Mirtazapine induced nightmares in an adult male

Abstract

A 21-year-old medical student was prescribed mirtazapine 15 mg once daily at bed time for his depressive symptoms. After taking the drug for approximately 2 weeks,he again presented to the psychiatry outpatient department with a history of severe nightmares almost every night. During history taking, he could recollect few of the horrifying experiences that he dreamt of. In one of the dreams he saw an unknown person trying to stab him with a knife. In another, he saw himself tied up to a pole over the bridge and gun shots hitting him from the sides. In the third, he visualized his girlfriend dead under a collapsed building. He also reported dreaming about his own cremation proceedings going on at a barren place, while he was still alive. Each time he woke up with confusion, palpitations, sweating and fear. In addition, he complained of malaise, confusion and increased sedation during day time, while on therapy. The drug was consequently stopped and, not surprisingly, the nightmares disappeared completely within a couple of days.Thereafter,he was put on fluoxetine and no such episodes were reported.On careful evaluation of past history, it was found that the patient had shown poor compliance to mirtazapine a few years back and had experienced similar nightmares. Therewasnohistoryofconcomitantuseofothermedications (including herbal medicines) or alcohol intake.The temporal relationship between the initiation of treatment with mirtazapine and onset of nightmares and their disappearance with discontinuation of the drug, and also their