Does Remeron Increase Suicidality Like SSRIs?
No, mirtazapine (Remeron) does not increase suicidality like SSRIs; in fact, pooled trial data demonstrate that mirtazapine is associated with statistically significantly lower suicidality risk compared to placebo, with an odds ratio of 0.38 (95% CI 0.21-0.66, P=0.0008). 1
Key Distinction Between Mirtazapine and SSRIs
Mirtazapine has a fundamentally different risk profile for suicidality compared to SSRIs:
SSRIs carry an FDA black-box warning for increased risk of suicidal thinking and behavior in children, adolescents, and young adults, with an absolute risk increase of approximately 0.7% (number needed to harm = 143) 2
Mirtazapine demonstrated protective effects in longitudinal analyses of 15 placebo-controlled trials, showing lower suicidality risk than placebo when measured using Hamilton Depression Rating Scale suicide item scores 1
The most recent systematic review (2025) found insufficient evidence to determine mirtazapine's effects on suicides or suicide attempts, but critically, no signal of increased risk was detected 3
Mechanistic Differences Explaining Lower Risk
Mirtazapine avoids the two primary mechanisms by which SSRIs trigger suicidality:
No behavioral activation syndrome: SSRIs commonly cause restlessness, impulsivity, aggression, insomnia, and irritability—particularly in younger patients—which can precipitate self-harm 2. Mirtazapine's sedating properties (somnolence is a common side effect) make this activation syndrome unlikely 3
No akathisia: SSRIs, especially fluoxetine, can induce akathisia (motor restlessness and inner tension), which has been specifically linked to SSRI-induced suicidal ideation 4, 5. Mirtazapine does not cause akathisia due to its different mechanism of action 6
Clinical Implications for Practice
When treating depression with suicidal ideation, mirtazapine may be a safer alternative to SSRIs, particularly in:
- Patients who have developed treatment-emergent suicidality on SSRIs 4
- Younger patients (children, adolescents, young adults) who are at highest risk for SSRI-induced suicidal ideation 2, 7
- Patients with prominent anxiety, agitation, or insomnia, where mirtazapine's sedating profile provides additional benefit 6
Important Caveats
Despite mirtazapine's favorable suicidality profile, standard safety monitoring remains essential:
- All antidepressants require removal of lethal means (firearms, medications) from the home before initiation 5
- Third-party medication monitoring by a responsible adult who can report behavioral changes is mandatory 4, 2
- Weekly visits during the first month to assess for new or worsening suicidal ideation are recommended 5
The evidence base has limitations: