What is the best antidepressant to take with mirtazapine? (3 choices)
By
Ivan Kahwa
| Reviewed by
Ivan Kahwa
The contents of this article are fact-based except otherwise stated within the article.
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Author bio
Mr Ivan Kahwa is a chemist and phytopharmaceutical scientist with expertise in chemistry, pharmacology, phytochemistry, and Nanobiotechnology. He writes and reviews content on these topics.
Mr Ivan Kahwa’s Highlights:
Guest Researcher at the University of Leipzig, Senior Research Fellow/Scientist, and Lecturer at the Department of Pharmacy, Faculty of Medicine, Mbarara University of Science and Technology.
Professional Experience:
Mr Ivan joined PHARMBIOTRAC as a research fellow/scientist during his master of science tenure. He contributed to the development of most of the phytopharmaceutical products in the project. Furthermore, he participated in carrying out the pharmacological activities of the developed products in laboratory animals such as mice and rats in order to develop proper doses hence leading to pre-clinical studies.
With the above relevant research experience, Ivan started to work with the University of Leipzig on collaborative projects with Mbarara University to develop the chemistry of Ugandan Medicinal plants and their pharmacological activities. This was coupled with several consultative positions by different German NGOs. Mr. Kahwa is also a supporting in the teaching and learning at the Departments of Pharmacy and Pharmaceutical Sciences, Faculty of Medicine, Mbarara University of Science and Technology.
With the increase in antimicrobial resistance globally, Ivan retooled his thinking towards developing new naturally derived antibiotic regimens from Ugandan propolis with the assistance of nanotechnology to improve their delivery to microbial cells. Kahwa has also published over 28 articles in peer-reviewed journals and he is currently reviewing for many journals.
Education:
2023-2027: PhD in Pharmaceutical Sciences (ongoing) with a focus on Pharmaceutical Microbiology and Nanobiology at Mbarara University of Science and Technology.
2022: 2Msc. in Pharmacognosy and Natural Medicine Science at Mbarara University of Science and Technology.
2018: Bachelor of Science (Chemistry) at Mbarara University of Science and Technology.
Publications:
▪ Iqbal, S., Jabeen, F., Kahwa, I., & Omara, T. 2023. Suberosin Alleviates Thiazolidinedione-Induced Cardiomyopathy in Diabetic Rats by Inhibiting Ferroptosis via Modulation of ACSL4-LPCAT3 and PI3K-AKT Signaling Pathways. Cardiovascular Toxicology. https://doi.org/10.1007/s12012-023-09804-7
▪ Gupta, A. K., Yadav, R., Sharma, S., Sawale, J., & Kahwa, I. 2023. Anti-ageing Activity and Antioxidant Activity of Methanol Extracts of Leaves and Flowers of Salvia officinalis and Rosmarinus officinalis. Journal of Young Pharmacists, 15(3), 448–455. https://doi.org/10.5530/jyp.2023.15.60
▪ Tolo, C.U., Kahwa, I., Nuwagira, U., Weisheit, A. and Ikiriza, H., 2023. Medicinal plants used in treatment of various diseases in the Rwenzori Region, Western Uganda. Ethnobotany Research and Applications, 25, pp.1-16.
https://ethnobotanyjournal.org/index.php/era/article/view/4683
▪ Kahwa, I., Ajayi, C.O., Yadav, R., Chauhan, N.S., Shah, K., Abdelgadir, A.A., Shegena, E.A., Daniel, S., Omara, T., Asiimwe, J.B. and Ikiriza, H., 2023. Pharmacognostic and phytochemical studies as an invaluable approach for correct identification of medicinal plants: The case of Artemisia vulgaris L. substituted for Artemisia annua L. in Western Uganda. TMR Integr Med, 7, p.e23004.
https://doi.org/10.53388/TMRIM202307004
▪ Nalimu, F., Oloro, J., Kahwa, I. and Ogwang, P.E., 2021. Review on the phytochemistry and toxicological profiles of Aloe vera and Aloe ferox. Future Journal of Pharmaceutical Sciences, 7, pp.1-21.
https://doi.org/10.1186/s43094-021-00296-2
▪ Elamin, O.H.S., Ali, M.A., Elgezuli, I.A.A., Bashir, M.A. and Kahwa, I., 2021. Diagnosis of pre-and post-treatment of echinococcus granulosus with counter current immune electrophoresis and bacterial co-agglutination. Journal of Microbiology and Infectious Diseases, 11(02), pp.88-94.
