Mirtazapine for Depression with Anorexia — SCE Palliative Medicine MCQ

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ModeratePsychological & PsychiatricMirtazapine for Depression with AnorexiaSCE Palliative Medicine

A 68-year-old man with advanced COPD on palliative care has developed clinical depression. His appetite is poor and he is losing weight. Which antidepressant would be most appropriate to treat both his mood AND stimulate appetite?

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Correct answer: B — Mirtazapine 15 mg at night

Mirtazapine is the only antidepressant in this list that reliably combines antidepressant efficacy with appetite stimulation and weight gain—a critical advantage in this palliative care context. Unlike SSRIs (citalopram, sertraline, fluoxetine), which do not stimulate appetite and may even cause weight loss early in treatment, mirtazapine blocks alpha-2 adrenergic autoreceptors and 5-HT2/5-HT3 receptors, promoting appetite and improving sleep quality alongside mood improvement. Evidence from randomized controlled trials in cancer patients shows mirtazapine achieves both significant depression score improvement and sustained weight gain within 4 weeks. The dose of 15 mg at night is standard in palliative practice, minimizing daytime sedation while maintaining appetite and sleep benefits. Venlafaxine may cause weight gain but does so inconsistently and as a side effect, not as a primary therapeutic mechanism. For a patient with overlapping depression, anorexia, and weight loss, mirtazapine addresses all three simultaneously.

Reference: Mirtazapine in Cancer-Associated Anorexia and Cachexia: A Double-Blind Placebo-Controlled Randomized Trial; Palliative Medicine, 2021; https://pubmed.ncbi.nlm.nih.gov/34051293/