![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 34. This is the beginning of the thread.
Posted by UgottaHaveHope on February 19, 2007, at 11:51:48
Based on the posts I've read on here and other places, it appears that if someone gives a MAOI a fair trail (at least two months) and does not have a medicinal conflict, they appear to almost always have a positive effect on depression, anxiety, etc., with the majority. (Of course, there are exceptions, as with any med).
I guess what I am trying to say, and this may be my own slanted perspective, is that it appears you hear less "unsuccess" stories about MAOIs than you do SSRIs, etc. Really, the only constant negative about MAOIs I read about everywhere are the dietary restrictions.
I realize "death" is not a fun side effect to think about with MAOIs, but on the other hand these drugs have been around so long (50 years) that the good news is that the restrictions and conflicts appear to be pretty well-documented, meaning it is pretty cut and dry on what to avoid. And, maybe this is just me, but the SSRIs can have dangers, too, hence the "black box" warnings.
So what do you think? Are MAOIs the "gold standard" for treatment of depression and anxiety? Are many people MISSING OUT by not trying them? In my opinion, a medicine around 50+ years (MAOIs) should've been kicked to the side decades ago, but there is something keeping them around. Something special.
Thoughts?
Posted by TheMeanReds on February 19, 2007, at 12:20:36
In reply to Are MAOIs ever ineffective?, posted by UgottaHaveHope on February 19, 2007, at 11:51:48
I think new drugs equal alot of money for the industry. But I guess I may be paranoid.
Posted by Phillipa on February 19, 2007, at 12:20:40
In reply to Are MAOIs ever ineffective?, posted by UgottaHaveHope on February 19, 2007, at 11:51:48
I'm afraid of them. Love Phillipa. I would have tried the EMSAM cause you can see it and the low patch now worries.
Posted by Declan on February 19, 2007, at 13:01:42
In reply to Re: Are MAOIs ever ineffective? » UgottaHaveHope, posted by Phillipa on February 19, 2007, at 12:20:40
PJ, IMO Emsam would not suit you as you suffer now from anxiety and insomnia.
MAOIs ever innefective? They are not always going to help. More than 10mg/d Parnate didn't really feel right with me, although 10 was reasonable. I suppose it depends on your brain chemistry.
Posted by Quintal on February 19, 2007, at 13:25:01
In reply to Are MAOIs ever ineffective?, posted by UgottaHaveHope on February 19, 2007, at 11:51:48
I've never read a report of someone actually dying from a hypertensive crisis on here despite the number who have used them. Hypertensive crises can be painful and scary, but they're not usually fatal. I get the impression most MAOI related fatalities are due to serotonin syndrome caused by drug-drug interactions rather than tyramine induced hypertensive crises caused by drug-food interactions.
I'm not sure everyone needs something so powerful for their symptoms, but yes, where people have tried standard drugs without success the MAOIs do seem to be more consistently beneficial than most other drugs bar opiates.
Q
Posted by halcyondaze on February 19, 2007, at 17:22:11
In reply to Are MAOIs ever ineffective?, posted by UgottaHaveHope on February 19, 2007, at 11:51:48
Well, there was the STAR*D depression study that found lower efficacy rates of Parnate as compared to Effexor XR + Remeron. However, the maximum dose was 60 mg/day and in people who had ALREADY failed the first four antidepressant stages, I'm guessing that 60 mg/day was simply not sufficient for most. Also, it was not "blinded" because they required that people do a 2 week washout (no wash out was required for the other group) as well as dietary restrictions. Many might have been uncomfortable with taking a MAOI, leading to a high drop out rate. Also, the two week washout period might have increased the depression from coming off the LAST medication in the 3rd stage of the trial and it was not given an adequate chance to work. Titration was pretty slow.
Posted by chiron on February 19, 2007, at 18:52:58
In reply to Are MAOIs ever ineffective?, posted by UgottaHaveHope on February 19, 2007, at 11:51:48
I think this Emsam patch is making me worse. I put it on last night & beginning this afternoon I feel like I have been slowly sinking (even though my day has been fine). This scares the hell out of me because I'm running out of options. The "death side effect" doesn't scare me, I'll do anything to feel better.
The literature in the Ensam package actually says that it may worsen depression or give you suicidal thoughts.
I know it is early, but I have found stories where people have felt better the next day. If this doesn't work I don't know what I'm going to do.
Posted by willyee on February 19, 2007, at 19:19:46
In reply to Are MAOIs ever ineffective?, posted by UgottaHaveHope on February 19, 2007, at 11:51:48
In a way its a lil simple,i think the serotionin theory is beginning to be a lil debuffed as simply raising a KNOWN FEEL GOOD chemical a bit which would obviously make most people feel better for a while,however i think and hope the serotonion obsession ends.
As far as Maois go,i believe the reason they are highly succesful is the same reason they also cause so much trouble,they are not SELECTIVE,they effect a wide range of chemicals,this does two things,
On the plus,opens up a pretty large THEPRUTIC WINDOW to hit on a troubled area.
