MAOI phobia

[kohut]

Despite being some of the oldest and most effective antidepressants, many psychiatrists refuse to prescribe MAOIs due to overblown fears of hypertensive reactions and 5-ht syndrome. Patients non-responsive to citalopram and venlafaxine are given escitalopram and desvenlafaxine by supposedly expert medical practitioners whom have been inveigled by the lure of free lunches and neato pens. Because I have had the unfortunate luck to be one of these very patients I feel a moral obligation to destigmatize the use of MAOIs, which for me have been the only class of drug to provide consistent relief from depression. But don’t take my (lay) word for it: http://www.dr-bob.org/tips/split/MAOIs-in-high-doses-and-wi.html.

In the interests of full disclosure, I currently take 60mg Parnate along with Dexedrine 5mg tid and lorazepam 1mg prn for anxiety or sleep. I’ve gone through the SSRI carousel, and this combination has been infinitely more effective. My own rather simple analysis is that the etiology of my mood issues is primarily dopaminergic, and the Parnate in conjunction with dextroamphetamine provides a robust DA increase, whereas the SSRIs were actually decreasing DA through TH (tyrosine hydroxylase) downregulation.

It seems that many young and/or aspiring psychiatrists who have been inculcated in the terrible dangers of MAOIs frequent this board. It is my hope that sharing my experience will help others like me find the relief that MAOIs can provide as a second-line treatment rather than something considered only after one has undergone ECT.

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[OldPsychDoc]

The moderator in me was almost tempted to shut this down, but this poster does not ask for personal medical advice (despite their unabashed self-disclosure), and is not promoting a specific product. In addition--they raise a very interesting point worth discussing--ARE you adequately trained in the use of MAOIs? Why or why not? What has been your experience as clinicians with this class?

 

[strangeglove]

I'm sure I'm not as adequately trained in the use of MAOI's as psychiatrists trained 20 years ago. That said, I have prescribed them to a small number of patients during residency, and I can see that they are very effective drugs with significantly worse side effects than any other treatment for depression, including ECT. This is why I only start an MAOI after treatment with safer side-effect profiles have been found to be ineffective. That includes SSRIs and SNRIs (Effexor, etc.), as well as TCAs and in some instances ECT. I don't think anyone doubts the efficacy of MAOIs, but it would be foolish, in my opinion, to try this medication as a first or second line when much safer treatments have a good chance of causing remission. Of course, to a patient suffering from depression, this effort to be safe can seem like withholding an important treatment, especially in retrospect after achieving remission on an MAOI. Regarding the "SSRI carousel": there is no reason to put someone on another SSRI after one has already failed. There is definitely no reason to have someone on 2 SSRIs at a time.

 

[billypilgrim37]

Yeah, I think the guy I saw in December that almost died from a hypertensive crisis after his Parnate was bumped from 15mg to 20mg might want to deflate your enthusiasm just a bit. But at 15mg, a guy with probably 30 admissions in the past 5 years had been out of the hospital for six months. And the primary team nearly killed us when we recommended restarting the 15mg and treating the HTN.

Similarly, one of our best known borderlines, another high utilizer, is now flourishing with an ACT team, an IOP with heavy DBT emphasis, and the Emsam patch. And I think the latter actually deserves a good 33% credit for her recovery.

I'm glad to hear somebody sing the praises of the MAO-Is. But the message should be, "the terrible side effects are totally worth it!"

 

[Chrismander]

I'm sure I'm not as adequately trained in the use of MAOI's as psychiatrists trained 20 years ago. That said, I have prescribed them to a small number of patients during residency, and I can see that they are very effective drugs with significantly worse side effects than any other treatment for depression, including ECT. This is why I only start an MAOI after treatment with safer side-effect profiles have been found to be ineffective. That includes SSRIs and SNRIs (Effexor, etc.), as well as TCAs and in some instances ECT. I don't think anyone doubts the efficacy of MAOIs, but it would be foolish, in my opinion, to try this medication as a first or second line when much safer treatments have a good chance of causing remission. Of course, to a patient suffering from depression, this effort to be safe can seem like withholding an important treatment, especially in retrospect after achieving remission on an MAOI. Regarding the "SSRI carousel": there is no reason to put someone on another SSRI after one has already failed. There is definitely no reason to have someone on 2 SSRIs at a time.