https://doi.org/10.5799/jmid.951600
Published book Chapter
▪ Kahwa, I., Ayesiga, I., Nakalema, S., Alinaiswe, R., Mbabazi, R. and Iqbal, S., 2023. Natural products in the management of onchocerciasis. In Natural Products in Vector-Borne Disease Management (pp. 63-80). Academic Press. Book Chapter.
https://doi.org/10.1016/B978-0-323-91942-5.00012-4
Submitted manuscripts Under Review:
▪ Comparison of the Wound Healing Activity of the Leaf and Leaf Ash Extracts of Vernonia amygdalina in Rats. Journal name: Clinical Phytoscience
▪ Ethnobotanical Survey of Medicinal plants used in the management of cancer in Uganda. Journal name: Journal of Herbal Medicine
▪ Ethnobotanical survey and phytochemical screening of medicinal plants used in treatment of epilepsy by PROMETRA-Uganda Traditional Health Practitioners in Mpigi District, Uganda. Journal name: Journal of Ethnopharmacology
Submitted book chapters under review
1.Book title: Algae as a Natural Solution for Water-Food-Energy Nexus, Section 4: Microalgae and cyanobacteria for food applications, Chapter 4.6: Safety, toxicological and allergenic aspects of using algae for food. Authors: Christine Kyarimpa, Tom Omute, Caroline K. Nakiguli, Alice V. Khanakwa4, Christopher Angiro, Ivan Kahwa, Fortunate Ahumuza, Timothy Omara*. Publisher: Springer Nature Singapore Pte Ltd. 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore.
2.Book title: Nutraceuticals Inspiring the Contemporary Therapy for Lifestyle Diseases. Chapter: Nutraceutical applications of Seaweeds and their Phytocompounds in Nutrition and Treatment of Diseases. Authors: Ivan Kahwa, Timothy Omara , Innocent Ayesiga , Gael Noel Neh Neba Ambe , Zehbanaz Javidbhai Panwala , Rachel Mbabazi , Shabnoor Iqbal , Christine Kyarimpa , Christine Betty Nagawa , Kamal Shah ,Nagendra Singh Chauhan* Publisher: CRC Press
You can view my works on the following professional sites:
Research Gate: https://www.researchgate.net/profile/Ivan-Kahwa
Google Scholar: https://scholar.google.com/citations?user=tOwrvqoAAAAJ&hl=en
ORCID: https://orcid.org/0000-0002-6440-3437
Linkedin: https://de.linkedin.com/in/ivan-kahwa-865450159
Reviewer bio
Mr Ivan Kahwa is a chemist and phytopharmaceutical scientist with expertise in chemistry, pharmacology, phytochemistry, and Nanobiotechnology. He writes and reviews content on these topics.
Mr Ivan Kahwa’s Highlights:
Guest Researcher at the University of Leipzig, Senior Research Fellow/Scientist, and Lecturer at the Department of Pharmacy, Faculty of Medicine, Mbarara University of Science and Technology.
Professional Experience:
Mr Ivan joined PHARMBIOTRAC as a research fellow/scientist during his master of science tenure. He contributed to the development of most of the phytopharmaceutical products in the project. Furthermore, he participated in carrying out the pharmacological activities of the developed products in laboratory animals such as mice and rats in order to develop proper doses hence leading to pre-clinical studies.
With the above relevant research experience, Ivan started to work with the University of Leipzig on collaborative projects with Mbarara University to develop the chemistry of Ugandan Medicinal plants and their pharmacological activities. This was coupled with several consultative positions by different German NGOs. Mr. Kahwa is also a supporting in the teaching and learning at the Departments of Pharmacy and Pharmaceutical Sciences, Faculty of Medicine, Mbarara University of Science and Technology.
With the increase in antimicrobial resistance globally, Ivan retooled his thinking towards developing new naturally derived antibiotic regimens from Ugandan propolis with the assistance of nanotechnology to improve their delivery to microbial cells. Kahwa has also published over 28 articles in peer-reviewed journals and he is currently reviewing for many journals.
Education:
2023-2027: PhD in Pharmaceutical Sciences (ongoing) with a focus on Pharmaceutical Microbiology and Nanobiology at Mbarara University of Science and Technology.
2022: 2Msc. in Pharmacognosy and Natural Medicine Science at Mbarara University of Science and Technology.
2018: Bachelor of Science (Chemistry) at Mbarara University of Science and Technology.
