Plain English Summary
Background and study aims
Depression is common and most depressed patients are treated by their general practitioner (GP). Antidepressants are very widely prescribed, but a substantial proportion of those who take them do not get better. There is very little evidence to guide GPs when this happens, and most are unsure what to do when their patients do not respond to the medication. Many patients remain in a depressed state for long periods of time, despite taking antidepressant treatment. We are looking for other ways to help those whose depression does not respond to initial treatment, and we think that it might be useful to use combinations of antidepressant drugs. Combination treatments are used in many areas of medicine, including other common conditions such as hypertension and diabetes. Most of the antidepressants prescribed in the UK as first line treatment are Selective Serotinin Reuptake Inhibitors (SSRIs) like Fluoxetine (Prozac). However, there is another well-established antidepressant called Mirtazapine, that works in a different way from SSRIs and the related noradrenaline reuptake inhibitors (SNRIs). We propose a large study in general practice, where most depression is treated, to examine the effectiveness and cost-effectiveness of the combination of mirtazapine and an SSRI or SNRI.
Who can participate?
Patients from primary care who are depressed and have taken an SSRI or SNRI antidepressant for at least six weeks without substantial benefit. They must be aged between 18 and 75 and must not be suffering from a psychotic disorder or be dependent on drugs and alcohol. They must not be pregnant.
What does the study involve?
Participants who agree will be randomly allocated to receive either mirtazapine treatment or a dummy drug (placebo) that appears identical. Neither the participant, GP, or study investigator will know whether the participant is taking mirtazapine or placebo. They will continue to take their SSRI antidepressant and be treated by their GP in the usual way.
What are the possible benefits and risks of participating?
If it proves effective, this combination has the potential to rapidly make a difference for people with depression that does not respond to usual first line antidepressant treatment. Mirtazapine has been licensed in the UK for the treatment of depression since 1994, and its adverse effect profile is well known. Its principal effects are increase in appetite, weight gain and drowsiness. Mirtazapine continues to be used in psychiatric settings in combination with other antidepressants without the reporting to date of any unexpected or new adverse events.
Where is the study run from?
Bristol University. The other participating centres are the Universities of Exeter, Manchester and York.
When is study starting and how long is it expected to run for?
The study begins in January 2013 and will run for 42 months
Who is funding the study?
NIHR Health Technology Assessment Programme (HTA)
Who is the main contact?
Dr David Kessler
david.kessler@bristol.ac.uk
Study website
Contact information
Type
Scientific
Contact name
Dr David Kessler
ORCID ID
http://orcid.org/0000-0001-5333-132X
Contact details
University of Bristol
School of Social & Community Medicine
Oakfield House
Oakfield Grove
Bristol
BS8 2BN
United Kingdom
-
david.kessler@bristol.ac.uk
Additional identifiers
EudraCT/CTIS number
IRAS number
ClinicalTrials.gov number
Protocol/serial number
HTA 11/129/76
Study information
Scientific title
A double blind placebo-controlled randomised trial of the addition of mirtazapine for patients with depression in primary care who have not responded to at least 6 weeks of treatment with a selective serotonin reuptake inhibitor or serotonin and noradrenaline reuptake inhibitor.
Acronym
MIR
Study hypothesis
That the addition of mirtazapine will improve outcome in depressed patients from primary care who have not responded to an SSRI antidepressant after at least 6 weeks of treatment.
Ethics approval(s)
South East Wales Research Ethics Committee C, 25/01/2013, ref: 12/WA/0353
Study design
A two parallel group multi-centre pragmatic placebo-controlled randomised trial with allocation
at the level of the individual
Primary study design
Interventional
Secondary study design
Randomised controlled trial
Study setting(s)
Hospital
Study type
Treatment
Patient information sheet
Not available in web format, please use the contact details to request a patient information sheet
Condition
Depression
Intervention
The addition of Mirtazapine to SSRI antidepressants
Added 27/07/2017:
To investigate whether combining mirtazapine with Serotonin-Noradrenaline Reuptake Inhibitor (SNRI) or Selective Serotonin Reuptake Inhibitor (SSRI) antidepressants results in better patient outcomes and more efficient NHS care than SNRI or SSRI therapy alone in Treatment Resistant Depression (TRD).
Design: MIR is a two-parallel group, multi-centre, pragmatic, placebo controlled, randomised trial with allocation at the level of the individual.
