A Week and a Day With Mirtazapine

On May 11, 2010, I attended my appointment with Dr. "A", the pdoc (psychiatrist). Most of my behavior with him is consistent with borderline personality disorder: giving out details not related to self to related to family of origin, but being vague about my own complaints.

At the conclusion of my first interview with Dr. "A", he writes me a script for mirtazapine at 15 mg to be taken at 1-2 pills nightly for one month (60 pills). He then states that serotonin may cause nausea, and I get the impression would have similar effects to Selective Serotonin Re-uptake Inhibitor (SSRI) antidepressants.

When the pdoc came to medication, I selected mirtazapine because my initial on-line research gave it a good safety profile for the average North American, which I am not.

For I am a Japanese-Canadian person, 51 years old, and male. IMHO the cultural and genetic (ethnic) background of all the mirtazapine test groups probably did not include a lot of Asians, but it should because of the Asian sensitivity to psychopharmaceuticals (psychiatric medication or pmeds). (See Ethnicity and psychopharmacology APT(1999), vol.5,p.91; A Psychiatric Residency Curriculum About Asian-American Issues Academic Psychiatry 26:225-236, December 2002)

On the other hand, my pdoc is Anglo-Canadian, and landed immigrant from the UK. Schooled in Western psychiatry, he's been trained to overlook my ethnic background and treat only my brain. Yet his faith in the "magic" of psychiatric medication had led him to assume my brain, physiologically, is like any other brain.

However, the following week only proves to me that my brain and my body is not made to take pmeds at the recommended doses.

In the following journal entries, I've redacted MHC professionals names to letters of the alphabet to protect their privacy. As well, when I need to comment on a journal entry, the commentary is quite obvious.

According to BC provincial health protocol for mental health, a mental health consumer (me) is assigned a case worker with a Bachelor's of Social Work at the local office, a pdoc to figure out which medication is prescribed, and a pyschotherapist with the expertise and qualification to handle the particular issue (integration of person of color into Western culture with focus on family of origin).

Even though there may be opinionated statements in this article, in no way do they reflect upon the professionals in a negative light. Any reader naïve to my style of hyperbole and its multifaceted confabulation should take a lot of salt to what they are about to digest...

SHK 20100522.0605
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Tuesday, May 11, 9:08 PM
I read up on Mirtazapine, and according to what I've read, it does not cause nausea. In fact, it relieves nausea. The antihistamine effect is stronger than hydroxyzine, though.

Reference: http://en.wikipedia.org/wiki/Mirtazapine

Tuesday, May 11, 9:40 PM
At 9:30 PM, I've taken the first mirtazapine dose (15 mg). Within the past ten minutes, I felt "better", which may be due to the antihistamine effect.

Also, the pain from a cold sore on my upper lip and earache in the right ear have faded somewhat. This may be due to moderate peripheral α1 adrenergic antagonism. [Commentary: It's actually due to the antihistamine effect.]

Tuesday, May 11, 9:51 PM: Hopefully the hypotension will be manageable. I just feel relaxed because of the antihistamine's effect. None of the nausea appeared at all, which proves that it is not a side effect.

Tuesday, May 11, 10:05 PM
The mellowness is a plus, though I have moderate difficulty in forming my thoughts.

Yet there is no real anxiety about this. I really like this effect, but feel that it's preventing me from freely expressing myself in the journal.

Currently, I just want to meditate while on mirtazapine. The more I focus on concentrating, the less I want to use that concentration to write.

There is very little anxiety, and if there is anxiety, then I do not feel it impeding my thoughts.

Tuesday, May 11, 10:17 PM
I ate a donut, and had a multivitamin. The mirtazapine's effects are still happening: calmness, mellowness, a sense of joy, serendipity, serenity... these words barely describe the feeling.

Yet not a tinge of nausea is present.

Tuesday, May 11, 10:36 PM
Oh, yes! I finished a bottle of water without thinking, thanks to mirtazapine.

[Commentary: Within an hour, I've turned off my computer because the sedative effect of 15 mg of mirtazapine has overtaken me.]

Wednesday, May 12, 12:21 PM
This morning I got up at around 10 AM. I spent the morning writing, but wrote only briefly about Buddha Nature. It seemed easily to read than it did to write. Though I am not surprised by the mood swing side effect, IMHO it should be easier to control because of experience with my changes in mood.
[Commentary: "mood swing side effect" refers to agitation, restlessness, irritability, aggression. On waking up at around 9 AM, I felt malaise or lassitude. After shaking off this feeling, I wrote in my Spiritual Journal about Buddha Nature, which will be added to my Buddhist notes as Buddhahood.]

Thursday, May 13, 9:52 AM
The mirtazapine appears to have worsened the cold sore and mouth cankers I had on the day I filled my prescription. I have fever blisters on my upper lip, and my mouth has been dry on waking.

I am getting mouth and skin rash/lesions because of side effect of Mirtazapine.

http://doublecheckmd.com/EffectsDetail.do?dname=mirtazapine&sid=13590&eid=6621#selist

I also have enlarged lymph nodes as a result of infection.

