb cravings that I got used to.

Is it possible Mirt has stopped working after 8 weeks? Could I have developed a tolerance? Or do I need to give this a bit longer to see if its a blip.

Thank you in advance,

RT

hello,

Ive been on ven of 150 and mirt of 30 for 4 years or so now. As far as anti deps are concerned, its as good as it gets. ive fiddled with amounts slightly, but always returned to this dose. its nice to reduce dose for a short while, as it makes me feel better initially, BUT within a couple of weeks, it bites me in the ass, and i revert to my dose. i have recurri ng depression, so i have accepted that im on them for life.

i mention all this, as once you feel as good as you can, you shouldnt alter your dose/meds. if im being honest, going up and down on ven sounds crazy to me.

Sometimes when you make significant changes, 75 to 37.5 of ven would be significant, you cant get back to where you were.

ven and mert do work very quickly, if they are going to.

you might be going through a blip, lasting 2 or 3 weeks. i would be tempted to wait it out for 2 to 3 weeks and see.

one thing that jumps out, is the much higher dose you are now taking. you were taking say 1/3 of normal max ven dose of 225 (can be a lot higher if required, personally, from experience, no point in going higher on ven, you end up increasing to stand still. you are now taking more than that dose, plus an additional anti dep in mert of 2/3 of max dose.

ven doesnt effect norenphrine below 150, so acts as a seratonin re uptake inhibiter only.

mert works on seratonin and noradrenaline from the start/very low doses. high levels of norepenphrine

ive found myself do not work, they keep me too energised. thats why i think going higher than 225 on ven, doesnt work for me, and a lot of people.

given in the past your ven dose was acting soley on seratonin.

if i was in your shoes, and knowing how well ven and mert work together, if i didnt get over the blip, i would reduce mert by 7.5, see what happens for 3 or 4 weeks, if no better, reduce mert by another 7.5mg', to 15mg.

judging by your previous ven dose, think 15mg of mert would work better.

rational in reducing mert dose, is a reduction in norepinphrine effect. 30mg of mirt, ought to be knocking you out at 30mg. its not, so think theres a chance your doses may be too stinulating.

show this to your dr or pysch, to get their opinion.

if you did make any changes in dose, give it at least 4 weeks.

you will find your dose levels eventually. when you do, i wouldnt change, even if you do feel better. the mert hasnt stopped working by the way, its still doing what its designed to. as youve felt better, you will have taken on more responsibility, which will cause stress. have a feeling the mert dose is too high, and gradually its started stimulating you too much, which has gradually built up. the faxt that it initially worked well, suggests the combo is right for you, its just the dose/doses.

wanted to add. its not been plain sailing for me. i had 2 smaĺl relapses myself in last year. after approx 3 to 4 weeks, it stopped. each caused by a different stressful situation. i didnt panic, stayed on same meds/dose, and came through them. each one no longer than a month, and returned to better state.

Thank you so much Nigel. This has been very insightful.

I have suffered with anxiety ever since my diagnosis with MS in 2005. I sought anxiety treatment after a particularly bad relapse in 2011 and was started on Ven 75. It took 8 weeks to get back to 100% normality and I was advised to come off Ven. I struggled to do so and ended up keeping a maintenance dose of 37.5. I have had probably 7-8 anxiety episodes between 2011 and 2022 and have adopted the same process with positive results. The change happened in May 2022 where I had two back to back anxiety relapses following Covid (a weird occurrence given my Covid symptoms were very mild). I had a anxiety relapse even though I was on Ven 75. I attempted to increase my Ven to 150mg however had to settle at 112.5mg as 150 was giving me ectopic heart beats (a known side effect apparently). I have since tried to find a combination therapy - have tried Ven and Quetiapine that worked for a bit then stopped before starting a combo of Ven 112.5 with 30mg Mirt. I was started at this dose as the psych thought the 15mg Mirt might be too sedating. This combo worked immeadiately, with a two week blissful window of 0% anxiety followed by 6 weeks of 80-90% reduction in anxiety, great sleep and eating very well. This week has been a tad strange in that I have returned to a pre-Mirt position both in terms of anxiety and lack of sleep and appetite.

