Hi and welcome to Healthcare Magic. Thanks for your question...

Avanza (Mirtazapine) is an anti-depressant medication which is used for the treatment of depression and anxiety symptoms. In addition to its anti-depressant properties, Avanza also has a positive effect on improving sleep and appetite. These effects usually kick off immediately and may be the reason for the immediate improvement felt. The effects on mood and anxiety symptoms usually take about 2 - 3 weeks to become noticable and it may take about 4 - 6 weeks for the complete effects to be seen. That is why it is usually advisable to wait for at least 6 weeks on a particular medication making any definitive conclusions about its benefit. However if symptoms are severe or distressing alterations can be made earlier.

In your case, you mention that you have had a significant improvement after starting Avanza, but of late seem to be getting down again. If you have been feeling down only since the last few days, then it may be advisable to wait for a week or two more. But if your symptoms are quite distressing or causing you socio-occupational dysfunction, then it may be okay to increase the dose of Avanza. The usual anti-depressant dose of Avanza 15 - 45mg. Though the side effects vary widely from person to person, it is unlikely that a 30 mg dose is going to make you 'feel like a zombie'. However, it would be best to do this dose adjustment in consultation with your psychiatrist.

Tinnitus (ringing in the ears) is not a common symptom of anxiety and is very unlikely to be a side effect of Avanza also. So, I think its better to have an ENT evaluation to find out the cause.

Another important thing in your case -smoking can interfere with the absorption of most psychiatric medication and hence can result in erratic levels of the medication. So, this may also be a reason for the altered efficacy of the medication. So, it is important to cut down on your cigarettes also.

I hope I have clarified your doubts. Wish you a speedy recovery.

- Dr. Jonas Sundarakumar
Consultant Psychiatrist

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Hello again and thanks for writing in.

Having mild fluctuations or dips during the course of your improvement is normal. Moreover, it's just been 10 days after increasing the dose and you should wait for a while longer to stabilize completely.

Often, such kind of mood dips could be a result of stress also. Learning stress management techniques, relaxation techniques and coping skills can all help in controlling these fluctuations. There is also certain effective psychotherapies (like Cognitive Behaviour Therapy - CBT) available which can be used as an adjunct to medication, which can help you deal with these depressive symptoms and the negative thoughts. It has been proven that a combination of medication with therapies like CBT gives maximum and long-lasting results. You can ask your psychiatrist about these therapies.

So, as of now, I don't think you have to worry too much about these mood fluctuations. Hopefully, with some more time you reach a stable state.

(Note: In case, these fluctuations keep persisting after a while also, then you may have to get a few tests done - because there can be certain medical conditions like thyroid disorders, certain vitamin deficiencies, etc. which may cause 'treatment resistance'. Your psychiatrist will be able to check and clarfy this for you.)

Wish you all the best.

- Dr. Jonas Sundarakumar
Consultant Psychiatrist

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Hello again and thanks for writing in.

Glad that my advise was of use. People often underestimate the effectiveness of psychotherapeutic techniques, but in fact, they have been proven to be as effective as medication in controlling anxiety / depressive symptoms and can give longer lasting results. It's just that it takes a bit more effort and dedication. Other than structured therapies like CBT, you can also try simple relaxation techniques like XXXXXXX breathing exercises, progressive muscle relaxation, applied relaxation, yoga, etc. You can also get the other tests done like B12, Folate levels, etc.

Stay positive and keep yourself active and engaged as much as possible. If you are feeling amotivated, then scheduling your activities in advance will help you stay functional. Exercise regularly and eat healthy. Do cut down on your cigarettes. Keep talking to someone about your feelings as it may help you offload some burden at least and make you feel supported.

Wish you all the best.

- Dr. Jonas Sundarakumar
Consultant Psychiatrist

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Hello again and thanks for writing in.

It's very nice to hear that you are putting in a lot of dedicated effort. I always tell my patients that they should consider medication as only one part of therapy. So, trying other psychological and self-improvement techniques, as well as making appropriate lifestyle adjustments are equally important.

It's quite okay to take vitamin supplements along with Avanza. If possible, it's better to take a multivitamin supplement with b complex, folic acid and vitamin c.

Wish you all the best.

- Dr. Jonas Sundarakumar
Consultant Psychiatrist

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Hi again,

We generally avoid two antidepressants together, unless monotherapy with at least two different classes of antidepressants have failed at their full therapeutic doses. This is because there is a higher risk of side effects with combination medication. If 30mg of Avanza is not working for you, further options can be increasing the dose to 45mg or switching to a different class of anti-depressant or may be augmentation with some other medication (e.g. an anti-anxiety medication or a small dose of a mood stabilizer). Your doctor will be able to suggest you the best-suited option after assessing your progress objectively.

Best regards,

- Dr. Jonas Sundarakumar
Consultant Psychiatrist

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Hi again and thanks for writing in.

