Antidepressants and Diabetes — MRCPsych Paper B MCQ

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ModerateMood DisordersAntidepressants and DiabetesMRCPsych Paper B

A 55-year-old man with type 2 diabetes has a depressive episode for which antidepressant treatment is being considered. He is particularly concerned about gaining weight because of its potential adverse metabolic consequences. Which antidepressant is most strongly associated with weight gain and would therefore be least attractive if minimising weight gain were the priority?

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Correct answer: E — Mirtazapine

Mirtazapine is the best answer. Its UK SmPC lists increased appetite and increased weight as very common adverse effects, and a large UK primary-care cohort found that mirtazapine had the strongest association with clinically significant weight gain among the antidepressants studied. This makes it relatively unattractive when avoiding weight gain is an important metabolic priority, although treatment must still be individualised. Amitriptyline is the most plausible distractor: it can cause weight gain and may alter insulin and glucose responses, but its observed association with weight gain was lower than mirtazapine’s in the comparative UK study. Sertraline, fluoxetine and duloxetine can also produce weight change, particularly during long-term treatment, so they should not be described as invariably weight-neutral; however, they are less strongly associated with weight gain than mirtazapine. Weight gain raises metabolic concern but does not inevitably worsen an individual patient’s glycaemic control.

Reference: Gafoor R, Booth HP, Gulliford MC. Antidepressant utilisation and incidence of weight gain during 10 years’ follow-up: population based cohort study. BMJ. 2018;361:k1951. https://www.bmj.com/content/361/bmj.k1951