Publications:
▪ Iqbal, S., Jabeen, F., Kahwa, I., & Omara, T. 2023. Suberosin Alleviates Thiazolidinedione-Induced Cardiomyopathy in Diabetic Rats by Inhibiting Ferroptosis via Modulation of ACSL4-LPCAT3 and PI3K-AKT Signaling Pathways. Cardiovascular Toxicology. https://doi.org/10.1007/s12012-023-09804-7
▪ Gupta, A. K., Yadav, R., Sharma, S., Sawale, J., & Kahwa, I. 2023. Anti-ageing Activity and Antioxidant Activity of Methanol Extracts of Leaves and Flowers of Salvia officinalis and Rosmarinus officinalis. Journal of Young Pharmacists, 15(3), 448–455. https://doi.org/10.5530/jyp.2023.15.60
▪ Tolo, C.U., Kahwa, I., Nuwagira, U., Weisheit, A. and Ikiriza, H., 2023. Medicinal plants used in treatment of various diseases in the Rwenzori Region, Western Uganda. Ethnobotany Research and Applications, 25, pp.1-16.
https://ethnobotanyjournal.org/index.php/era/article/view/4683
▪ Kahwa, I., Ajayi, C.O., Yadav, R., Chauhan, N.S., Shah, K., Abdelgadir, A.A., Shegena, E.A., Daniel, S., Omara, T., Asiimwe, J.B. and Ikiriza, H., 2023. Pharmacognostic and phytochemical studies as an invaluable approach for correct identification of medicinal plants: The case of Artemisia vulgaris L. substituted for Artemisia annua L. in Western Uganda. TMR Integr Med, 7, p.e23004.
https://doi.org/10.53388/TMRIM202307004
▪ Nalimu, F., Oloro, J., Kahwa, I. and Ogwang, P.E., 2021. Review on the phytochemistry and toxicological profiles of Aloe vera and Aloe ferox. Future Journal of Pharmaceutical Sciences, 7, pp.1-21.
https://doi.org/10.1186/s43094-021-00296-2
▪ Elamin, O.H.S., Ali, M.A., Elgezuli, I.A.A., Bashir, M.A. and Kahwa, I., 2021. Diagnosis of pre-and post-treatment of echinococcus granulosus with counter current immune electrophoresis and bacterial co-agglutination. Journal of Microbiology and Infectious Diseases, 11(02), pp.88-94.
https://doi.org/10.5799/jmid.951600
Published book Chapter
▪ Kahwa, I., Ayesiga, I., Nakalema, S., Alinaiswe, R., Mbabazi, R. and Iqbal, S., 2023. Natural products in the management of onchocerciasis. In Natural Products in Vector-Borne Disease Management (pp. 63-80). Academic Press. Book Chapter.
https://doi.org/10.1016/B978-0-323-91942-5.00012-4
Submitted manuscripts Under Review:
▪ Comparison of the Wound Healing Activity of the Leaf and Leaf Ash Extracts of Vernonia amygdalina in Rats. Journal name: Clinical Phytoscience
▪ Ethnobotanical Survey of Medicinal plants used in the management of cancer in Uganda. Journal name: Journal of Herbal Medicine
▪ Ethnobotanical survey and phytochemical screening of medicinal plants used in treatment of epilepsy by PROMETRA-Uganda Traditional Health Practitioners in Mpigi District, Uganda. Journal name: Journal of Ethnopharmacology
Submitted book chapters under review
1.Book title: Algae as a Natural Solution for Water-Food-Energy Nexus, Section 4: Microalgae and cyanobacteria for food applications, Chapter 4.6: Safety, toxicological and allergenic aspects of using algae for food. Authors: Christine Kyarimpa, Tom Omute, Caroline K. Nakiguli, Alice V. Khanakwa4, Christopher Angiro, Ivan Kahwa, Fortunate Ahumuza, Timothy Omara*. Publisher: Springer Nature Singapore Pte Ltd. 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore.
2.Book title: Nutraceuticals Inspiring the Contemporary Therapy for Lifestyle Diseases. Chapter: Nutraceutical applications of Seaweeds and their Phytocompounds in Nutrition and Treatment of Diseases. Authors: Ivan Kahwa, Timothy Omara , Innocent Ayesiga , Gael Noel Neh Neba Ambe , Zehbanaz Javidbhai Panwala , Rachel Mbabazi , Shabnoor Iqbal , Christine Kyarimpa , Christine Betty Nagawa , Kamal Shah ,Nagendra Singh Chauhan* Publisher: CRC Press
You can view my works on the following professional sites:
Research Gate: https://www.researchgate.net/profile/Ivan-Kahwa
Google Scholar: https://scholar.google.com/citations?user=tOwrvqoAAAAJ&hl=en
ORCID: https://orcid.org/0000-0002-6440-3437
Linkedin: https://de.linkedin.com/in/ivan-kahwa-865450159
In this article, we will discuss the best antidepressants to take with mirtazapine. We will also discuss some research studies and the potential risks of such combinations.