Avanza (Mirtazapine) in fact, has a side effect of causing sleepiness, which is often used to the benefit of patients who have sleep problems. Aropax (Paroxetine) does not usually have a side effect of causing sleepiness, but sometimes can disturb sleep. This is the reason why your doctor may have thought that Avanza would be a good option for you. So, if Aropax had worked well for you and you had to stop it only due to the insomnia, then technically it doesn't qualify as a failed trial of anti-depressant.

So, like I had mentioned earlier, there are is still an option of switching to another anti-depressant class. If sleep disturbance has been a significant problem in the past, then further switch options would be to put you on another sedating antidepressant e.g. Venlafaxine or to put you on a non-sedating SSRI anti-depressant and add a small dose of a non-addictive sedative like Trazadone (which is also another anti-depressant, but is frequently used in very small doses along with SSRIs, for its sedtive properties)

During your review, you can have a discussion with your doctor about the various options.

Best regards,

- Dr. Jonas Sundarakumar
Consultant Psychiatrist

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Hello again,

A flu-like syndrome can occur in a small percentrage of people, with many anti-depressants including Avanza. However this is usually limited to mild symptoms like sore throat, mild congestion, body ache, slight fever, etc. They usually occur during the first few days of treatment and should subside within a week or two.

It would be worthwhile to wait for a couple of weeks more on this dosage. But if the ringing is still persisting and you havent seen much progress, then you'll have to consider other options. Anyway, let's stay optimistic and hope that you'll see further improvement as the medication takes full effect.

Best wishes,

- Dr. Jonas Sundarakumar
Consultant Psychiatrist

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Hello again,

Well, I would say that it's not essential, given your age and the fact that you don't have any significant neurological signs or any known medical conditions or risk factors. If the headache or tinnitus is really bothering you, I would advise you to see a neurologist for a detailed evaluation, and if he still feels that it may be worthwhile to do a brain scan after examining you, then you can go in for it.

Wish you all the best.

- Dr. Jonas Sundarakumar
Consultant Psychiatrist

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Hello again,

Glad to hear that your mood has improved. I think this is more to do with your regular exercise and XXXXXXX breathing which must definitely be helping you by acting as a de-stressor, by keeping your mind off the anxious and depressive thoughts as well as giving you an over all 'feel-good' factor. The other possibility could be that your depression was just taking time to lift (in it's own course) and the decrease in dose may just be co-incidental.

I would suggest that you take this opportunity to keep building-up on the improvement that you have sustained. 'Coz it's difficult to stay motivated and put in more efforts when you are at a low. So, I think you should 'ride this wave' continue to put in more efforts, think more positively and streamline your thoughts.

By the way, why did your doctor decide that you come off the Avanza? Are there any other plans of switching over to another medication or trying psychotherapy?

Regards,
Dr. Jonas Sundarakumar
Consultant Psychiatrist

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Thanks for the reply. That sounds like a reasonable plan. In the meantime, stay positive and be persistent in your efforts, and I'm sure you'll continue to do well.

Avoid stress as much as possible. Don't take too much which you can't handle. Take one step at a time.

Ensure that you get 7 to 8 hours of continuous sleep ay night (not less, not more also)

Along with the XXXXXXX breathing and regular exercise, also learn not to get carried away into a downspiral when you get anxious / negative thoughts (This is one of the core concepts in CBT). With practise, it is possible to decide which thoughts to allow and which to reject. Remember, your thoughts determine your mood and behaviour. So, you have to be vigilant and prevent negative thoughts from taking hold. As soon as you become aware of anxious / negative thoughts, you should learn to detach from these thoughts. Tell yourself that they are like passing clouds and that if you ignore them, they will pass away soon.

Best wishes,
Dr. Jonas Sundarakumar
Consultant Psychiatrist

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Hi,

The symptoms which you have mentioned such as tenderness / soreness of the nasal bridge and left eye could be due to a migraine or a sinusitis. Heaviness of the head or generalized headache can be a symptom of withdrawal from Mirtazapine, but not the kind of specific pains you are having. If however, you do have any other symptoms such as difficulty in sleeping, nausea, heaviness of the head, dizziness, etc. then it may be a better idea to take 7.5 mg of Mirtazapine for a week or two before stopping it completely.

Regards,
Dr. Jonas Sundarakumar
Consultant Psychiatrist

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Hi again,

It's not advisable to take both Lexapro and Valium in the morning, since Valium will cause drowsiness and if you end up being sleepy in the morning, then the night's sleep is gonna be disturbed. So, I would advise you to take Lexapro in the morning and Valium at night (1 hour prior to your indended bed time). This will keep ensure that you stay awake and active in the morning and help you to sleep well at night.

Regards,
Dr. Jonas Sundarakumar
Consultant Psychiatrist

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