Really? Wasn't part of the STAR*D algorithm to switch from celexa to either zoloft, bupropion, effexor or to augment? I don't have the paper in front of me but I thought there wasn't a significant difference between switching to zoloft vs. another class...

 

[kugel]

http://www.dr-bob.org/tips/split/MAO...es-and-wi.html

Your points are well taken. When patients are in severe distress and not responding to the typical treatments, we do need to think about trying things other than just "more of the same." Patients do have a right to know the alternatives, but that does not mean we have to offer everything that has ever been tried, esp if there are safer ones that are even more likely to be effective. Stimulants are a reasonable adjunct to antidepressants, but why not add them to antidepressants that aren't quite as likely to produce autonomic side effects before adding them to MAOI's?

The URL you posted is a series of emails from 1995, and those emails reference articles from 1985. That does not make them wrong, but it does bring up questions about how relevant they are after the advent of SSRI's and other antidepressants.

 

[Abacab]

Out of curiosity, how comfortable do the current psych residents/fellows out there feel using MAOIs? Personally, I only have one patient on MAOIs and don't feel that I would be very confident about using them safely when out there on my own. I don't know about other programs, but I just don't feel like I've had enough experience using MAOIs over the duration of my residency.

 

[kohut]

Thanks all for the replies. I realize my first post was a bit polemical, but I wanted to open up a dialogue that would hopefully make some here more amenable to atypical treatment modalities. It seems like no one here questions the efficacy of MAOIs, but rather their safety is of concern.

Kugel also mentions that the discussion from 1995 I linked to championing MAOIs may be out of date due to innovations in pharmacotherapy. I actually had a consultation with a physician involved in that discussion a few months back (he is the departmental head of psychiatry at a major medical school, fwiw). I will post a selection of his report which hopefully will be edifying:

"If he had a good response to addition of an MAO inhibitor to the TCA (nortriptyline), the combination would probably just be continued. If he had only a partial response, the MAO inhibitor-TCA combination could be augmented a number of ways. Mr. [Kohut's] hypothesis was that he might get a good response to addition of a stimulant, and this is a very reasonable supposition. Ritalin is usually easier to combine with MAO inhibitors than Dexedrine and other dopamine releasing drugs. Other potential augmenting agents include lithium, Neurontin, or pregabalin."

Many of these treatments are supposedly contraindicated, however they have been shown to be safe and effective in this doctor's experience. He also mentioned to me that most of the newer drugs are not helpful for refractory mood disorders, and that MAOIs are still pretty much the gold standard. Also, the concomitant use of a tricyclic with MAO inhibitors can drastically decrease the risk of hypertensive crisis (http://www.ncbi.nlm.nih.gov/pubmed/6123888?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_SingleItemSupl.Pubmed_Discovery_RA&linkpos=4&log$=relatedarticles&logdbfrom=pubmed), thus diminishing one of the main risks of MAO inhibitors.

To Billypilgrim: Tranylcypromine does have the unfortunate ability to induce spontaneous hypertensive crises in a small number of individuals (as described here: http://www.dr-bob.org/tips/split/Spontaneous-hypertensive-r.html). Hopefully the patient wasn't simply taken off of the Parnate without first breaking up the dose and/or treating the HTN using the pharmacolgic methods enumerated in the link. It seemed like he had a great response, it would be unfortunate to deny him efficacious treatment. Selegiline and moclobemide would be worth looking into if the problem persisted.

To Strangeglove: Yes, MAO-inhibitors carry greater risk than SSRIs and should not be tried until SSRI treatment has failed, however I must disagree with your opinion that ECT is safer than and should be considered before MAOI treatment. The psychiatrist I saw for my consultation and my current pdoc (a Weill graduate) agree with me. Because it is done in a controlled environment, ECT may certainly present less of a risk to the prescribing physician regarding malpractice and litigation, but I would hardly say it prevents fewer side effects to the patient. Inducing seizures is quite serious, and I personally believe it should not be done until fringe treatments such as tramadol or buprenorphine are attempted. It's no surprise that opioids make people feel better, and despite the addiction/tolerance risks many people have found long-term relief on these drugs (see Bodkin et al.).

I guess my question to everyone here is this: do you really think MAOI/stimulant/opioid treatment for refractory mood disorders is more dangerous than, say, ECT or other invasive procedures, or does the fear of litigation and malpractice lead you down the path of least resistance and perhaps cause a cognitive dissonance justification for more anemic treatment protocols and ECT?

