Globus, Mirtazapine and Libido

I'm a 49 year old male. 18 months ago my doctor suggested I try anti -depressants to control symptons of anxiety. At the time I was feeling quite low and dissillusioned, although I wouldn't say I was depressed. I have had panic attacks over the years since my early teens so I guess I am prone to being at the mercy of my mind despite my best efforts to control it. Panic attacks were not frequent - they seemed to arrive about every 7 years and effect me on and off for a couple of weeks - the first one on each occasion being the worst, which would build gradually and then completely floor me for twenty excruciating minutes before lifting. In recent years though more constant anxiety symptons seemed to have taken the place of the panic attacks. These were numerous - classic and extreme vertigo, nausea, sharp (but not agonising) chest pains, fatigue, heart burn ( for which I have been taking 20 mg of Omeprazole daily for the last 6 years), indigestion and feelings of suffocation. Shortly after a family bereavement I started to suffer from Globus Sensation (the feeling of something trapped or lodged in the throat), and it was only with this that a doctor I was seeing at the time felt that everything I was experiencing was down to anxiety. I was offered councelling - which I accepted - and it helped to a certain degree, but the numerous symptons would always come back. I should say that I am also asthmatic so Globus Sensation and the associated suffocation feeling can make it hard to know exactly what is happening and what is the best remedy. Just the act of breathing becomes the all consuming thought. Also I fully accept that a combination of ashtma and globus can lead to a lot of worry which in itself spirals and the anxiety of that only makes globus worse. Sometimes for up to an hour my mind gets the worst of me and it's only afterward when the globus sensation has lessened that I can look at things more realistically. Because of the globus I decided to try an anti-depressant after my new doctor suggested it. I reinterate that I was not feeling depressed but wanted to get on top of the physical symptoms of anxiety - which increasingly felt like they were ruling my life, making me withdrawn and also rather self possessed. I suppose that was enough to make me feel low - being less connected with friends etc, but I really didn't ever feel like harming myself or anything like that. The first anti-depressant I tried was Sertraline. I had some fairly severe side effects in the first couple of weeks - disorientation, nausea, nightmares, sweats, but it did settle. However after just a few days it created a sexual disfunction in that I could not reach orgasm. I stayed on the drug for about 3 months though. In all that time the sexual disfunction remained. Friends however, did appear to notice an improvement in my mood and my ability to engage with them again. Unfortunately I could not live with the side effect and my doctor said there were other options that were less likely to effect sexual function. After tapering off of Sertraline and a short period without any antidepressant I started Mirtazapine. First at 15mg, moving up to 30 mg after a few weeks. There were no evident side efects. When asked if I felt any positive effects after 3 months I could not honestly say I felt any different. My doctor pointed out though, that I might notice the difference If I stopped. Unsure of this I said I was willing to carry on seeing as I didn't feel that there were any negative effects. I have now been on Mirtazapine for close to a year, I still get globus, the odd chest pain and heart burn (if I neglect the Omeprazole). The problem is, that very gradually I have reallised I have had a loss of libido. With Sertraline the effect was so immediate and frustrating (failing to reach orgasm) that it was very obvious. With Mirtazapine the ability to achieve orgasm is still there, but a slow decline in interest has become increasingly evident. I had wondered if this was just a natural state of affairs for a man approaching 50, so I did see my doctor about this. She assured me that there was no reason that my age should play much if any part in a lack of libido and she suggested a blood test to check on my level of testosterone. The result came back at '9' - low testosterone is considered 1 to 8, normal is considered 9 to 18. So my testosterone is at the low end of normal. I am now being referred to a specialist in male sexual health who will consider whether the Mirtazapine is the cause of my lack of libido. I have never been tested for testosterone before this so I don't know what my level might have been previously, but I'm guessing that as it is something I myself noticed and brought to the attention of my doctor, that my testosterone was higher before. It's not just libido, it's my passion for everything in life feeling less acute. 

I am giving serious consideration to stopping the Mirtazapine for, as stated above, many of the anxiety symptoms remained anyway. My doctor is concerned that coming off of anti-depressants might put me into a more depressed state, or that my anxiety might get the better of me to a far more crippling degree than before. I will wait for the specialists opinion but I am hoping that I can taper off of Mirtazapine without major withdrawal problems - I live alone so I'm a bit worried that if I do have a depressive reaction to coming off of the drug there's nobody around to talk me around or reassure me. If I can come off it without too many problems I think I will still have benefitted from the fact that it may have helped me look at the wider view around the things that cause my anxiety - even if many of the symptoms remained. I have to say though that I have never really found it easy to work out what does cause me anxiety - I always thought I was quite laid back and not up-tight at all and often it's only months after that I can look back and see that things I felt I was coping with were in fact knawing away at me little by little - giving me this now almost constant globus sensation in place of the infrequent but dramatic panic attacks.

I have agreed to try Cognative Behavioural Therapy as an alternative option - although my lack of passion and enthusiasm, and natural cynicism might be a big stumbling block there.

If anyone has experience of lack of libido or a decrease in testosterone through taking Mirtazapine I would be grateful for any further insights. Ie, do you put lack of sexual drive down to depression/anxiety or the antidepressant drug?

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