I take your point on not changing too much, and seeing things out. I do however think my Mirt dosage might be a tad too high and will ask my Psych on Wednesday if he thinks reducing this is a good idea.

Thank you again for listening and providing such considered advice.

Thanks,

i think ven and mirt suit you, because of your initial positive response. i know someone else that was responding, until their pysch upped the mirt dose. if your pysch didnt do 15 mg, because too sedative, that supports idea of 30mg being too activating, in hindsight. this would be due to the higher amount of norpenphrine. its a balancing act. sometimes more norepinephrine works, in my case 30mg works. i got up to 375 on ven, before i did the combo. each small ven increase initially worked, but after a month or two, would relapse into anxiety. increasing to stay still. happens to most ven users, due to ever higher norepinephrine. it motivates to a degree, but doesnt take much to go too far. it can easily be too energising. i did try 37.5 mirt, made me too anxious.

Not sure this helps. like i said, for me my dose is as good as it gets. not ideal. saw a few articles on news about micro dosing. found someone who does it. tried it myself for last 2 weeks. it works very well. take it in addition to anti deps. loads of info online. couldnt find info about taking both. just went ahead. did lots of research, nothing definitive yet, though current research suggests it works. i take 0.5 grams at moment, every other day. relaxes me, without drowsiness.

have found gentle swimming early evening works well. has to be calm, as you dont want to produce adrenaline.

Hi Nigel,

Spoke to my psych who didnt think going down to 15mg would be a good idea yet due to the sedation effect. I am now at the 2 week mark of feeling like I'm back to square one/pre Mirt levels in terms of anxiety symptoms. I am thinking of giving it another week before dropping to 15mg and giving that a try for 3-4 weeks.

Thanks for your help

RT

my own experience is that 30mg is more sedative that 15mg. i need the sedation that 30mg gives. i tried numerous times to drop to 22.5mg and 15mg. i feel better, more clear headed waking up, and more motivated for a week, then i get too anxious/hyper and cant sleep, and have to go back up. its the opposite to what your pysch thinks ?? i think he is possibly getting mixed up by the fact that mirt up to 15mg is used as a sleeping tablet, for people that have MILD anxiety. it wasnt designed for this use, but it is a good and safe solution to be used in this way. from what i have consistantly have found, the higher the dose, the more sedative. i believe mirt is less successful over 30mg, like ven over 225mg. why is your psych worried about you being too sedative at 15mg? as you currently cant sleep. by his logic (which i dont agree with), i would have thought being more sedative would be good? lots of people on here find going above 30mg, doesnt work, as the higher norepinephrine makes them manic/hyper. norepinephrine is generally better for more severe depression, than anxiety, as its stimulating. ven works as a ssri at 150 and below. above 150, ssri effect is maintained, but snri action kicks in. mirt is a snri from lowest dose. no one knows precisely how they work, they have a vague idea. to me, 30mg worked well for 8 weeks, but as you got better, you gradually got more stimulated, from the snri effect. above 150mg of ven, all acts on norepinephrine (seratonin gets maxed and remains constant). i kept on increasing ven above 150mg in 37.5mg increments. would work for a month or 2, then id have to go up, and repeat. happens to most people going above 225mg. people end up on very high doses, to maintain same level of recovery. mirts ssri and snri effects are linear, both get increased as you increase dose.

Thanks Nigel.

I am at 12 weeks of 30mg Mirt and 112.5mg Ven and think I have now reached a plateau. Anxiety is levelling out - not awful and I can manage it without having to take Lorazepam. Wondering if I should change to a lower dose of Mirt to see if that works for me? Cant go up on Ven as I get ectopic heartbeats so the only option is to reduce the Mirt and see how I get on. I might try and go down to 15mg straight as I havent been on Mirt for that long. Interested in your views on this as an option.

Thanks,

RT