Mirtazapine-Associated Hallucinations: Clinical Recognition and Management

Clinical Presentation

The American Heart Association, as published in Circulation, notes that serotonin syndrome can present with mental status changes, including agitation, hallucinations, delirium, confusion, or coma, as well as autonomic instability and neuromuscular symptoms 1
The ESMO guidelines, as reported in Annals of Oncology, highlight that antipsychotics and benzodiazepines can cause hallucinations and delirium, particularly in cancer patients 2, 4

The American Academy of Family Physicians recommends that elderly patients, who are particularly vulnerable to mirtazapine's neuropsychiatric side effects, should be monitored closely for adverse effects, including sedation and perceptual abnormalities 5
For cardiovascular patients, the American College of Cardiology, as published in Circulation, suggests that sertraline has a lower QTc prolongation risk than citalopram or escitalopram and has been extensively studied in this population 1
The American College of Cardiology also recommends avoiding tricyclic antidepressants and MAOIs due to cardiovascular side effects 1