Dr. Rego has seen incredible changes in patients with severe depression who were struggling with profound anxiety, insomnia, and suicidal thoughts and taking strong doses of antipsychotic medication and SSRIs. After taking an MAOI, their symptoms \u201cvanished.\u201d<\/p>\n
After her husband passed away, Sue Trupin fell into a deep depression that lasted 3 years. During this time, she tried over 10 different medications in different combinations. She was hospitalized twice. She received 12 sessions of electroconvulsive therapy. Finally, a new psychiatrist prescribed the MAOI tranylcypromine (Parnate).<\/p>\n
As Trupin writes in her eloquent piece<\/a>, \u201cAbout 10 days later, sitting in my parked car, I heard on the radio the legendary jazz saxophonist Ben Webster. A shiver of pleasure invigorated me. Later in the day, I bought bags of fresh food at the market, smiled at a chubby baby, and became overwhelmed by the devotion of a friend. The lights were blinking brightly, and then miraculously they were staying on. I\u2019ve been well now for four years, in my right mind because of an old, inexpensive, and uncommonly prescribed drug.\u201d<\/p>\n Discovered in the late 1950s, MAOIs have a well-established history of efficacy, particularly in managing\u00a0difficult-to-treat depression. *<\/p>\n So why aren\u2019t MAOIs prescribed more often?<\/p>\n For starters, today\u2019s psychiatrists may have less experience with this drug class, said Kristina Deligiannidis<\/a>, M.D., an associate professor at\u00a0The Feinstein Institutes for Medical Research at Northwell Health.<\/p>\n In his editorial, Much Ado About Nothing<\/a>, Australian neuropharmacologist and MAOI expert Ken Gillman, M.D., cites research that\u2019s found this to be true.<\/p>\n Gillman also notes that \u201cthe ability to properly manage MAOI treatment should be in the repertoire of all psychiatrists. It is regrettable that this is not the case.\u201d In fact, Gillman is part of the \u201cInternational MAOI Expert Group,\u201d which includes clinicians, academics, and researchers.<\/p>\n In this statement<\/a>, he and his colleagues note that the \u201cgroup was formed in March 2018 to promote actions aimed at: improving education; stimulating research; increasing clinical usage; and assuring continued availability of MAOIs worldwide.\u201d<\/p>\n While MAOIs aren\u2019t the right choice for everyone, Dr. Deligiannidis noted that they \u201cshould be considered part of a comprehensive treatment plan\u201d for individuals with treatment-resistant depression or atypical depression. She defined atypical depression as \u201cmood reactivity, significant weight gain or increase in appetite, hypersomnia, leaden paralysis, and long-standing pattern of interpersonal rejection sensitivity.\u201d<\/p>\n There are other reasons MAOI use has declined\u2014reasons that have more to do with misunderstandings than actual facts. Below, you\u2019ll find several common concerns followed by the reality.<\/p>\n One of the biggest concerns with prescribing MAOIs is that patients won\u2019t be able to adhere to the stringent diet that\u2019s required. This means abstaining from foods that are high in the amino acid tyramine because of the danger of a hypertensive crisis (a severe spike in blood pressure that can lead to stroke).<\/p>\n However, today, this stringent diet isn\u2019t actually all that stringent.<\/p>\n According to Rego, \u201cYou have to almost go out of your way to get a [hypertensive] reaction.\u201d He gives patients taking MAOIs a simple list with foods that aren\u2019t allowed and foods that are allowed in moderation.<\/p>\n Deligiannidis noted that in the past, some foods that were believed to have high tyramine levels contain little or no tyramine, including: raspberries, chocolate, avocadoes, bananas, and Chianti wine.<\/p>\n Plus, as Gillman notes in his editorial, because of recent changes in food production techniques, the once high concentrations of tyramine in foods such as aged cheeses, salami, and soy sauce have significantly diminished. In fact, today, many matured cheeses\u2014once thought to be dangerous\u2013 have negligible concentrations of tyramine, he writes.