The 30 mg dose also makes me feel more aggressive, angry, hostile, and mean. Though, I'm sure that what it actually does is moderate impulse control negatively.

Friday, May 14, 9:11 AM
Today I called the MHC (Mental Health Centre) and reported the symptoms I've been experiencing, which now includes fever and swollen upper lip.

The medication causing these symptoms is mirtazapine. Tuesday evening, I took 15 mg at bedtime; and Wednesday evening, 30 mg.
After experiencing the physical symptoms, the use of mirtazapine was discontinued Thursday, but the only medication used Thursday evening was one 10 mg dose of hydroxyzine to act as a sedative.

So the physical symptoms are fever, sore throat, mouth ulcers, skin lesions, and fever blisters.

The psychological symptoms are: depression, aggression, agitation. There also is a negative self image due to skin lesions on the face.

Friday, May 14, 10:46 AM
Dr. "A" called back, and I gave him the list of symptoms I had. He confirmed that I had discontinued mirtazapine as of Thursday. While he stated that hydroxyzine may be too expensive for me to use, and that he may be recommending other medication, since I have 8 capsules left, IF the swollen upper lip and face becomes a problem, then I will take hydroxyzine tonight at bedtime.
[Commentary: the pdoc also claimed that mirtazapine usually never has that effect. This is true, but it did contribute to a change in body chemistry which IMHO lowered my WBC rapidly enough for the zoster virus to activate as shingles. It also indirectly worsened my psychoneurotic behaviorisms I exhibit when not able to express myself by either read, writing, and writing in my journal on the computer.]

Friday, May 14, 2:23 PM
Since I am able to tolerate the pain, I want to tough out the symptoms. The reason is, I am not in very much discomfort. This is why when the roommate expressed her concern, I wasn't willing to agree that it needs a doctor to be looked after properly.

IMHO, swollen lymph nodes mean that my body is fighting off the infection. Fever means that the infection is bad, but not life threatening.

However, before deciding to act, the symptoms need to be much worse than this.

[Commentary: Between 3:00 PM and 6:00 PM I visit Emergency Ward at the local hospital.]

Friday, May 14, 6:03 PM
It turns out that the mirtazapine may have reactivated the herpes zoster virus (chicken pox) as shingles.

http://en.wikipedia.org/wiki/Herpes_zoster

After getting my condition diagnosed at the hospital, the emergency doctor gave me a prescription for acyclovir, a potent antiviral drug, which is to be taken 5 x daily for 7 days.

So I have to take 5 times daily Acyclovir for a week, religiously, and preferably with food, from May 14 until May 20.

Friday, May 14, 6:14 PM
The lesions and fever blisters are due to herpes simplex zoster (originally chicken pox), which reactivated as shingles. Most likely, mirtazapine played an indirect part in reactivating it.

IMHO influenza may have reactivated the herpes virus, and both hydroxyzine and mirtazapine may have been the most recent trigger, due to their effect on the immune system via histamine suppression.

When I took my first dose, Mirtazapine had a strong histamine rebound effect on me.

Friday, May 14, 7:46 PM
On Monday (May 16) I intend to call Dr. "A" to update him about the symptoms I previously attributed to mirtazapine.

It turns out that the dormant herpes zoster virus reactivated, IMHO due to a combination of stress, including the use of hydroxyzine & recently mirtazapine.

After getting my condition diagnosed at the hospital, the emergency doctor gave me a prescription for acyclovir, a potent antiviral drug, which is to be taken 5 x daily for 7 days.

[Commentary: when I compare the name of my pdoc in this entry with the previous entry on Fri, May 14, 10:46 AM, his name has changed in this entry. Nine hours have passed by this point.]

Saturday, May 15, 11:40 PM
One side effect of recovery from mirtazapine I noticed was mild hallucinations where I see a comic book. [Commentary: though this can be attributed to having finished inventory on the last 30 comics in my collection. These hallucinations only occur when I am tired, IMHO as a reminder from my subconscious to take a break from whatever I am doing at the moment and rest. I also have a dream later on that night, though 72 hours later, no recall of details of that dream remain, due to it being trivial in nature.]

Sunday, May 16, 1:54 PM
The right side of my face is slightly swollen. There are two lesions under the eye near the nose, two across the cheek, three on the right side of the nose, and one large one at the top of the middle of the upper lip. They all follow a serpentine pattern from eye to upper lip. This is the symptom of shingles.

http://en.wikipedia.org/wiki/Dermatomic_area

Monday, May 17, 10:58 AM
At 10:41 AM I called up the MHC, and got Dr. "A" surname wrong. After the initial confusion experienced with the receptionist, I left a message for my caseworker, "B", mentioned the herpes (shingles), being medicated for it, being on hydroxyzine, and asking if I could return to mirtazapine at 7.5 mg on May 23 after the hydroxyzine runs out.

Monday, May 17, 6:08 PM
Quite possibly the activation of shingles (herpes zoster) was precipitated by a rapid onset of neutropenia.

