Remeron (Mirtazapine) Is Not Recommended for Binge Eating Disorder
Remeron (mirtazapine) should not be used to treat binge-eating disorder, as it is not supported by current treatment guidelines and its side effect profile—particularly increased appetite and weight gain—directly worsens the condition.
Guideline-Based Treatment Approach
The 2023 American Psychiatric Association guidelines provide clear direction for binge-eating disorder treatment 1:
First-Line Treatment
- Psychotherapy is the primary recommendation: eating disorder-focused cognitive-behavioral therapy or interpersonal therapy (individual or group format) 1
Medication Considerations
- When medication is appropriate: Only for adults who prefer medication or have not responded to psychotherapy alone 1
- Recommended medication options: Either an antidepressant or lisdexamfetamine (this is a suggestion-level recommendation, 2C) 1
Why Mirtazapine Is Contraindicated
The FDA label for Remeron explicitly lists increased appetite (17% vs 2% placebo) and weight gain (12% vs 2% placebo) as common adverse reactions 2. These effects directly oppose the treatment goals for binge-eating disorder.
Recent expert consensus (2024) specifically identifies mirtazapine as a medication that "should be avoided where possible" in patients with binge-eating disorder, particularly because obesity is a frequent health consequence of the condition 3.
Evidence-Based Alternatives
Preferred Pharmacological Options:
- Lisdexamfetamine: The only FDA-approved medication for BED in some countries 3
- Topiramate: Off-label but evidence-supported 3
- SSRIs (when treating comorbid depression/anxiety): Citalopram, fluoxetine, sertraline 3
Emerging Options:
- GLP-1 receptor agonists (semaglutide, liraglutide) show promise for both binge eating reduction and weight management 3, 4
- Naltrexone-bupropion combination for patients with comorbid obesity 4
Clinical Algorithm
- Start with psychotherapy (CBT or interpersonal therapy)
- If inadequate response by 6 weeks or patient preference for medication: Consider lisdexamfetamine or topiramate
- If comorbid depression/anxiety: Add SSRI (avoid mirtazapine)
- If comorbid obesity: Consider GLP-1 agonists or naltrexone-bupropion
Critical Pitfall to Avoid
Do not prescribe mirtazapine for depression in a patient with binge-eating disorder without considering alternative antidepressants. The appetite stimulation and weight gain will likely exacerbate the eating disorder, worsening both morbidity and quality of life despite potential mood benefits.