From the Guidelines
Mirtazapine is the most suitable antidepressant for minimizing gastrointestinal side effects and sexual dysfunction while promoting somnolence, due to its strong sedative properties and favorable side effect profile. When considering antidepressants that meet these criteria, several options come into play, including:
- Mirtazapine, which is typically started at 7.5-15mg taken at bedtime, has strong sedative properties that help with sleep and tends to cause fewer sexual side effects than SSRIs or SNRIs, as noted in studies such as 1.
- Trazodone, usually prescribed at 50-150mg before bed, with strong sleep-promoting effects and minimal sexual dysfunction, although it may have a higher incidence of somnolence compared to other antidepressants, as seen in 1.
- Bupropion, worth considering for daytime use (150-300mg daily) as it has minimal sexual side effects and gut issues, though it may worsen insomnia if taken late in the day, and is noted for its lower rate of sexual adverse events compared to fluoxetine or sertraline in 1.
- Vortioxetine, at 5-20mg daily, also has a favorable side effect profile regarding both sexual function and gut symptoms, although it is not specifically mentioned in 1, its multimodal effects on serotonin receptors make it a potential option. These medications work through different mechanisms, including affecting multiple neurotransmitter systems such as serotonin, norepinephrine, histamine, dopamine, and having multimodal effects on serotonin receptors. The choice among these depends on individual factors including depression severity, other symptoms, and personal health history, with the goal of minimizing adverse effects like gastrointestinal issues and sexual dysfunction while promoting beneficial effects like somnolence, as guided by evidence from studies like 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Antidepressants with Minimal Gastrointestinal Side Effects and Sexual Dysfunction
- Mirtazapine is an antidepressant that has been reported to have a low incidence of agitation, anxiety, and insomnia, which may be due to blockade of 5-HT(2) and 5-HT(3) receptors 2.
- It has been shown to diminish SSRI-related sexual dysfunction without compromising the patient's therapeutic response to the medication 2.
- Mirtazapine has a beneficial effect on sexual functioning in both depressed women and men, with improvements in desire, arousal/lubrication, and ease/satisfaction of orgasm 3.
Promoting Somnolence
- Mirtazapine has been reported to have a unique multireceptor-mediated clinical pharmacologic profile that may reduce the need for polypharmacy in selected patients, including those with insomnia 2.
- It has been shown to successfully treat mood disorders and insomnia in patients, with rapid resolution of symptoms 2.
Comparison with Other Antidepressants
- Selective serotonin reuptake inhibitors (SSRIs) and serotonin and noradrenaline reuptake inhibitors (SNRIs) have a higher risk of sexual dysfunction compared to mirtazapine, tricyclic antidepressants, and other antidepressants 4.
- Bupropion and nefazodone have been associated with lower rates of sexual dysfunction compared to SSRIs and venlafaxine XR 5.
- Mirtazapine has been shown to have a lower incidence of sexual dysfunction compared to other antidepressants, including SSRIs and venlafaxine XR 5.