How soon can the dose of Remeron (mirtazapine) for sleep be increased?

Dose Escalation Timing for Mirtazapine (Remeron) in Insomnia

Increase the dose of mirtazapine for sleep after 1-2 weeks if the initial dose is inadequate, starting at 7.5-15 mg and titrating up to a maximum of 30 mg for sleep purposes. 1

Dosing Algorithm for Sleep

Initial dosing:

• Start with 7.5-15 mg at bedtime 2, 1
• The lower end (7.5 mg) may be preferred initially to assess tolerability 3, 4

Timing of dose increases:

• Wait a minimum of 1-2 weeks before increasing the dose 1
• This interval allows sufficient time to evaluate response to the current dose 1
• Clinical improvement in sleep and anxiety symptoms may begin within the first week, though full antidepressant effects take 2-4 weeks 5

Dose escalation:

• If inadequate response after 1-2 weeks, increase to 15 mg if started lower 3, 4
• Maximum recommended dose for sleep is 30 mg at bedtime 2
• For depression treatment, doses can go up to 45 mg, but for off-label insomnia use, 30 mg is the typical ceiling 2, 1

Critical Clinical Considerations

Important paradox about sedation:

• Sedation is actually more common at lower doses (subtherapeutic range) 6
• Higher therapeutic doses (≥15 mg) may produce less sedation than expected 6
• This occurs because mirtazapine's antihistaminic effects dominate at lower doses, while noradrenergic effects increase at higher doses 7, 6

Evidence quality for insomnia:

• Mirtazapine is not FDA-approved for insomnia and evidence for this indication is relatively weak 2
• The American Academy of Sleep Medicine (2017) does not recommend trazodone for insomnia (showing only 8-10 minute improvements), and mirtazapine has similar limited evidence 2
• A 2025 randomized controlled trial showed mirtazapine 7.5-15 mg provided statistically significant and clinically relevant improvement at 6 weeks, but this benefit was not sustained at later time points 4

Common pitfalls:

• Weight gain and increased appetite occur in approximately 10-11% of patients and are significant concerns 2, 7, 3
• Consider adding melatonin (2-3 mg) if planning to taper off mirtazapine to maintain sleep benefits while avoiding weight gain 3
• Avoid in elderly patients with cognitive impairment or fall risk due to sedation 2

Monitoring strategy:

• Assess sleep quality at 1 week (early effects on sleep may be apparent) 5
• Formal reassessment at 2 weeks before dose adjustment 1
• Monitor weight and appetite throughout treatment 3, 6
• After 9 months, consider dose reduction to reassess need for continued medication 2

Alternative considerations:

• If comorbid depression exists, standard antidepressant dosing (15-45 mg) is required, as low-dose sedating antidepressants do not constitute adequate depression treatment 2
• FDA-approved options like eszopiclone, zolpidem, or suvorexant have stronger evidence for insomnia specifically 2