Interventions: Participants are randomised to receive either oral mirtazapine or matched placebo, starting at 15mg daily for two weeks and increasing to 30mg daily thereafter, for up to 12 months to be taken in addition to their usual antidepressant.
Intervention type
Drug
Pharmaceutical study type(s)
Phase
Not Applicable
Drug/device/biological/vaccine name(s)
Mirtazapine
Primary outcome measure
Change in Beck Depression Inventory score at 12 weeks (added 27/07/2017: measured using the BDI-I) measured as a continuous variable
Secondary outcome measures
Current secondary outcome measures:
The following are measured at 12, 24, and 52 weeks:
1. Response
2. Remission of depression symptoms
3. Changes in anxiety symptoms
4. Adverse Effects
5. Quality of life
6. Adherence to antidepressant medication
7. Health and social care use
8. Time off work
9. Cost effectiveness
All outcomes are analysed on an intention to treat basis.
Previous secondary outcome measures:
1. 50% improvement in BDI score (remission)
2. A measure of anxiety (GAD7)
3. Quality of life (EQ-5D-5L)
4. Health care utilisation
Overall study start date
01/01/2013
Overall study end date
30/06/2016
Reason abandoned (if study stopped)
Eligibility
Participant inclusion criteria
1. Aged 18-75 years
2. Currently taking any of the following SSRI or SNRI antidepressants, for at least 6 weeks at recommended (BNF) doses:
2.1. Fluoxetine
2.2. Sertraline
2.3. Citalopram
2.4. Escitalopram
2.5. Fluvoxamine
2.6. Paroxetine
2.7. Duloxetine
2.8. Venlafaxine and who have done so for at least 6 weeks at
3. Patients who score 14 or more on the Beck Depression Inventory (BDI)
4. Patients who have adhered to their medication and meet ICD-10 criteria for depression (assessed using the Computerised Interview Schedule Revised version (CIS-R))
Participant type(s)
Patient
Age group
Adult
Lower age limit
18 Years
Upper age limit
75 Years
Sex
Both
Target number of participants
400
Participant exclusion criteria
GPs will be asked to exclude patients who have bipolar disorder, psychosis or alcohol/substance abuse/dependence or who are pregnant. In addition, we will exclude patients who: are not able to complete the study questionnaires or have a past history of an adverse reaction to mirtazapine.
Recruitment start date
01/01/2013
Recruitment end date
30/06/2016
Locations
Countries of recruitment
England, United Kingdom
Study participating centre
University of Bristol
Bristol
BS8 2BN
United Kingdom
Study participating centre
University Of Exeter Medical School
St Lukes Campus
Magdalen Road
Exeter
EX1 2LU
United Kingdom
Study participating centre
Keele University
Primary Care And Health Sciences
Keele
ST5 5BG
United Kingdom
Study participating centre
Hull York Medical School
Cottingham Road
Hull
HU6 7RX
United Kingdom
Sponsor information
Organisation
University of Bristol (UK)
Sponsor details
c/o Dr Birgit Whitman
Research Governance and Compliance Manager
Research and Enterprise Development
Senate House
Tyndall Avenue
Bristol
BS8 1TH
England
United Kingdom
-
Birgit.Whitman@bristol.ac.uk
Sponsor type
University/education
Website
ROR
Funders
Funder type
Government
Funder name
Health Technology Assessment Programme
Alternative name(s)
NIHR Health Technology Assessment Programme, HTA
Funding Body Type
government organisation
Funding Body Subtype
National government
Location
United Kingdom
Results and Publications
Publication and dissemination plan
Planned publication in a high-impact peer reviewed journal.
Intention to publish date
Individual participant data (IPD) sharing plan
The current data sharing plans for the current study are unknown and will be made available at a later date
IPD sharing plan summary
Data sharing statement to be made available at a later date
Study outputs
Output type | Details | Date created | Date added | Peer reviewed? | Patient-facing? |
---|---|---|---|---|---|
Protocol article | protocol | 03/02/2016 | Yes | No | |
Results article | results | 31/10/2018 | Yes | No | |
Results article | results | 01/11/2018 | Yes | No | |
Results article | qualitative study results | 14/12/2018 | Yes | No | |
HRA research summary | 28/06/2023 | No | No |