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Table of Contents
Year : 2020  |  Volume : 3  |  Issue : 1  |  Page : 69-70

Mirtazapine for the treatment of psychosis in Parkinson’s disease: Any silver linings?

Department of Neurology, MedStar Georgetown University Hospital, Washington, District of Columbia, USA

Date of Submission23-Feb-2020
Date of Decision04-Mar-2020
Date of Acceptance08-Mar-2020
Date of Web Publication01-Apr-2020

Correspondence Address:
Dr. Abhishek Lenka
Department of Neurology, MedStar Georgetown University Hospital, Washington, DC 20007.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/AOMD.AOMD_9_20

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How to cite this article:
Lenka A. Mirtazapine for the treatment of psychosis in Parkinson’s disease: Any silver linings?. Ann Mov Disord 2020;3:69-70

How to cite this URL:
Lenka A. Mirtazapine for the treatment of psychosis in Parkinson’s disease: Any silver linings?. Ann Mov Disord [serial online] 2020 [cited 2023 Mar 21];3:69-70. Available from: https://www.aomd.in/text.asp?2020/3/1/69/281753

Dear Editor

I appreciate the letter to the editor on the review article on “Approach to the management of psychosis in Parkinson’s disease” published in the last issue of the journal.[1] The author has highlighted the potential role of mirtazapine in the treatment of psychosis in Parkinson’s disease (PD). Mirtazapine is a potent tetracyclic antidepressant having a complex mechanism of action. It augments norepinephrine and serotonin release through central presynaptic α2-adrenergic antagonistic effects. In addition, mirtazapine also antagonizes 5-hydroxytryptamine2 (5-HT2), 5-hydroxytryptamine3 (5-HT3), and H1 histamine receptors.[2] As pointed out by the author, a number of case reports have observed clinically meaningful amelioration of psychotic symptoms by mirtazapine in patients with PD.[3],[4],[5] However, the biggest problem lies in the fact that we do not have further evidence to justify the claim that mirtazapine leads to a promising therapeutic avenue for PD-associated psychosis. Moreover, several reports have documented acute psychosis after initiating treatment with mirtazapine.[6],[7] Hyponatremia, delirium, and drowsiness have also been noted as the side effects of mirtazapine.[8] In view of these adverse effects and the lack of higher level of evidence, mirtazapine does not stand out well among the currently available pharmacological options (pimavanserin, quetiapine, and clozapine) for PD-associated psychosis. In summary, mirtazapine seems to be far from being recognized as a first-line agent for the treatment of psychosis in PD until we attain better insights into its role through larger clinical trials. However, the only silver lining would be the fact that mirtazapine can be preferred over other antidepressants if patients with PD have coexisting depression and psychosis. As depression is frequently associated with psychosis in PD,[9] treatment with mirtazapine while being vigilant about the aforementioned adverse effects may be effective.

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  References Top

Lenka A, Gomathinayagam V, Bahroo L. Approach to the management of psychosis in Parkinson’s disease. Ann Mov Disord 2019;2:83.  Back to cited text no. 1
  [Full text]  
Anttila SA, Leinonen EV. A review of the pharmacological and clinical profile of mirtazapine. CNS Drug Rev 2001;7(3):249-64. DOI: 10.1111/j.1527-3458.2001.tb00198.x  Back to cited text no. 2
Tagai K, Nagata T, Shinagawa S, Tsuno N, Ozone M, Nakayama K. Mirtazapine improves visual hallucinations in Parkinson’s disease: A case report. Psychogeriatrics 2013;13:103-7.  Back to cited text no. 3
Nagata T, Shinagawa S, Tagai K, Nakayama K. A case in which mirtazapine reduced auditory hallucinations in a patient with Parkinson disease. Int Psychogeriatr 2013;25:1199-201.  Back to cited text no. 4
Godschalx-Dekker JA, Siegers HP. Reduction of parkinsonism and psychosis with mirtazapine: A case report. Pharmacopsychiatry 2014;47:81-3.  Back to cited text no. 5
Felthous AR, Wenger PJ, Hoevet R. Acute psychosis associated with dissociated sleep-wakefulness state after mirtazapine treatment. Pharmacotherapy 2010;30:145e-50e.  Back to cited text no. 6
Padala KP, Padala PR, Malloy T, Burke WJ. New onset multimodal hallucinations associated with mirtazapine: A case report. Int Psychogeriatrics 2010;22:837-9.  Back to cited text no. 7
Ghosh A, Hegde A, Grover S. Mirtazapine-associated hyponatremia presenting as delirium. Indian J Pharmacol2014;46:448-9.  Back to cited text no. 8
[PUBMED]  [Full text]  
Lenka A, Herath P, Christopher R, Pal PK. Psychosis in Parkinson’s disease: From the soft signs to the hard science. J Neurol Sci 2017;379:169-76.  Back to cited text no. 9


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