What is the best antidepressant to take with mirtazapine?
The best antidepressants to take with mirtazapine include:
- Selective serotonin reuptake inhibitors (SSRIs)
- Serotonin-norepinephrine reuptake inhibitors (SNRIs)
- Bupropion
Selective serotonin reuptake inhibitors (SSRIs)
Mirtazapine can be combined with SSRIs, which typically include: (1)
- Fluoxetine (Prozac)
- Sertraline (Zoloft)
- Paroxetine (Paxil)
- Fluvoxamine (Luvox)
- Citalopram (Celexa)
- Escitalopram (Lexapro)
SSRIs are commonly prescribed antidepressants and are often used as a first line of treatment for depression and anxiety. However, SSRIs monotherapy might not be sufficient for some individuals, or mirtazapine monotherapy might not yield satisfactory results.
In such cases, it is common for doctors to consider a suitable combination of antidepressants. The combined use of mirtazapine with a suitable SSRI can offer potential health benefits.
However, the decision to prescribe this combination depends on several patient-specific factors, and such combinations might not provide added therapeutic benefits compared to monotherapy with either of these medications.
Therefore, it is important to rely on your doctor’s expertise and refrain from making any changes to your treatment plan.
Serotonin-norepinephrine reuptake inhibitors (SNRIs)
SNRIs can also be prescribed with mirtazapine. Venlafaxine, in particular, could be considered a drug of choice to combine with mirtazapine for the management of treatment-resistant depression (2). Other SNRIs might also be used after properly weighing the risk-benefit ratio.
SNRIs typically include: (3)
- Venlafaxine (Effexor)
- Duloxetine (Cymbalta)
- Desvenlafaxine (Pristiq)
- Levomilnacipran (Fetzima)
However, such combinations should be closely monitored for side effects, as what works for one person may not work for another. Some individuals might not respond well or might have additional underlying factors that could make this combination unsuitable for them.
Bupropion (Wellbutrin)
Bupropion can also be prescribed with mirtazapine. It might not be considered an ideal choice, considering how both of these medications have different effects on your energy levels – bupropion is activating, and mirtazapine is a sedative antidepressant (4,5).
However, this combination may provide more therapeutic benefits compared to monotherapy. It is also important to note that patient-specific factors are crucial in determining whether this is a suitable combination for them.
What does research suggest?
Several research studies have discussed the combined use of mirtazapine with other antidepressants. It is a known fact that antidepressants take 2-6 weeks to generate a response, and some individuals may take even longer (6).
If an antidepressant does not begin to work, it typically means that either the choice of drug is not suitable to manage the symptoms of a specific individual or antidepressant monotherapy is not sufficient (6).
This is where research suggests that combining mirtazapine with another antidepressant could be a good treatment approach in some cases.
The combination of mirtazapine and venlafaxine, according to research, is a safe and well-tolerated option to manage depression that does not respond to monotherapy (2). No serious adverse events were reported during the trials, and the response rate is also good enough to consider this combination as effective (2).
Some research studies have also indicated that combining mirtazapine with an SSRI or an SNRI might not offer clinically significant results (7). These combinations might not provide any additional antidepressant effects when used together, making them less reliable treatment approaches.
However, some studies do suggest that mirtazapine, when combined with SSRIs, can safely and effectively manage treatment-resistant depression and PTSD (8,9). Some studies have also shown that mirtazapine and bupropion can be more effective than an SSRI, such as fluoxetine monotherapy (10).
What are the potential risks of combining mirtazapine with other antidepressants?
The potential risks of combining mirtazapine with other antidepressants include:
| Antidepressant Combinations | Common Side Effects | Rare Side Effects |
| Mirtazapine + SSRIs | Increased sedation, early anxiety, nausea, vomiting, diarrhoea, tiredness, and low energy levels. | Serotonin syndrome, severe drowsiness, confusion. |
| Mirtazapine + SNRIs | Enhanced sedative effects, nausea, vomiting, diarrhoea, tiredness, and low energy levels. | Serotonin syndrome, increased blood pressure. |
| Mirtazapine + Bupropion | Dry mouth, nausea, vomiting, constipation, lethargy, mood swings, etc. | Increased risk of seizures and agitation. |
These side effects can vary from person to person and some may require immediate medical attention.
