Sir: While alcohol dependence is highly prevalent, pharmacotherapy options for its management remain relatively limited 1 or underutilized.2 Mirtazapine is indicated for the symptomatic treatment of depression. We report a case in which mirtazapine aided the treatment of a depressed alcoholic man, speculating that its 5-HT 3 antagonism may have contributed to its beneficial effect on his alcoholism. Case report. Mr. A was a 59-year-old married white man with early-onset (prior to 25 years of age) 3 DSM-IV-TR alcohol dependence, consuming 26 ounces of Scotch daily over the past 5 years. He previously had experienced delirium tremens. His alcohol use was characterized by loss of control with legal charges and serious impairment in his work and marriage due to his drinking.Mr. A was hospitalized in July 2004 after a suicide attempt following 6 months of daily depressed mood associated with anhedonia, decreased appetite, insomnia, poor concentration, and anergia. He also described ongoing uncontrollable worry and daily panic attacks and was using alprazolam at a dose of 0.5 mg/day. Prior trials of citalopram, paroxetine, sertraline, and fluoxetine adequate in dose and duration were ineffective in treating his mood and anxiety or altering his alcohol use. Prior residential addiction treatment resulted in only brief periods of abstinence. Liver function test results at admission were abnormal with a γ-glutamyl transpeptidase (GGT) level of 417 U/L (normal level, < 63 U/L), an aspartate aminotransferase (AST) level of 124 U/L (normal level, < 40 U/L), and an alanine aminotransferase (ALT) level of 184 U/L (normal level, < 60 U/L).The patient was admitted to the hospital and detoxified via chlordiazepoxide taper (initially 50 mg/day) over 5 days. Motivational interviewing promoted further addiction treatment and abstinence. His suicidality resolved, but he remained overtly depressed with marked anxiety and sleep disturbance. Mirtazapine was introduced on day 4 of his hospitalization and titrated to 30 mg/day for management of his depression. Based on clinical observation and patient report, his mood improved and sleep normalized after 9 days in the hospital, allowing him to be followed thereafter as an outpatient.At 3 months, Mr. A reported an absence of depression and insomnia, decreased anxiety, and continuous abstinence from alcohol and benzodiazepines with resolution of his liver function test abnormalities (GGT = 48 U/L, AST = 23 U/L, ALT = 22 U/L).