Letters to the Editor
Functional Dyspepsia and Mirtazapine
Dear Editor:
Functional dyspepsia (FD), also known as nonulcer dyspepsia or
dyspepsia of unknown cause, refers to a complex of symptoms characterized
by pain or discomfort and bloating centred in the upper abdomen,
early satiety, fullness, and nausea. These upper gastrointestinal
symptoms are not associated with any structural abnormality demonstrable
by standard diagnostic investigations (that is, radiological, endoscopic,
and histological). There is no evidence that dyspepsia is exclusively
relieved by defecation or associated with the onset of a change
in stool frequency or stool form (1). FD is one of the most common
clinical problems in medical outpatients and is associated with
considerable health and economic burden (2). The available literature
reports that FD is associated with a higher lifetime prevalence
of psychiatric illness, predominantly anxiety and depressive disorders
(3,4). I report the efficacy of mirtazapine in treating a patient
with FD and depression.
Case Report
Ms A, a 54-year-old married woman with epigastric discomfort, fullness,
nausea, and postprandial bloating, was referred for what her gastroenterologist
had diagnosed as FD according to Rome II criteria (5). The FD symptoms
had been present episodically for the last 5 years and had been
virtually unremitting for the last 6 months. The results of extensive
medical evaluation, including esophageal manometry, 24-hour ambulatory
intraesophageal pH monitoring, and electrogastrography, were negative.
Her gastroenterologist had treated her with valium 2 mg 3 times
daily and cisapride 10 mg 3 times daily, with minimal improvement.
When Ms A was seen by a psychiatrist, she met the criteria for
major depression. She began treatment with mirtazapine 15 mg, which
was increased to 30 mg daily after 3 days. After 4 weeks, Ms A was
significantly improved and reported that mirtazapine had helped
her. She stated that she had a marked decrease in all FD symptoms
and an increased appetite. Her quality of life was measured with
the Medical Outcomes Study 36-Item Short Form Health Survey–Korean
version (SF-36-K), and depression was measured with Beck Depression
Inventory (BDI).
The limbic system is involved in emotion, mood, and visceral autonomic
control, and limbic abnormalities are seen in depression and functional
gastrointestinal disorder (6). These indicate the relation between
depression and FD. Studies of 5-HT3 antagonists indicate that this
pharmacologic class increases the threshold for the sensation of
first perception and pain and that 5-HT3 receptors mediate gastrointestinal
reflexes and secretion. This blunts the visceral perception, leading
to therapeutic efficacy in the inhibition of emesis and treatment
of functional motility disorders (7). Because mirtazapine is an
antidepressant with a postsynaptic 5-HT3 blocking effect (8), it
can be used to treat FD with depression.
Further study is needed of the relation between mirtazapine, depression,
and the psychophysiological reaction, such as gastric emptying in
FD, as indicated by electrogastrography.
Funding and Support
This paper was supported by Wonkwang University and Wonkwang Medical
Center in 2002.
References
1. Rees WD, Miller LJ, Malagelada
JR. Dyspepsia, antral motor dyspfunction and gastric stasis of solids.
Gastroenterology 1980;78:360–5.
2. Mendeoff AI. Epidemiology of functional gastrointestinal
disorders. In: Cey WY, editor. Functional disorders of the digestive
tract. New York: Raven Press; 1983. p 13–9.
3. Magni G, di Mario F, Bernasconi G, Mastropaolo G.
DSM-III diagnoses associated with dyspepsia of unknown cause. Am
J Psychiatry 1987;144:1222–3.
4. Benett E, Beasurepaire J, Langeluddecke P, Kellow
T, Tennant C. Life stress and non-ulcer dyspepsia: a case-control
study. J Psychosom Res 1991;35:579–90.
5. Drossman DA, Corraziari E, Talley NJ, Thomson WG,
Whitehead WE. The functional gastrointestinal disorders. 2nd ed.
Mclean (VA): Degnon Associates; 2000
6. Mega M, Cummings JL, Salloway S. The limbic system:
an anatomic, phylogenetic, and clinical perspective. J Neuropsychiatry
Clin Neurosci 1997;9:315–30.
7. Delvaux M, Louvel D, Mamet JP. Effect of alostron
on response to colonic distension in patients with irritable bowel
syndrome. Aliment Pharmacol Ther 1998;12:849–55.
8. Montgomery SA. Safety of mirtazapine : a review.
Int Clin Psychcopharmacol 1995;10 (Suppl 4):37–45.
Sang-Yeol Lee, MD
Seung-Ho Rho, MD
Suck-Che Choi, MD
Iksan, Republic of Korea
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