What are the mirtazapine alternatives?

In this blog post, we are going to talk about mirtazapine alternatives. Mirtazapine is an antidepressant which is used to treat a variety of mental health conditions. 

However, some people may not be able to tolerate mirtazapine well which makes the treatment with this antidepressant unbearable. This is exactly why we are here to discuss some other options if mirtazapine does not work for you. 

What are the mirtazapine alternatives? 

Some other antidepressants that can be used as mirtazapine alternatives include:

• Selective serotonin reuptake inhibitors (SSRIs) 
• Serotonin-norepinephrine reuptake inhibitors (SNRIs) 
• Tricyclic antidepressants (TCAs) 
• Monoaminoxidase inhibitors (MAOIs) 

Selective serotonin reuptake inhibitors (SSRIs) 

SSRIs are the most commonly prescribed antidepressants and are used as a first line of therapy. Several research studies have named this class of antidepressants the ‘safest class’. 

Experts believe that SSRIs are the easiest of antidepressants and are usually tolerated well by people. However, no medication is a magic pill, especially drugs that can change the chemical composition of your brain. Examples of SSRIs include:

• Zoloft (Sertraline) 
• Lexapro (Escitalopram) 
• Celexa (Citalopram) 
• Paxil (Paroxetine) 
• Prozac (Fluoxetine) 

SSRIs, as their name indicates, is a serotonin specific antidepressant. They work by inhibiting the reuptake of serotonin from the synaptic cleft back to the presynaptic neuron, which released this excitatory neurotransmitter in the first place. 

SSRIs do that by blocking serotonin transporters (SERT) which are responsible to move serotonin back into the neuron. This results in increased amounts of active serotonin in your body which binds to its respective receptors present throughout the body. 

Serotonin is a neurotransmitter responsible for modulating mood, cognition, reward, learning, memory, and various other psychological processes. 

SSRIs are not just used for the treatment of anxiety and depression, but they are also used to treat several other mental health conditions including obsessive compulsive disorder (OCD), social anxiety disorder (SAD), post-traumatic stress disorder (PTSD), eating disorders and premenstrual dysphoric disorder (PMDD).

Several experts believe some SSRIs are safer than the others. One study suggests that escitalopram and citalopram have a better efficacy and tolerability profile, as compared to sertraline (zoloft) and paroxetine (Paxil). They are better tolerated by people and are often considered the safest SSRI. 

Like every other class of antidepressants, SSRIs are also associated with some side effects. The most common side effects include:

• Nausea 
• Vomiting 
• Diarrhoea or Constipation 
• Acid reflux or heartburn 
• Abdominal pain 
• Loss of appetite 
• Weight gain or loss 
• Excessive sweating or night sweating (nocturnal/night hyperhidrosis) 
• Frequent urination 
• Polydipsia or excessive thirst
• Tremors 
• Muscle twitching and pain
• Drowsiness 
• Dizziness 
• Excessive tiredness or fatigue 
• Insomnia or inability to fall asleep 
• Xerostomia or dry mouth 
• Dysmenorrhea or heavy periods
• Flu like symptoms including irritation in eyes and runny nose
• Loss of libido in both male and females. Males may suffer from inability to ejaculate, while females may suffer from inability to have an orgasm. 

SSRIs are also associated with some serious side effects, which may include:

• Allergic reaction associated with symptoms like redness of skin, itching, burning sensation, blisters, blue-purple patches, tightness of chest, wheezing, difficulty in breathing, hoarseness etc. 
• Auditory or visual hallucinations 
• Nose bleeds
• Severe headache
• Arrhythmia or abnormal heartbeats
• Impaired memory and concentration 
• Convulsions 
• Swelling or tenderness in different parts of the body.

Make sure you do not overuse these meds. SSRIs come with a suicidal behavior in users younger than 24 years of age. If you have someone who shows suicidal behavior or you see hopelessness in them, make sure you keep an eye on them and get medical attention as soon as you can. 

Serotonin-norepinephrine reuptake inhibitors (SNRIs) 

SNRIs are another class of antidepressants which can also be used for several other mental health illnesses. These antidepressants have a broader spectrum of fighting against the symptoms associated with depression. 