<\/p>\n Combining certain drugs with MAOIs can cause serotonin syndrome, also known as serotonin toxicity. Serotonin syndrome can range in severity and can be fatal. Some individuals have mild symptoms, such as increased blood pressure and heartbeat, dilated pupils, sweating, shivering, and twitching muscles. Others can additionally have hyperthermia, agitation, and frenetic speech. In severe cases, individuals have all of these symptoms, along with muscle rigidity, delirium, and rapid, dramatic swings in pulse rate and blood pressure.<\/p>\n According to Rego, taking the over-the-counter cough suppressant dextromethorphan, along with an MAOI, can cause serotonin syndrome. So can taking an SSRI or SNRI.<\/p>\n Fortunately, these drug interactions are \u201call easily avoidable,\u201d Rego said. He noted that he\u2019s less concerned about patients making a mistake, and more concerned about them going to the hospital where the staff is unaware that they\u2019re taking an MAOI or doesn\u2019t understand how MAOIs work.<\/p>\n To avoid this, he stresses the importance of wearing an alert bracelet or a pendant\u2014just like you would if you had severe allergies or diabetes.<\/p>\n It\u2019s common for individuals to be taking an SSRI or SNRI before trying an MAOI. To avoid serotonin syndrome, it\u2019s important to have a \u201cwash-out\u201d period. This is when individuals need to wait weeks for their bodies to eliminate a drug before they can start the new one. Understandably, during this time, there\u2019s a concern that depression symptoms will worsen.<\/p>\n Consequently, Rego prescribes medication to help bridge this gap. For example, if a patient is taking Zoloft, he might prescribe a benzodiazepine to manage anxiety, and lithium to manage mood during the 2-week waiting period. He also recommends patients alert their loved ones about the change and get extra support; make sure they\u2019re getting enough sleep and rest; and keep stressors at bay.<\/p>\n Therapy also is a critical part of a comprehensive plan, and could help tremendously during this transition.<\/p>\n Rego noted that there are four licensed MAOIs in the U.S. Selegiline (Emsam) is an MAO-B inhibitor, which comes in a skin patch. The other three MAOIs are non-selective. \u201cMarplan is almost never used [simply because] we\u2019re not that familiar with it,\u201d Rego said. \u201cNardil is commonly used, but it\u2019s sedating and causes weight gain.\u201d<\/p>\n Rego prefers Parnate and noted that it \u201cshould be everyone\u2019s number one choice.\u201d \u201cIt\u2019s the easiest to take and doesn\u2019t make you tired or gain weight.\u201d The only significant side effect, he said, is that it\u2019s stimulating. Which is why whenever he\u2019s prescribing any antidepressants, Rego asks patients how well they can tolerate caffeine. If they mention adverse reactions (e.g., faster heartbeat, shortness of breath), Rego might prescribe a medication to control anxiety until the stimulating effects wear off.<\/p>\n MAOIs won\u2019t work for everyone. For example, they\u2019re typically contraindicated for people with severe personality disorders. That\u2019s because, Rego said, these individuals tend to be impulsive, struggle with suicidal thoughts (and attempts), and engage in self-injurious behavior. Which means they can intentionally take a medication that interacts with their MAOI, he said.<\/p>\n However, for some individuals with severe depression, MAOIs can be transformative. As Rego said, \u201cIt is not an exaggeration to say, it can change a person\u2019s life.\u201d And that means physicians must become experts in prescribing MAOIs and offer them as a viable option when other antidepressants haven\u2019t worked.<\/p>\n * For example, here\u2019s a\u00a02013 review on MAOIs<\/a>; a\u00a02017 review on tranylcypromine<\/a>\u00a0(Parnate); and an article on MDedge Psychiatry<\/a>. <\/em><\/p>\n Visit Original Source<\/a><\/p>","protected":false},"excerpt":{"rendered":" Many people with clinical depression have tried an array of medication and still feel sick. Maybe they\u2019ve tried different selective serotonin reuptake inhibitors (SSRIs) or selective norepinephrine reuptake inhibitors (SNRIs). Maybe they\u2019ve taken these antidepressants along with an antipsychotic (a common strategy to boost effectiveness). Either way, the lack of <\/p>\n Read More<\/a>Concern: Too Restrictive Diet<\/h3>\n
Concern: Serotonin Syndrome<\/h3>\n
Available MAOIs<\/h3>\n
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Shared by Margarita Tartakovsky, M.S., Contributing Blogger<\/a> November 27, 2019<\/p>\n