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Mirtazapine /venlafaxine

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A 40 year old man with depression is on Mirtazapine 45 mg and Venlafaxine 225 mg. He has shown little improvement, he also has memory problems which is a longstanding problem due to previous head injury, your next option is

 

stop ven and add lithium

stop mirt and add lithium

ect

 

ans was stop mirt add li.

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I've seen a different scenario where a patient is on a same combination of antidepressants but presenting with a current mixed state and answer was to stop venlafaxine and add lithium.

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Mixed state should be treated as mania, so I quite understand why Venlafaxine should be stopped. I have no clue why Mirtazapine should be stopped in a depressed patient with cognitive impairment (by the way, it seems that Mirtazapine has got an enhancing effect on cognitive functions). Maybe only because 2 antidepressants + lithium is too much? :)

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