This is because they do not inhibit the reuptake of one, but two excitatory neurotransmitters. It inhibits the reuptake of both serotonin and norepinephrine by blocking SERT and NET respectively. 

Norepinephrine is another excitatory neurotransmitter which is responsible for a number of physiological functions including breathing rate and blood pressure. 

SNRIs can also be used as a first line of treatment in some patients and are considered quite effective in the treatment of depression and several other mental health conditions. Examples of SNRIs include:

• Effexor (Venlafaxine) 
• Pristiq (Desvenlafaxine) 
• Ixel (Milnacipran) 
• Fetzima (levomilnacipran) 

Like every other class of antidepressants, SNRIs are also associated with some side effects. The most common side effects include:

• Nausea
• Vomiting 
• Abdominal pain 
• Sleepiness or somnolence 
• Fatigue or excessive tiredness
• Muscular pain
• Joint pain 
• Nightmares 
• Insomnia or inability to fall asleep 
• Headaches 
• Loss of appetite 
• Weight loss
• Tremors
• Excessive sweating 
• Diarrhoea 
• Acid reflux 
• Tinnitus 
• Mydriasis
• Infections including sore throat, ear and eye infections etc. 
• Bad or metallic taste in mouth
• Loss of libido in both male and females. Males may suffer from inability to ejaculate, while females may suffer from inability to have an orgasm. 

SNRIs also cause some serious side effects. These include:

• Allergic reactions associated with symptoms like redness of skin, hives, itching, burning sensation, blisters, blue-purple patches, tightness of chest, wheezing, difficulty in breathing, hoarseness etc. 
• Irregular heartbeat or arrhythmia 
• Convulsions 
• Chills and fever with confusion, hallucinations and inability to recognise one’s surroundings. 
• Impairment of motor coordination 
• Coma

Tricyclic antidepressants (TCAs)

Tricyclic antidepressants (TCAs) are another class of antidepressants, but they are not used as a first line of therapy. They once were, but TCAs are associated with a number of side effects and this is why it is not suitable to use this class unless absolutely necessary. 

These agents work by inhibiting serotonin and norepinephrine transports, SERT and NET respectively. This way they can help increase the amounts of excitatory neurotransmitters in your system and cure your depression. 

The reason why TCAs are associated with disturbing side effects is the ability of this antidepressant to bind with several other receptors in your body. One study suggests that TCAs have much more affinity for other receptors including cholinergic receptors. 

The more they bind to different kinds of active sites, the more side effects occur. Examples of TCAs include:

• Elavil (Amitriptyline) 
• Pamelor (Nortriptyline) 
• Tofranil (Imipramine) 

TCAs are associated with the following side effects:

• Painful urination 
• Dry mouth or xerostomia
• Gastrointestinal side effects, including nausea and vomiting 
• Weight gain
• Vertigo 
• Drowsiness or extreme fatigue 
• Constipation 
• Abdominal pain
• Enlarged breasts
• Heartburn
• Excessive sweating 

In severe conditions, TCAs can cause an allergic reaction, associated with painful rash, redness, pus filled blisters, itching, eczema, and burning sensation etc. They can also cause suicidal behavior in people older than 24 years of age. 

The effects of TCAs are unpredictable, because of their affinity to bind with multiple receptors. This is one of those drugs which are not that easily tolerated by a majority of the population. 

TCAs can significantly cause QT elongation which can result in deadly arrhythmia. This class of antidepressants is well known for its cardiac toxicity. It can cause sudden cardiac arrest and death upon overdose. 

Monoaminoxidase inhibitors (MAOIs) 

Monoaminoxidase inhibitors (MAOIs) are another class of antidepressants, which are also not used as the first line of therapy. These agents work by inhibiting the enzyme monoaminoxidase which is responsible for the breakdown and metabolism of serotonin and norepinephrine. 

