Mirtazapine added to selective serotonin reuptake inhibitors for treatment resistant depression in primary care (MIR trial): study protocol for a randomised controlled trial

Background

People with depression are usually managed in primary care and antidepressants are often the first-line treatment, but only one third of patients respond fully to a single antidepressant. This paper describes the protocol for a randomized controlled trial (MIR) to investigate the extent to which the addition of the antidepressant mirtazapine is effective in reducing the symptoms of depression compared with placebo in patients who are still depressed after they have been treated with a Selective Serotonin Reuptake Inhibitor (SSRI) or Serotonin and Noradrenaline Reuptake Inhibitor (SNRI) for at least six weeks in primary care.

Methods/Design

MIR is a two parallel group, multi-centre, pragmatic, placebo controlled, randomised trial with allocation at the level of the individual. Eligible participants are those who: are aged ≥18 years; are currently taking an SSRI/SNRI antidepressant (for at least 6 weeks at an adequate dose); score ≥14 on the Beck Depression Inventory (BDI-II); have adhered to their medication; and meet ICD-10 criteria for depression (assessed using the Clinical Interview Schedule-Revised). Participants who give written, informed consent, will be randomized to receive either oral mirtazapine or matched placebo, starting at 15mg daily for 2 weeks and increasing to 30mg daily thereafter, for up to 12 months (to be taken in addition to their usual antidepressant). Participants, their GPs, and the research team will all be blind to the allocation. The primary outcome will be depression symptoms at 12 weeks post-randomisation, measured as a continuous variable using the BDI-II. Secondary outcomes (measured at 12, 24 and 52 weeks) include: response (reduction in depressive symptoms (BDI-II score) of at least 50% compared to baseline); remission of depression symptoms (BDI-II<10); change in anxiety symptoms; adverse effects; quality of life; adherence to antidepressant medication; health and social care use, time off work and cost-effectiveness. All outcomes will be analysed on an intention to treat basis.A qualitative study will explore patients’ views and experiences of either taking two antidepressants, or an antidepressant and placebo; and GPs’ views on prescribing a second antidepressant in this patient group.

Discussion
The MIR trial will provide evidence on the clinical and cost-effectiveness of mirtazapine as an adjunct to SSRI/SNRI antidepressants for patients in primary care who have not responded to monotherapy.

Trial registration: EudraCT Number: 2012-000090-23 (Registered Jan 2012); ISRCTN06653773 (Registered Sept 2012)

Funding: National Institute for Health Research (Health Technology Assessment)