Mirtazapine (Remeron) for Panic Attacks
Mirtazapine is an effective treatment option for panic disorder and can help with panic attacks, with evidence showing 74% of patients responding with at least 50% reduction in panic attack frequency, and rapid onset of benefit within 2 weeks of starting treatment. 1
Evidence Supporting Use in Panic Disorder
Direct Evidence for Panic Attacks
Mirtazapine demonstrated significant efficacy in panic disorder, with 74% of patients achieving responder status (≥50% reduction in panic attack frequency) in a 12-week trial 1
Rapid onset of action occurs within 2 weeks of starting active treatment, with all primary and secondary efficacy measures showing significant improvement from week 2 onwards 1
Clinical experience confirms effectiveness, with 7 of 10 patients (70%) demonstrating acute response by weeks 5-7, and 6 maintaining positive long-term response at 16 weeks 2
Mechanism Supporting Anti-Panic Effects
Dual neurotransmitter enhancement through presynaptic alpha-2 antagonism increases both noradrenergic and serotonergic neurotransmission, specifically via 5-HT1 receptors, while blocking postsynaptic 5-HT2 and 5-HT3 receptors 3, 4
This mechanism addresses the pathophysiology of panic disorder, which involves both serotonergic and noradrenergic neurotransmitter systems 2
Practical Prescribing for Panic Attacks
Dosing Strategy
Start with 7.5 mg at bedtime, increasing to 15 mg after 4 days if tolerated 5
Target therapeutic range is 15-30 mg daily for panic disorder and associated sleep disturbances 5
Effective dosage range extends to 15-45 mg/day based on individual response 4
Expected Timeline and Benefits
Anxiety symptoms improve within the first week of treatment, even before full antidepressant effects emerge 4
Sleep disturbances improve rapidly, typically within the first week, which is particularly beneficial since insomnia often accompanies panic disorder 4, 5
Additional benefits include anxiolytic effects and appetite stimulation, with potent sedating properties that promote sleep 5
Guideline Context for Anxiety Treatment
First-Line Recommendations
Psychological treatments remain first-line for moderate anxiety symptoms, including CBT, behavioral activation, structured physical activity, and psychosocial interventions with empirically supported components 6
Pharmacotherapy is appropriate for patients without access to first-line psychological treatment, those expressing preference for medication, or those who do not improve with psychological/behavioral management 6
Specific Guidance on Panic
WHO guidelines recommend CBT-based psychological treatment as the primary approach for people concerned about prior panic attacks 6
However, when pharmacotherapy is needed, mirtazapine represents a viable option given the specific evidence in panic disorder 1, 2
Side Effect Profile
Common Adverse Effects
Sedation is the most commonly reported side effect, appearing less frequent at higher dosages due to dose-dependent antihistaminic effects 3, 4
Weight gain occurs in approximately 50% of patients, along with increased appetite 5, 2
Other reported effects include pain in the legs, which differs from typical SSRI side effects 1
Advantages Over SSRIs
Lacks serotonin-related side effects such as gastrointestinal symptoms, insomnia, and sexual dysfunction that are common with SSRIs 4
No significant cardiovascular effects at doses up to 22 times the maximum recommended dose, making it safer than tricyclic antidepressants 3
Minimal anticholinergic effects compared to traditional antidepressants 4
Critical Monitoring Parameters
Monitor for weight gain and sedation, particularly in the initial weeks of treatment 5
Assess panic attack frequency at regular intervals to determine response 1
Evaluate sleep quality improvement, which should occur within the first week 5, 4
Important Clinical Considerations
When Mirtazapine is Particularly Appropriate
Patients with panic disorder plus insomnia benefit from dual therapeutic effects 5
Those with comorbid depression and anxiety may achieve synergistic benefits 6, 7
Patients who cannot tolerate or have failed SSRIs due to side effects like sexual dysfunction or gastrointestinal symptoms 1, 4
Combination Safety
Can be safely combined with beta-blockers like atenolol for patients with hypertension and panic disorder, as mirtazapine lacks significant effects on blood pressure, heart rate, or cardiac conduction 5
Avoid combining with opioids for any chronic pain symptoms, as opioids should not be used for visceral pain management 6