Does “California Rocket Fuel” Work?
The combination of Effexor (venlafaxine) and Remeron (mirtazapine) has been dubbed “California Rocket Fuel” by Stephen Stahl (see page 290 of his Essential Psychopharmacology, 2nd Edition) because of the multiple ways the combination boosts various neurotransmitter systems. The STAR-D study found that this combination outperformed the MAOI Parnate (tranylcypromine), though the difference was not statistically significant (McGrath PJ et al., Am J Psychiatry 2006; 163(9): 1531-1541). Psychiatrists in Ireland recently reported on a series of 32 patients with refractory depression who were given this combination. The response rate, based on the Clinical Global Impression Scale, was 44% at four weeks and 50% at eight weeks. Most patients who responded were on Effexor XR at 225 mg/day or higher and Remeron 30 mg to 45 mg HS. In terms of side effects, 12% of patients reported moderate to severe weight gain and another 12% reported at least moderate sedation (Hannan N et al., J Psychopharm 2007;21(2):161-164).
Since this is only a case series, it doesn’t prove the value of Effexor/ Remeron, but the combination is fairly well tolerated and certainly worth trying in patients who have not responded to anything else.