This is similar to the case study online:
http://psy.psychiatryonline.org/cgi/content/full/50/3/299?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=mirtazapine&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT

Tuesday, May 18, 8:32 AM
I just thought of something: improvement of my neutrophil count, to lower the risk of mirtazapine causing a bad reaction.

For now, it's in my best interest to get a baseline blood test done.

[Commentary: this entry is important to explain the next entry.

Eating a lot more than I usually do when not ill should improve the neutrophil count, as well as taking the antiviral medication.]

Tuesday, May 18, 6:50 PM
After updating "B" Monday through voice-mail, there's been no response from Dr. "A" regarding returning to Mirtazapine. Also, my research on-line about mirtazapine indicates that returning to the drug may reduce my ANC (absolute neutrophil count) and WBC (white blood count). The symptoms of being on Mirtazapine from May 11 to 12, were similar to hypomania. [Commentary: IMHO it seems similar to cyclothymia. However, when I've been isolated on the computer for more than 4 hours, I may become mute and may show irritability to interruption of my current activity. This is probably one of the symptoms of the borderline personality disorder.]

From Friday May 14 until Sunday May 16 it felt more like a return to depression, but I attribute that feeling to change in self-image due to the temporary disfigurement shingles causes when it affects the face.

Self-care has been reduced, and every second or third day I spend too much time behind the computer, in an attempt to avoid facing with the reality effectively.

[Commentary: Actually, being on the computer almost continuously for almost 10 hours had led to a deterioration of mood and behavior around 6:30 PM.]

Recommendations:

From pdoc, ask for SCID-DSMIV diagnosis.
Request starting dose of mirtazapine at 3.75 mg indefinitely.
From GP, ask for blood test to get baseline.

Friday, May 21, 9:38 PM
Update: so I called the MHC, inform the receptionist of what I've learned about mirtazapine, and the shingles which results from its use. 15 minutes later the psychologist calls back to tell me to discuss it with my GP.

After talking to my GP, he told me that he can't approve of any reduction in dosage for mirtazapine, and that the pdoc will have to try another medication. At this point, I replied "I really rather stick with mirtazapine at the lowest dose ( less than 3.75 mg) possible than try an SSRI!"

Why? Because the pdoc made it seem like he'll be playing SSRI roulette until we find the correct dose, or even better, stuck on Seroquel or olanzapine because of a calculated risk with an SSRI.

Regarding Remeron, I've read its monograph from Health Canada, and it states that mirtazapine has antidepressant activity at 0.5 and 1.0 mg.

So, obviously, going from 15 to 30 mg over 48 hours precipitated the shingles (varicella zoster virus aka VZV ) reaction to rapid changes in my WBC.

Had I wisely titrated from 3.75 mg over a week, I wouldn't have gone through a week of pain to endure a few days of depressive psychosis ("I feel too self-conscious with this painful, blistering skin rash - and the painful neuralgia!"), only to recover a few days later, and make my psychologist's first interview.

Saturday, May 22, 5:02 AM
Addendum: If my math skills are up to snuff, it appears that mirtazapine's clinical trials have given enough statistics to help me calculate the number needed to cause harm.

That number is 17, but the odds are 1.25-1.75 to 1 that you'd get any one of the side effects. With paxil, the number needed to harm is 50, but the odds are like 2 to 1 i.e. you are twice a likely to get any side effect than you would with placebo.

Therefore, mirtazapine evens the odds ever so slightly. The only benefits in exchange for risk of lowering WBC that is appealing is its ability to tolerate nausea, and the lack of serotonin withdrawal symptoms which the SSRI and SNRI medications have in spades.

So I am going to build tolerance to mirtazapine by titrating using the hydration method i.e. dissolve 3.75 mg of the drug in about 250 ml water, let it sit for a few hours, and then sip it slowly.

Since that much water takes about 4-5 sips, I could titrate the drug over 4 hours, rather than ingest one half dose at bedtime. The only risk here is that of waking dreams, which the literature calls "hallucinations".

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References:

1. Ethnicity and psychopharmacology APT(1999), vol.5,p.91: http://apt.rcpsych.org/cgi/reprint/5/2/89.pdf
   
2. A Psychiatric Residency Curriculum About Asian-American Issues : http://ap.psychiatryonline.org/cgi/content/full/26/4/225
   

Ethnopsychopharmacology: http://en.wikipedia.org/wiki/Ethnopsychopharmacology

Varicella Zoster virus: http://en.wikipedia.org/wiki/Varicella_zoster_virus
Zoster reactivation worst case: http://www.hivinsite.org/InSite?page=kb-05-03-01


Statistics involving pharmacology:
Number needed to harm: http://en.wikipedia.org/wiki/Number_needed_to_harm

Health Canada Database for Drugs:
http://www.hc-sc.gc.ca/dhp-mps/prodpharma/databasdon/index-eng.php
Both hydroxyzine and mirtazapine have lots of pages about their pharmacology and toxicology. The Health Canada website should have the main monograph to make the probability statistics.