 

[kugel]

do you really think MAOI/stimulant/opioid treatment for refractory mood disorders is more dangerous than, say, ECT?

The short answer is, "Yes!"

MAOI? Depends on case details, comorbid medical conditions, pt reliability, etc. Selegiline patch is definitely a reasonable possibility.

MAOI combination with stimulants? - very tricky. If the pt is extremely reliable and understands the risks, then I'd be willing to consider it AFTER looking at the research to see if I can find evidence that pt's who've failed multiple adequate other treatment modalities respond as often as they do to ECT. And AFTER we have tried other safer alternatives, like vigorous exercise program, intensive group/individual psychotherapy of different types, light therapy, other safer adjunct and combo pharmacology tx's.

MAOI/opioid combo? I can't imagine getting that far down a list of treatment options. Quite frankly, I don't know that I'll be in practice enough years to get that far down a list of options with any one patient. ECT would be much higher on my list, even in a world where lawyers don't exist.

In general, just because a published psychiatrist can provide anecdotal stories of success will not cause me to prescribe a treatment so fraught with problems when more reasonable treatments are available and have not been tried.

At least a couple times a week I have a patient threaten to sue me because I will not continue his/her outpatient treatment while in the hospital even though, "It's the only thing that works for me and my doctor prescribes it and you have no right to prevent me from having my prescribed treatment and I have a legal Medical Marijuana Card and everything!" My response is, "Our pharmacy will never carry it, and I'm not permitted to prescribe it here, and I wouldn't even if I was allowed. You can call your lawyer as soon as we get done talking. You always have that right and I'm more than happy to help you make the call. But for the time we have together, let's move on to talking about what I can do to try and help you while you're here."

 

[whopper]

I agree that several practitioners base their decisions with more influence from drug rep advertising and using the "easy way out" instead of real scientific basis.

But all in all--I still don't like to give out MAO-Is. I'd rather use polypharmacy with an SNRI or SSRI combined with a bupriopion, maybe even a little augmentation with buspirone, lithium, S-Adenosyl-Methionine and EPA (found in fish oil).

I am open to giving out MAO-Is, but I still don't like it.

I've only seen one patient so far where the person was depressed and no medication got her better. In her case, however, I don't think medication was the main issue. I think she suffered a major narcissistic injury (her mental illness lead to her losing a 7 figure job with major exposure in news outlets and the local community) and her bout with mental illness put her in a place where she could not get her job that she loved back.

In her situation I think the main thing that might have helped her was psychotherapy in dealing with the narcissistic injury, and yes, in her case MAO-Is were tried with no benefit.

 

[kugel]

Whopper makes a great point:
Anytime your treatment plan does not work (psych, gen med, whatever), it's important to reconsider the diagnosis. You might be wrong, or there might be co-morbidities of which you were unaware.

"We've certainly got other treatment options and we'll discuss those in just a moment, but let's go back and talk more about what led up to this - so we can be sure about where we're going."

And then do another psychiatric and medical review of systems, get more collateral info about the pt and the family history, review records to be sure pt got the correct prescribed treatments and was compliant, check for potentially interfering supplements/herbals or drugs/alcohol.

Axis II disorders and Substance Use disorders are commonly the complicating factors. Sometimes low intelligence is a critical issue in understanding your questions, pt's use of labels and terminology, correctly using treatments.

 

[Regnvejr]

History, history, history. Gotta know what they have been on in the past, and avoid the "more of the same" stuff. In my clinic intakes, if history indicates, we spend 10 minutes going through just about the entire psychotropic arsenal to get yes or no on past use, and how it worked (or at least who prescribed it). Very useful for when everything you do fails or makes them worse =8^0

I have used Parnate with good success (the benefit of a good VA residency rotation is exposure to MAOIs), but mainly in the chronically depressed but stable patients where nothing else really get them to the point where they can actually enjoy life. They better have good internal locus of control before I go with the old ones, but I have about 15 patients on them, and the patients sure swear by them. I will use ECT over MAOI when the patient has that pseudo-dementia "I can't even get out of the chair to kill myself" a-motivation, but otherwise the MAOI are very good at treating refractory depression. I will rather use MAOI than tripple-dosing SSRI, SNRI, Abilify/Seroquel/Lithium/Synthroid/whatever-augmentation-looks-appealing, not to mention Provigil which always take 2 mths of PA process to even get approved.

