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Mirtazapine (Remeron): Substantial weight gain: average 5-15 pounds in studies, often much more in practice Among the most weight-promoting antidepressants Strong H1 antihistamine effects drive appetite increase Carbohydrate cravings are particularly intense Weight gain may be more pronounced at lower doses (15-30mg) due to antihistamine predominance Highly sedating Increases risk of metabolic syndrome and diabetes When mirtazapine might be appropriate: Depression with severe insomnia where sedation is desired Depression with significant appetite loss and weight loss that needs to be reversed When SSRIs have failed and weight is not a concern Elderly patients with poor appetite (weight gain can sometimes be beneficial) When to avoid mirtazapine: Patients with obesity Patients with metabolic syndrome or prediabetes/diabetes Patients with eating disorders (binge eating disorder in particular) Patients who have previously gained significant weight on psychiatric medications Paroxetine (Paxil): Most weight-promoting SSRI Average 7-10+ pounds, can be much more with long-term use Weight gain often continues over months to years of use Mechanisms not fully understood but may include mild antihistamine effects and metabolic changes Also associated with cholesterol increases in some studies Difficult to discontinue (significant withdrawal/discontinuation syndrome) Overall paroxetine assessment: Among SSRIs, paroxetine should be avoided in patients with weight or metabolic concerns

The most concerning signals were for severe abdominal pain, cholecystitis, and reports of suicidality

Im switching medications When switching from semaglutide to another diabetes or weight management treatment, your provider may recommend a washout schedule

The dosing framework is similar but with additional glycemic monitoring requirements