SECOND ON THE FLIP SIDE,along with that is will also raise other chemicals that one does not really need,everyone differs,so each person can be sensative to a overload of a certain chemical,which may be why complaints often vary as well.
If you not POSITIVE ON THE PROBLEM,i dont see why you wont to be selective,as in ssris,id imagine youd want to touch on a few areas in hopes you might at least offer some reliaf.But again the problem here arises what to do when unwanted areas are affected?
Either way i washed my hands for life on ever using a ssri again and would go no med or herbs if maois became unavailable.
Also i dont think emsam should at this point even be regarded with the older maois such as parnate,nardil,and marplan,not even moclimice.
If you want to try a maoi,then the three above should be an option,if you afraid,then you really shouldent the side effects might be worse one day then the next and a person not sure of being on it will prob freak out.
If you go on a maoi,make the decision u want to do it,be sure,go full speed ahead.
Personaly i dont very few things worse than living with untreated depression,and id risk my life and have as i have recently laid upon a Er TABLE WITH TUBES IN ME and a large cup of activated charcoal due to reading stupid posts and trying stuff i knew better,but again i dont regret it,not even if i died on that table,i will die fighting it,not living suffering it.
Posted by Cecilia on February 19, 2007, at 21:33:16
In reply to Are MAOIs ever ineffective?, posted by UgottaHaveHope on February 19, 2007, at 11:51:48
Posted by lcat10 on February 19, 2007, at 22:21:40
In reply to Are MAOIs ever ineffective?, posted by UgottaHaveHope on February 19, 2007, at 11:51:48
Parnate once worked for me really well--around 20 years ago and worked well for the 8 or 9 years I took it. When I got depressed again a couple of years ago, I tried it again, and it no longer worked. I have now tried Emsam, and it didn't work either. Other than the MAOI's, I have not been able to tolerate antidepressants without adverse or allergic reactions before getting to a therapeutic dose, so I will be doing ECT in a couple of weeks once the Emsam is out of my system. Sorry for the sour note.
Posted by UGottaHaveHope on February 19, 2007, at 22:36:13
In reply to Re: Are MAOIs ever ineffective? » UgottaHaveHope, posted by lcat10 on February 19, 2007, at 22:21:40
There's always Nardil, and there's also taking a MAOI with a TCA, as some on this board have done (SLS, check archives).
Posted by Ken Blades on February 20, 2007, at 5:41:11
In reply to Are MAOIs ever ineffective?, posted by UgottaHaveHope on February 19, 2007, at 11:51:48
Nothing will work for everyone, every time;
some people respond well to things and some not at
all. You just have to try this-or-that and
see what works for you.Over the period of 30+ years I've been
on various antidepressants and antianxiety
drugs, Parnate has been the only thing that
has helped to any significant degree. I've
tried benzos; they work but the doses they
took to be effective also impaired my thinking
and reflexes. TCA's didn't do much for depression but caused a lot of bothersome side effects.
Serzone..Wellbutrin...nothing.
SSRI's either didn't work or in the case of Effexor, had an antidepressant effect in the
sense that it made me so emotionless that I
didn't feel depressed...or happy, or cared
about much of anything. I was no longer 'me'.I participated in a drug trial sponsored by
CIBA-Geigy[now Novartis]in the early 90's
for a drug, brofaromine, a type of MAO inhibitor
in the class with moclobemide[see below]. It
was the first time I knew I had social phobia..
prior to that, I was being treated for GAD and
depression.This drug really worked...I could FEEL it...I
couldn't believe the situations I could handle
where prior to this I would leave in a panic.
The trial went on for about nine months, and
then I was told the drug company was abruptly
stopping the trial...because of an error on
the part of CIBA-Geigy. They had intended to
have simultaneous trials for the drug in
depression going in the US; starting them
after these trials were over would delay the
FDA phases to approval of the drug. They
decided that they could not recoup their
costs through sales in the US. My supply
was gone..cold turkey. Very unpleasant
withdrawal.So, this was my way of finding out that
MAO inhibitors worked for me. It took
four years but I found a psych who would
prescribe Parnate and have been on it
ever since.
--------------------------------
"Another RIMA[reversible inhibitor of MAO - A] , brofaromine, has been showing good therapeutic results.
The first double-blind trial
with brofaromine
in 30 patients with SAD[Social anxiety disorder] was a 12-week
placebo controlled design. A significant improvement was
seen in 80% of the brofaromine group (150mg daily) but
not on placebo. Most common side effect was middle sleep
disturbance. During a follow-up period of 12 weeks a fur-
ther improvement was found in patients treated with
brofaromine. In another double-blind trial
77 patients
were randomized to treatment with brofaromine (n=37)
or placebo (n=40) for 12 weeks. In the brofaromine group,
78% of the patients scored much or very much improved
on the Clinical Global Impression scale, compared with
23% in the placebo group. The drug group improved fur-
ther during 9-month follow-up treatment period, whereas
60% of the placebo responders who continued long-term
treatment relapsed. The most frequent side effects in the
brofaromine group were sleep disturbances, dry mouth
and nausea.