I have not done a lot of the Emsam, the pharmacies in town are not carrying them (I have trouble enough having them carry enough Dexedrine and Ritalin), so I have no experience with it, can only read about it with envy like I can read about a San Fransisco Sushi restaurant. Of course, one of the local family-owned pharmacies just shut down, so now I have to scramble to see if another pharmacy will carry the MAOIs. Else it's back to mail-order.

 

[kugel]

can only read about it with envy like I can read about a San Fransisco Sushi restaurant.

a perfectly good "antidepressant" itself, if the patient has a sufficient funding source.

 

[Regnvejr]

a perfectly good "antidepressant" itself, if the patient has a sufficient funding source.

 

[OldPsychDoc]

a perfectly good "antidepressant" itself, if the patient has a sufficient funding source.

High in omega-3s!

 

[hippiedoc13]

Unfortunately, I don't have any significant MAOI-prescribing experience to speak of in residency. I do think this is an area where my education is lacking, because they can be a tremendously powerful treatment for patients who have failed multiple trials of other, "safer" agents.

My personal experience with having a loved one start on an MAOI was amazing enough to make me a "believer" that for some patients, these medications can make all the difference. However my optimism at their efficacy has been tempered by seeing that the side effects are hard to tolerate, and most recently, I've been spooked after one of my favorite nurses got admitted to the ICU with a huge subarachnoid hemorrage secondary to hypertensive crisis--induced by accidentally eating a soy product that contained tyramine, and it turned out that person was taking an MAOI.

I wonder whether one of the reasons we don't get much MAOI experience these days is that it really requires the "right" patient--someone who is depressed enough and has failed enough other trials to warrant trying this class, but who is also intelligent and high-functioning enough to be able to navigate all the dietary restrictions, drug-interaction precautions, etc. At least in my residency, that's not the majority of our patient population.

Given the tremendous potential of these meds, but the caution required to use them appropriately, I really wish I had a lot more experience using them during residency.

 

[whopper]

Due to the high rate of side effects with MAO-Is and the lifestyle changes someone may have to make (e.g. the diet), I'd rather try polypharmacy with an SSRI or SNRI combined with wellbutrin and antidepressant augmentation with Buspirone, lithium and perhaps some non prescription supplements such as SAM-E before I'd try an MAO-I.

IMHO-giving out an MAO-I is similar to giving a patient a loaded gun--because it is very easy for a patient to do serious harm to themself with it.

Also factor that there may be other, non-pharmacological interventions that could be attempted--E.g. psychotherapy.

That said, each medication still has a place given the right circumstances. There will be some patients that may still need an MAO-I. At least know them because they will test you on them on the board exam.

 

[bth7]

Despite being some of the oldest and most effective antidepressants, many psychiatrists refuse to prescribe MAOIs due to overblown fears of hypertensive reactions and 5-ht syndrome. Patients non-responsive to citalopram and venlafaxine are given escitalopram and desvenlafaxine by supposedly expert medical practitioners whom have been inveigled by the lure of free lunches and neato pens. Because I have had the unfortunate luck to be one of these very patients I feel a moral obligation to destigmatize the use of MAOIs, which for me have been the only class of drug to provide consistent relief from depression. But don’t take my (lay) word for it: http://www.dr-bob.org/tips/split/MAOIs-in-high-doses-and-wi.html..
.
In the interests of full disclosure, I currently take 60mg Parnate along with Dexedrine 5mg tid and lorazepam 1mg prn for anxiety or sleep. I’ve gone through the SSRI carousel, and this combination has been infinitely more effective. My own rather simple analysis is that the etiology of my mood issues is primarily dopaminergic, and the Parnate in conjunction with dextroamphetamine provides a robust DA increase, whereas the SSRIs were actually decreasing DA through TH (tyrosine hydroxylase) downregulation. .
.
It seems that many young and/or aspiring psychiatrists who have been inculcated in the terrible dangers of MAOIs frequent this board. It is my hope that sharing my experience will help others like me find the relief that MAOIs can provide as a second-line treatment rather than something considered only after one has. undergone ECT..

This topic is SO important. I love the phrase "SSRI carousel." So many young psychiatrists treat depression with a never ending parade of SSR/NIs fearful of taking any risk. Totally unaware of the radically powerful antidepressant properties of MAOi and even TCAs. It's a sad state of affairs. Any PMD can (and should) prescribe Zoloft. But we're the ones who should be ready to offer the necessary options for treatment when 1st line treatments fail, which they so often do.

