Research has shown that Mirtazapine has been effective in stimulating appetite in the elderly. We present a case series of three patients with Moderate Intellectual Disability, each presenting with intractable refusal to eat over several months. They did not have overt symptoms of depression according to carers and family. Two patients were being considered for Percutaneous Endoscopic Gastrostomy (PEG) feeding in view of their significant weight loss and deteriorating physical health.

Mirtazapine was introduced as an appetite stimulant, despite the apparent lack of depressive symptoms. All three patients experienced an improvement in their appetite within days of initiation of Mirtazapine, increasing their calorie and fluid intake and obviating the need for PEG feeding. During the following 3 months, the patients also developed an increased interest in activities, improved sleeping pattern and improved concentration.

These patients had very limited communication skills and there was little suggestion of depression at the time of assessment. The families and carers also did not feel that their relative was significantly depressed. Despite this, Mirtazapine had the two fold benefit of early appetite stimulation and, over the subsequent weeks, treating what in hindsight had been an underlying depressive episode. A lesson to be learnt is that primary refusal to eat, even in the absence of overt depressive symptoms may indicate an occult depressive episode in this patient group. We have shown that Mirtazapine can be an effective treatment in such cases and can prevent distressing medical intervention from having to be used.