Mirtazapine is NOT Contraindicated in Binge Eating Disorder
Mirtazapine is not contraindicated in patients with binge eating disorder, but it should be avoided whenever possible due to its significant appetite-stimulating and weight-gain properties, which directly worsen the core pathology of BED. 1
Why Mirtazapine Should Be Avoided (But Is Not Contraindicated)
The FDA labeling for mirtazapine explicitly warns about increased appetite and weight gain as major adverse effects:
- 17% of patients experience increased appetite (vs. 2% placebo)
- 7.5% gain ≥7% of body weight (vs. 0% placebo)
- 8% of patients discontinued mirtazapine specifically due to weight gain in premarketing trials 1
These effects are particularly problematic in BED, where:
- Patients already struggle with binge eating episodes
- Weight gain and obesity are common comorbidities
- Treatment goals include normalizing eating behaviors and managing weight
Evidence-Based Treatment Recommendations for BED
The 2023 APA guidelines recommend:
- First-line: Eating disorder-focused cognitive-behavioral therapy or interpersonal therapy 2
- Second-line pharmacotherapy: Either an antidepressant or lisdexamfetamine for patients who prefer medication or have not responded to psychotherapy alone 2
Recent research (2024) specifically identifies mirtazapine as a medication that "should be avoided where possible" in BED due to its weight gain-inducing properties 3. This review places mirtazapine in the same category as olanzapine, clozapine, tricyclic antidepressants, and valproate—all medications to avoid in BED patients.
When Antidepressants Are Needed in BED
If treating comorbid depression or anxiety in a BED patient, prefer:
- SSRIs: Citalopram, fluoxetine, sertraline
- SNRIs: Duloxetine, venlafaxine 3
These options do not carry the same appetite-stimulating and weight-gain risks as mirtazapine.
Clinical Bottom Line
While not formally contraindicated, prescribing mirtazapine to a patient with binge eating disorder is clinically inadvisable because it will likely exacerbate their eating disorder symptoms and contribute to weight gain—working directly against treatment goals. Choose alternative antidepressants that do not stimulate appetite if pharmacotherapy is needed for comorbid conditions.