This notion of MAOi and some "extreme risk" is so grossly overblown.

 

[thoffen]

Anyone use Moclobemide before? Not FDA approved in US, but could be bought online from a legit manufacturer. It's a reversible monoamine oxidise-A inhibitor (RIMA), so should very much attenuate risk of hypertensive crisis and limit post-MAOI washout. Considered as a first-line option in some places.

 

[OldPsychDoc]

Anyone use Moclobemide before? Not FDA approved in US, but could be bought online from a legit manufacturer. It's a reversible monoamine oxidise-A inhibitor (RIMA), so should very much attenuate risk of hypertensive crisis and limit post-MAOI washout. Considered as a first-line option in some places.

Yep--was encouraged by an attending to try this in a couple of patients. I trained near enough to Canada that they could get it filled across the border.

 

[Liquid8]

I've only had limited exposure to a handful of cases involving MAOIs during my training. I'm not sure if the experience of residency in the US is comparable, but the majority of Psychiatry training in Australia occurs in the public system: one of the things I noticed is that we got a lot of exposure to low prevalence/high severity disorders (Schizophrenia, Bipolar or Depression with Psychotic features etc), but limited exposure to high prevalence disorders like depression and anxiety; which are generally considered not severe enough to be treated in that setting.

The first time I encountered them was actually prior to starting psychiatry. The patient had an atypical depression, a presentation that was not typically seen in an public acute inpatient setting, and was used as an instructive teaching case. Fast forward 5-6 years later towards the end of my training, the next time I saw it in use was when when working in a private setting, in chronic, treatment-resistant depression cases who had only had a partial/failed response to ECT (which also brings into question the diagnosis). Overall it had reasonable results, as long as the side effects could be tolerated.

I think MAOIs certainly have a place in our arsenal of psychopharmacological treatments; and as a specialist I think we should have some familiarity with this class of drugs although with the strict dietary requirements and potential for dangerous side effects it is hard to justify use while other options remain untried. It also needs the right kind of patient - a treatment resistant MDD, but with an high enough functioning or level of obsessiveness to manage the diet. From a medication perspective I'd favour an SSRI with less CYP450 interactions like escitalopram or sertraline, then mirtazapine or one of the SNRIs; then consider either augmentation, combination or TCA. We have access to moclobemide which can also be considered, but buproprion is very expensive in Australia (~$2 for a 150mg tablet). If there still hasn't been any improvement, at that point I'd probably consider ECT and MAOIs, and possibly a second opinion.

 

[cookymonster]

It's not that I'm afraid of MAO-I's. I just have a difficult time justifying them when I have all of these other options available, none of which have the same severity of drug and food interactions:

1. SSRIs
2. SNRIs
3. Bupropion
4. Mirtazapine
5. TCAs
6. Nefazodone
7. Vilazodone
8. Vortioxetine
9. ECT
10. Bright Light

So when should I use an MAO-I before any of these options? I guess it makes sense if cost is a big factor, the depression has strong atypical features, or the extremely rare circumstance that there's a family history of positive response to MAO-Is. Otherwise, what is the advantage?

 

[Shikima]

Forgot SGAs.

 

[hamstergang]

6. Nefazodone

Where do you live that this is still an option?

 

[splik]

Where do you live that this is still an option?

nefazodone is still fairly widely available. the brand was discontinued by BMS but generic nefazodone is still around.

 

[notdeadyet]

Where do you live that this is still an option?

I've used it. Definitely not a go to, but it's boogey-man status is over-hyped.

It's a viable alternative (or precursor) to ECT.

I think that in psychiatry, our treatment options are sometimes limited by a reluctance to do a deep read. Mentors say things like "never use MAOIs or nefazodone" and that gets taken off the table without reading the why (many folks don't know about Emsam or the actual hepatic risk of nefazodone). Which is interesting, because things like Lithium and ECT sound WAY scarier at first glance.

 

[Shikima]

I've used it. Definitely not a go to, but it's boogey-man status is over-hyped.

It's a viable alternative (or precursor) to ECT.

I think that in psychiatry, our treatment options are sometimes limited by a reluctance to do a deep read. Mentors say things like "never use MAOIs or nefazodone" and that gets taken off the table without reading the why (many folks don't know about Emsam or the actual hepatic risk of nefazodone). Which is interesting, because things like Lithium and ECT sound WAY scarier at first glance.

As I have no information about Nefazodone, how would one use this for stubborn depression symptoms?