Mirtazapine, Tinnitus and other Antidepressants.

Mirtazapine is a tricyclic (older style) anti-depression medication. It's used in particular when the patient also has insomnia and/or anxiety because it's been found to have beneficial effects on those conditions.

Unfortunately, it has been found to have specific side-effects for some patients. Tinnitus, ototoxicity (hearing damage) and musical hallucinations have been reported. The worst of these side effects are very, very rare. There are only a few case reports and these cases have underlying psychological conditions that are likely more impactful than the Mirtazapine.

While reviewing the literature on Mirtazapine for a specific tinnitus patient today, I searched for tinnitus and anti-depressant literature, and concluded that there is no stand-out alternative. SSRI and tricyclic antidepressants are both often linked to tinnitus. It seems inescapable that a proportion of people who begin anti-depressant treatment will link tinnitus symptoms to use of the medicine. As all tinnitus patients will have that 'first day' where they notice their tinnitus, it does not mean that the drug is necessarily at fault.

Depression and anxiety are common in people who are distressed by their tinnitus. antidepressants are therefore even more likely to be falsely linked to tinnitus than other medications.

Where mirtazapine differs slightly is that tinnitus has been linked with finishing a course of the drug, and withdrawing from it. In the case of tinnitus sufferers who are already on mirtazapine then, they would want to withdraw slowly. Stopping any anti-depressant is usually done slowly, and under the guidance of the prescribing doctor, so there is no real change here.

I realise this blog post is not particularly reassuring or concrete! It is not clear from even the most up to date literature that there is any one brand or type of anti-depressant that is 'best' for tinnitus sufferers - or one that is worst.

However, I have some general advice if you are looking for information:

• Even if a medication has tinnitus listed as a side-effect, it does not mean you will get it or that yours will worsen

• If your doctor has already started you on anti-depressant medication, continue it until you see them and ask them for advice on how/when to stop it. Follow their guidance.

• If you strongly feel your tinnitus has worsened or begun due to the new medicine, seek the doctor's advice ASAP and ask them if a different medication might be more suitable for you. If your doctor is dismissive of your concerns, please seek a second opinion.

• Doctors work in your best interests and generally decide on medications that are more likely to do more good for you than it is to harm you.

• Anti-depressants have been found to help with depression, anxiety and over-activity of your emotional responses. These medication effects can help you manage your tinnitus distress, especially when combined with seeking specific tinnitus support and advice.

• I have noted from anecdotal/clinical experience that if a medication is going to make your tinnitus more prominent, it usually happens very quickly on starting or stopping. I also note that patients who see an increase in tinnitus symptoms on starting a medication can find it is temporary; it causes a spike but not permanent change,

Above all, whatever caused your tinnitus, whatever made it spike, the solutions are always the same. Seek support (my blog is a good place to start!), distract yourself, do not dwell on the tinnitus signal. Once you have had a checkup with an audiologist/doctor, do not dwell on the cause of it either - it's done. Look to the future and how you are going to move on to habituating.

References:

Zhang V, Opler DJ. A side effect you’ve never heard of: ototoxicity associated with mirtazapine. Prim Care Companion CNS Disord. 2024;26(6):24cr03795.

Vos D, Nicholson D, Johnson M, Gottschalk D. The Effectiveness of Serotonin and Tricyclic Antidepressants in Tinnitus Management: A Rapid Review. The Internet Journal of Allied Health Sciences and Practice. 2023 Sep 21;21(4), Article 19.

Robinson, S. Antidepressants for treatment of tinnitus. Progress in Brain Research. 2007;pp263-271

Langguth et al. Persistent tinnitus induced by tricyclic antidepressants. Journal of Psychopharmacology. 2010; 24(8)