Mirtazapine For PTSD: Cochrane Article Finds Little Support

Mirtazapine For PTSD

PTSD stands for post-traumatic stress disorder and is a mental condition that can occur after an individual experiences a traumatic event that causes them to feel shocked, fearful, or helpless (e.g. abuse, accidents, war, death of a loved one, and more). Effects of PTSD include re-experiencing traumatic events, irritability and anger outbursts, sleep problems, anxiety, avoidance of emotions & thoughts, as well as social withdrawal. PTSD can be either acute or chronic.

Mirtazapine is an atypical antidepressant medication that affects both serotonin and noradrenaline levels. It is most commonly prescribed for major depressive disorder and is sometimes used off-label for sleep and anxiety disorders because of its sedative properties. Mirtazapine is most commonly sold under the brand name Remeron in the U.S. 

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Using Mirtazapine For PTSD: The Current Evidence

In a Cochrane article from 2022, they looked at the evidence for different medications for PTSD. Amongst those medications was Mirtazapine, and the following findings were observed:

• Mirtazapine did show evidence of benefiting PTSD symptoms compared to placebo. Participants taking mirtazapine had a 45% reduced risk of experiencing PTSD symptoms compared to those on placebo. However, the conclusion is drawn from a trial involving only 26 participants (Davidson 2003), and the evidence quality for this outcome is considered low-certainty by Cochrane.
  
  
• Mirtazapine did not show any significant beneficial effect in reducing PTSD symptoms on various measures such as CAPS (a structured interview used by clinicians to evaluate PTSD symptoms) total score, re-experiencing/intrusion subscale, avoidance/numbing subscale, and hyperarousal subscale. Similarly, there was no evidence of benefit in reducing PTSD symptoms on the self-rated DTS scale, though some moderate variation was detected in the self-rated DTS measures.
  
  
• However, there was evidence that mirtazapine had a positive impact on reducing PTSD symptoms according to the SPRINT and CGI-S scales. These measures showed a statistically significant decrease in symptoms among participants taking mirtazapine compared to the placebo.
  
  
• Mirtazapine did not demonstrate a significant advantage over placebo in reducing depression symptoms as assessed by the HADS-D and MADRS scales. For anxiety symptoms, mirtazapine showed a benefit on the HADS-A scale, but this effect was marginally significant (P = 0.05). This conclusion was based on one trial with 25 participants.

What Does This Mean? 
[Simplified Explanation]

• In simplified terms, there is only currently weak evidence showing the beneficial effects of using Mirtazapine for PTSD. 
  
  
• Mirtazapine did not consistently demonstrate advantages over placebo for depression symptoms, although it showed a marginally significant reduction in anxiety symptoms.
  
  
• Nonetheless, further research may be needed to better understand the potential benefits and limitations of mirtazapine for treating PTSD.
  
  
• This information is sourced from Cochrane, a respected global network that conducts systematic reviews of medical research to provide evidence-based information for healthcare decisions.

Mirtazapine in PTSD Nightmares

There has been a debate amongst professionals about whether Mirtazapine may decrease or increase the amount of nightmares in individuals with PTSD. Here are the results from a published medical article from 2018 that looks at the medical management of nightmares in post-traumatic stress disorder:

• Mirtazapine initially demonstrated promise in reducing the frequency and intensity of nightmares among a population of more than 200 refugees.
  
  
• However, a clinical experience reported from a VA Medical Center revealed a 50% failure rate, with the remaining 50% reporting either partial or complete response when using Mirtazapine for PTSD nightmares. Rather, Mirtazapine has been associated with the onset of new nightmares, contradicting its initial observation.
  
  
• Furthermore, it is worth noting that Mirtazapine has been associated with the potential induction of restless legs syndrome in a notable proportion of patients, potentially affecting up to 28% of individuals.

Conclusion

The Cochrane study indicates that Mirtazapine shows some evidence of benefiting PTSD symptoms, but compared to the evidence of using Sertraline for PTSD, the evidence for Mirtazapine is of low certainty and it lacks FDA approval for the treatment of post-traumatic stress disorder. Unfortunately, Mirtazapine did not consistently reduce PTSD symptoms across different measures, yet showed a small impact on the reduction of anxiety. 

Mirtazapine's effect on PTSD nightmares is mixed - while initially promising, some experiences reported new nightmares, and it may induce restless legs syndrome, further reducing the sleep quality in a patient group already suffering from a lack of high-quality sleep. More studies are most likely needed to further evaluate its effects.

Author: J. Martin, M.D. 
Last updated: August 19, 2023

Disclaimer: The information provided is intended for general informational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. Always consult with a qualified healthcare provider, such as a physician, before starting any new treatment or making changes to your existing treatment plan. Individual responses to treatment may vary, and a healthcare professional can provide personalized guidance based on your specific needs and circumstances. If you are experiencing severe or persistent symptoms of disease seek immediate medical attention.