Banerjee S, High J, Stirling S, Shepstone L, Swart AM, Telling T, Henderson C, Ballard C, Bentham P, Burns A, Farina N, Fox C, Francis P, Howard R, Knapp M, Leroi I, Livingston G, Nilforooshan R, Nurock S, O'Brien J, Price A, Thomas AJ, and Tabet N
Background: Agitation is common in people with dementia and negatively affects the quality of life of both people with dementia and carers. Non-drug patient-centred care is the first-line treatment, but there is a need for other treatment when this care is not effective. Current evidence is sparse on safer and effective alternatives to antipsychotics. We assessed the efficacy and safety of mirtazapine, an antidepressant prescribed for agitation in dementia., Methods: This parallel-group, double-blind, placebo-controlled trial-the Study of Mirtazapine for Agitated Behaviours in Dementia trial (SYMBAD)-was done in 26 UK centres. Participants had probable or possible Alzheimer's disease, agitation unresponsive to non-drug treatment, and a Cohen-Mansfield Agitation Inventory (CMAI) score of 45 or more. They were randomly assigned (1:1) to receive either mirtazapine (titrated to 45 mg) or placebo. The primary outcome was reduction in CMAI score at 12 weeks. This trial is registered with ClinicalTrials.gov, NCT03031184, and ISRCTN17411897., Findings: Between Jan 26, 2017, and March 6, 2020, 204 participants were recruited and randomised. Mean CMAI scores at 12 weeks were not significantly different between participants receiving mirtazapine and participants receiving placebo (adjusted mean difference -1·74, 95% CI -7·17 to 3·69; p=0·53). The number of controls with adverse events (65 [64%] of 102 controls) was similar to that in the mirtazapine group (67 [66%] of 102 participants receiving mirtazapine). However, there were more deaths in the mirtazapine group (n=7) by week 16 than in the control group (n=1), with post-hoc analysis suggesting this difference was of marginal statistical significance (p=0·065)., Interpretation: This trial found no benefit of mirtazapine compared with placebo, and we observed a potentially higher mortality with use of mirtazapine. The data from this study do not support using mirtazapine as a treatment for agitation in dementia., Funding: UK National Institute for Health Research Health Technology Assessment Programme., Competing Interests: Declaration of interests SB reports personal fees and non-financial support from Lilly; personal fees from Boehringer-Ingelheim, Axovant, Lundbeck, and Nutricia; and honoraria from the Hamad Medical Service for lectures and talks; outside the submitted work. He is a Trustee of the Alzheimer's Society and has research grants from UK National Institute for Health Research (NIHR), Economic and Social Research Council, and Engineering and Physical Sciences Research Council. AB reports being National Clinical Director for Dementia at NHS England and receiving professional fees from NHS England, personal fees from International Journal of Geriatric Psychiatry, personal fees from lectures and talks and from medico-legal reports and the Driver and Vehicle Licensing Authority, outside the submitted work. CB reports grants and personal fees from Acadia, Lundbeck; personal fees from Roche, Otsuka, Novartis, Eli Lilly, Suven, Sunovion, ADDEX, and Exciva; personal fees and travel expenses from Synexus, Novo Nordisk; and travel expenses from Biogen; outside the submitted work. PB reports work as a paid consultant for TauRx Therapeutics outside the submitted work. RH reports grant support from NIHR and being a Trustee of Alzheimer's Research UK. JO reports personal fees from TauRX Therapeutics, Axon, GE Healthcare, Roche, and Eisai; non-financial support from Alliance Medical; and grants from Merck; outside the submitted work. NT reports grant support from Avenir Pharma and NIHR Applied Research Collaborations and Comprehensive Research Network leadership roles. AJT reports grants from the NIHR Health Technology Assessment Programme, during the conduct of the study. All other authors declare no competing interests other than NIHR funding for investigator time on this grant., (Copyright © 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)