This results in increased amounts of these excitatory neurotransmitters which counteract the symptoms of depression. Examples include:

• Nardil (Phenelzine) 
• Marplan (Isocarboxazid) 
• Emsam (Selegiline) 
• Parnate (Tranylcypromine) 

MAOIs are associated with the following side effects:

• Lightheadedness 
• Drowsiness 
• Nausea 
• Vomiting 
• Diarrhoea 
• Constipation 
• Heartburn 
• Abdominal pain 
• Flatulence 
• Insomnia or inability to fall asleep 
• Muscular pain
• Joint pain
• Fainting 
• Depression 
• Discoloration of skin
• Headache 

Some serious and rare side effects include:

• Allergic reactions associated with symptoms like redness of skin, hives, itching, burning sensation, blisters, blue-purple patches, tightness of chest, wheezing, difficulty in breathing, hoarseness etc. 
• Arrhythmia or abnormal heartbeats 
• Convulsions 
• Hallucinations 
• Visual changes 
• Excessive sweating 
• Muscle stiffness 
• Tremors

Conclusion 

In this blog post, we have discussed mirtazapine alternatives. Your doctor may prescribe SSRIs, SNRIs, TCAs, or MAOIs. Make sure you do not take any of these antidepressants without your doctor’s approval. In case of overdose, immediately reach out to the hospital. 

Make sure you properly guide them about how much drug you have taken and when. If you have missed a dose and you’re way past the usual time at which you take your med, do not take it. It will cause you to overdose when you take your next dose, which is not too far away. 

It’s better to skip the missed dose and take the next one. If you remember your missed dose earlier, it’s safe for you to take it.

FAQs: mirtazapine alternatives

Is there a better antidepressant than mirtazapine?

Mirtazapine is a good antidepressant, but not everyone can tolerate it. There are other antidepressants that can be used as mirtazapine alternatives, if this antidepressant does not work for you. These include:

• Selective serotonin reuptake inhibitors (SSRIs) 
• Serotonin-norepinephrine reuptake inhibitors (SNRIs) 
• Tricyclic antidepressants (TCAs) 
• Monoaminoxidase inhibitors (MAOIs) 

What is a natural alternative to mirtazapine?

There is no alternative to antidepressants, but there are some ways to increase the amount of serotonin in your body naturally. These include:

• Eggs, Pineapples, cheese, salmon, nuts and seeds are known for containing a generous amount of tryptophan, an amino acid from which serotonin is synthesised. 
• Exercise is one of the best ways of increasing ‘happy chemicals’ in our system. Workout for at least half an hour, 3 to 4 times a week.
• Learn new yoga moves, as yoga is one of the best ways to relax your racing mind.
• Research shows a close relationship between sunlight and serotonin levels in your body. Go for a walk in the morning or afternoon to boost your serotonin and to enhance your sleep quality. 
• Studies show that your gut microflora has a great impact on your serotonin levels through the gut-brain axis. Make sure to add fibre and probiotics in your diet. 

What drug is the same as mirtazapine?

Mirtazapine is an atypical antidepressant. Another atypical antidepressant is trazodone. Trazodone is a serotonin specific antidepressant. 

It basically agonises the effects of this excitatory neurotransmitter, while inhibiting its reuptake. This way, the amount of serotonin increases in your body to counteract the symptoms associated with depression and other mental health conditions. 

Can you switch from mirtazapine to another antidepressant?

Yes, you can switch from mirtazapine to another antidepressant if your healthcare provider recommends it. The choice of new antidepressant and initial dose is also determined by your doctor. It is strictly prohibited to start or stop using any antidepressant without your doctor’s approval. 

What to expect when switching antidepressants?

When you switch your antidepressant, it is expected to receive better therapeutic outcomes. One of the possible reasons for antidepressant discontinuation is inadequate therapeutic response. 

If you continue to take your antidepressant but it does show any sign of relief from your symptoms, it clearly indicates that the drug is not the right choice for you and it can not help to treat your symptoms in the long run. 

References 

• Antidepressant switching guidelines (1998) https://www.nps.org.au/assets/Products/Guidelines-switching-antidepressants_A3.pdf 
• James M. Ferguson, M.D. – SSRI Antidepressant Medications: Adverse Effects and Tolerability https://www.ncbi.nlm.nih.gov/pmc/articles/PMC181155/
• Strategies and Solutions for Switching Antidepressant Medications https://www.psychiatrictimes.com/view/strategies-and-solutions-switching-antidepressant-medications