The overall efficacy of mirtazapine combination treatments
As a pharmacist, I do suggest using mirtazapine in combination with a suitable antidepressant if monotherapy is not enough to manage your symptoms. I have come across many patients struggling with depression and related symptoms even while taking an antidepressant.
Some of these patients do feel a lot better when their antidepressant is combined with psychotherapy. However, major depressive disorder may require psychotherapy along with a combination of antidepressants.
If your depression is comorbid with insomnia, taking mirtazapine with a suitable antidepressant could be a good treatment approach. However, it is important to note that what works for someone else might not work for you.
I have patients coming up to me all the time saying why a certain medication does not work for them but does help someone they know. It’s worth noting that we all have unique body physiology, and we can respond differently to medications.
Just trust your doctor’s expertise, keep following the directions properly, and attend follow-up appointments to monitor your progress.
References
- Chu A, Wadhwa R. Selective Serotonin Reuptake Inhibitors. 2023 May 1. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 32119293. https://www.ncbi.nlm.nih.gov/books/NBK554406
- Hannan N, Hamzah Z, Akinpeloye HO, Meagher D. Venlafaxine-mirtazapine combination in the treatment of persistent depressive illness. J Psychopharmacol. 2007 Mar;21(2):161-4. doi: 10.1177/0269881107065738. Erratum in: J Psychopharmacol. 2008 Aug;22(6):698. PMID: 17329295. https://pubmed.ncbi.nlm.nih.gov/17329295/
- Sansone RA, Sansone LA. Serotonin norepinephrine reuptake inhibitors: a pharmacological comparison. Innov Clin Neurosci. 2014 Mar;11(3-4):37-42. PMID: 24800132; PMCID: PMC4008300. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4008300/
- Huecker MR, Smiley A, Saadabadi A. Bupropion. 2023 Apr 9. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 29262173. https://www.ncbi.nlm.nih.gov/books/NBK470212
- Jilani TN, Gibbons JR, Faizy RM, Saadabadi A. Mirtazapine. 2023 Aug 28. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 30085601. https://www.ncbi.nlm.nih.gov/books/NBK519059
- Álvarez E, Viñas F. Mirtazapine in combination. Actas Esp Psiquiatr. 2010 Mar-Apr;38(2):121-8. PMID: 21361055. https://pubmed.ncbi.nlm.nih.gov/21361055/
- Kessler D, Burns A, Tallon D, Lewis G, MacNeill S, Round J, Hollingworth W, Chew-Graham C, Anderson I, Campbell J, Dickens C, Macleod U, Gilbody S, Davies S, Peters TJ, Wiles N. Combining mirtazapine with SSRIs or SNRIs for treatment-resistant depression: the MIR RCT. Health Technol Assess. 2018 Nov;22(63):1-136. doi: 10.3310/hta22630. PMID: 30468145; PMCID: PMC6287172. https://pubmed.ncbi.nlm.nih.gov/30468145/
- Arockiaraj N, Gupta R, Ahmad R, Halder S, Bhatia MS. Sertraline with desvenlafaxine and sertraline with mirtazapine as treatment initiation in MDD patients with moderate to severe depression and effect on inflammatory markers. Int J Psychiatry Clin Pract. 2023 Nov 29:1-8. doi: 10.1080/13651501.2023.2287754. Epub ahead of print. PMID: 38019131. https://pubmed.ncbi.nlm.nih.gov/38019131/
- Schneier FR, Campeas R, Carcamo J, Glass A, Lewis-Fernandez R, Neria Y, Sanchez-Lacay A, Vermes D, Wall MM. COMBINED MIRTAZAPINE AND SSRI TREATMENT OF PTSD: A PLACEBO-CONTROLLED TRIAL. Depress Anxiety. 2015 Aug;32(8):570-9. doi: 10.1002/da.22384. Epub 2015 Jun 26. PMID: 26115513; PMCID: PMC4515168. https://pubmed.ncbi.nlm.nih.gov/26115513/
- Blier P, Ward HE, Tremblay P, Laberge L, Hébert C, Bergeron R. Combination of antidepressant medications from treatment initiation for major depressive disorder: a double-blind randomized study. Am J Psychiatry. 2010 Mar;167(3):281-8. doi: 10.1176/appi.ajp.2009.09020186. Epub 2009 Dec 15. PMID: 20008946. https://pubmed.ncbi.nlm.nih.gov/20008946/
