Introduction

Are you struggling with difficult-to-treat depression, plus are you having any of the following:

• Low motivation with extreme difficulties starting tasks
• Lack of pleasure or enjoyment in things
• Mood that seems flat or numb?

If so, then read on to learn more…

What is Pramipexole (Mirapex)?

Pramipexole (tradename Mirapex) is a dopaminergic agent (i.e. it increases dopamine function) that has long been used in the treatment of Parkinson's disease and restless leg syndrome.

A grower evidence base suggests that it may have antidepressant properties, and as such, it has been used in studies of treatment-resistant depression for both depression and bipolar depression.

People that might benefit in particular are those with symptoms that suggest problems with dopamine, such as:

• Lack of pleasure (aka anhedonia)
• Lack of motivation
• Inability to initiate behaviours
• Unreactive mood

Dosage

Fawcett recommends the following (Fawcett, 2016): 

• Start at 0.125–0.50 mg at bedtime
  • Only dose once a day at bedtime unless the patient has trouble with sleep (rare).
• Increase to an initial target of 2 mg daily.
• Reassess and further increase up to 5 mg daily.
• Most people respond between 1-5 mg daily (aka therapeutic dose range).
• Go up slowly in younger patients.
  

When can results be seen?

• Expected benefit, if it occurs, by 4 weeks at maximally tolerated dose.

How to stop the medication?

• If it is decided to stop the medication, it can be stopped gradually. Avoid abrupt discontinuation because of the risk of dopamine agonist withdrawal syndrome (seen in as many as 1 in 7 patients).

Side Effects

More common side effects are

• Nausea,
• Sleepiness,
• Dizziness,
• Tremors

Less common side effects are

• Compulsive behaviours (such as pathologic gambling) reported in patients with Parkinson's disease and restless legs syndrome)
• Sleep attacks (usually only in patients with Parkinson's disease)
• Psychosis (rare) 

Are there mild side effects such as nausea?

• If so, then reduce the dosage for 1-2 weeks until nausea resolves.
• After that, try to raise the medication again after 1–2 weeks

For this reason, close monitoring of the medication is required, and if negative effects are severe and not improving, then the medication can be stopped.

Reference

Aiken CB. Pramipexole in psychiatry: a systematic review of the literature. J Clin Psychiatry. 2007 Aug;68(8):1230-6. PMID: 17854248.

Akdeniz F, Aldemir E, Vahip S. Tedaviye Dirençli Bipolar Depresif Dönemlerin Tedavisinde Düşük Doz Pramipeksolun Yeri [The role of low-dose pramipexole in the treatment of treatment-resistant bipolar depression: a case report]. Turk Psikiyatri Derg. 2009 Spring;20(1):94-8. Turkish. PMID: 19306131.

https://pubmed.ncbi.nlm.nih.gov/19306131/

Cusin C, Iovieno N, Iosifescu DV, Nierenberg AA, Fava M, Rush AJ, Perlis RH. A randomized, double-blind, placebo-controlled trial of pramipexole augmentation in treatment-resistant major depressive disorder. J Clin Psychiatry. 2013 Jul;74(7):e636-41. doi: 10.4088/JCP.12m08093. PMID: 23945458.

Fawcett J et al.: Clinical Experience With High-Dosage Pramipexole in Patients With Treatment-Resistant Depressive Episodes in Unipolar and Bipolar Depression. Am. J. Psychiatry, 2016 Feb 1.
https://ajp.psychiatryonline.o...

About this Document

Written by the eMentalHealth Team.

Disclaimer

Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from your health provider. Always contact a qualified health professional for further information in your specific situation or circumstance.

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