Mirtazapine, bupropion and multimodal antidepressants — consultant viva

Opening (30–45 seconds)

These agents are phenotype-driven alternatives and sequential options after SSRIs/SNRIs: mirtazapine (NaSSA), bupropion (NDRI), and multimodal drugs such as vortioxetine, vilazodone and agomelatine. I match mechanism to sleep–appetite versus energy–sexual–smoking problems, name oral doses, and refuse casual polypharmacy or MAOI improvisation.[1][9][10]

Core viva map

1. Define NaSSA. Mirtazapine enhances NA/5-HT via α2 antagonism; 5-HT2/5-HT3 block; H1 drives sedation/appetite — not an SSRI.[1]
2. Define NDRI. Bupropion inhibits NET/DAT; minimal SERT; nAChR link to smoking cessation trials.[7]
3. Dose mirtazapine. Adult 15 mg nocte → 30–45 mg; lower start in frail; low-dose sedation pearl.[1][10]
4. Dose bupropion XL. 150 mg then 300 mg oral daily; respect labelled maxima and seizure risk.[6]
5. Seizure red flags. Eating disorders, withdrawal states, prior seizures, high dose/IR peaks.[6]
6. STAR*D switch. Bupropion-SR ≈ sertraline ≈ venlafaxine-XR after SSRI failure.[2]
7. STAR*D augment. Bupropion vs buspirone after incomplete SSRI response.[3]
8. Rocket fuel. Venlafaxine + mirtazapine is STAR*D L4 vs MAOI — low yield, specialist intensity.[4]
9. CO-MED. Do not routinely start two antidepressants on day 1 for all-comers.[5]
10. Vortioxetine cognition. Multimodal AD with RCT cognitive signal in depression — not a dementia cure.[8]
11. Cipriani humility. Modest rank differences; choose by tolerability phenotype.[9]
12. Guideline frame. RANZCP stepped formulation-based care.[10]

Hostile examiner prompts

"Isn't mirtazapine just a strong SSRI?"
No — primary story is α2 and receptor antagonism, not SERT blockade.[1]

"Patient has bulimia and low mood — bupropion 150 mg OK?"
No — eating disorder is a classic seizure-risk contraindication context; choose another agent.[6]

"Why not rocket fuel tonight after one failed SSRI?"
Because L4 data are late-step/low-remission and CO-MED argues against unselected early dual therapy.[4][5]

"Prove smoking indication."
Jorenby NEJM trial of bupropion SR ± nicotine patch for cessation.[7]

Close

Mechanism → phenotype → dose → red flags → named trials (STAR*D, CO-MED, Jorenby, McIntyre) → guideline humility. That is consultant-level prescribing of these atypical and multimodal antidepressants.[2][5][9][10]