Brofaromine was also analyzed in an another double-
blind study with placebo.
After one week of placebo,
102 patients were treated for 10 weeks (50 with placebo
and 52 with brofaromine). Brofaromine started with a 50
mg/day dose and was progressively increased up to 150
mg/day according to therapeutic response. Brofaromine
was significantly superior to placebo in the utilized evalu-
ation methods. 14 patients using brofaromine dropped
from the study precociously, 11 due to adverse effects.
The most commom adverse effects were insomnia, dizzi-
ness, dry mouth, anorexia and shaking.""Although it is also a RIMA, brofaromine (Conosar) differs from moclobemide
by having serotonin reuptake properties as well. There are 3 published studies
of brofaromine in patients with SAD,34–36 all of which have shown brofaromine
to be an efficacious treatment. Unfortunately, the development of brofaromine was
stopped by the manufacturer due to reasons unrelated to its safety or efficacy in SAD, and
it is not available for treatment. However, the effect size of brofaromine in the published
trials is similar to that of the MAOIs and SSRIs, suggesting that its clinical
development may have been stopped prematurely."
Posted by naughtypuppy on February 20, 2007, at 9:20:54
In reply to Re: Are MAOIs ever ineffective? » UgottaHaveHope, posted by Quintal on February 19, 2007, at 13:25:01
> I've never read a report of someone actually dying from a hypertensive crisis on here despite the number who have used them. Hypertensive crises can be painful and scary, but they're not usually fatal. I get the impression most MAOI related fatalities are due to serotonin syndrome caused by drug-drug interactions rather than tyramine induced hypertensive crises caused by drug-food interactions.
I guess it depends on your point of view. You could equally claim that SSRI's are causing the serotonin syndrome when they are added to MAOI's instead of the other way around.
>
> I'm not sure everyone needs something so powerful for their symptoms, but yes, where people have tried standard drugs without success the MAOIs do seem to be more consistently beneficial than most other drugs bar opiates.
>
> Q
Posted by naughtypuppy on February 20, 2007, at 9:25:41
In reply to Re: Are MAOIs ever ineffective? » UgottaHaveHope, posted by lcat10 on February 19, 2007, at 22:21:40
> Parnate once worked for me really well--around 20 years ago and worked well for the 8 or 9 years I took it. When I got depressed again a couple of years ago, I tried it again, and it no longer worked. I have now tried Emsam, and it didn't work either. Other than the MAOI's, I have not been able to tolerate antidepressants without adverse or allergic reactions before getting to a therapeutic dose, so I will be doing ECT in a couple of weeks once the Emsam is out of my system. Sorry for the sour note.
I had the same problem. Second time around did nothing.
Posted by Quintal on February 20, 2007, at 9:36:57
In reply to Re: Are MAOIs ever ineffective?, posted by naughtypuppy on February 20, 2007, at 9:20:54
>I guess it depends on your point of view. You could equally claim that SSRI's are causing the serotonin syndrome when they are added to MAOI's instead of the other way around.
I don't understand where you're coming from. I said:
'I get the impression most MAOI related fatalities are due to serotonin syndrome caused by drug-drug interactions'
I.e. it is the drug-drug *interaction* that is the cause of the fatality. SSRIs aren't combined with MAOIs anyway, many cases of MAOI serotonin syndrome seem to be caused by serotonergic opiates like DXM, pethidine and tramadol as well as OTC antihistamines like Benadryl and Piriton which have some SRI action.
Q
Posted by Crazy Horse on February 20, 2007, at 10:08:36
In reply to Re: Are MAOIs ever ineffective?, posted by willyee on February 19, 2007, at 19:19:46
i dont regret it,not even if i died on that table,i will die fighting it,not living suffering it.
Amen! Bottom line MAOI's (Parnate, Nardil and Marplan) work..they do come with some risks, but hell, life is full of risks. I'm w/Willyee, i'd rather die fighting this horrible illness with a very effective drug that comes with some possible dangers, then living a miserable existance going from one ineffective ssri to another losing ground and wishing i were dead.
-Monte
P.S. I finally start Parnate on Thurs. Feb. 22nd! :)
Posted by Chairman_MAO on February 20, 2007, at 14:25:28
In reply to Are MAOIs ever ineffective?, posted by UgottaHaveHope on February 19, 2007, at 11:51:48
Of course they can be "ineffective", but their success rate--especially with social phobia and atypical depression--far exceeds that of SSRIs and SNRIs, which differ from placebo by the barest of margins. The work of Quitkin, et. al. clearly demonstrates that atypical depression responds better to MAOIs.
Your opinion that a medicine which has been around for 50+ years should be "kicked to the side" is, frankly, ill-informed; although you did pick up on the fact that they're documented, so I don't get how you arrived at that conclusion. Given the choice of taking something that's been around for a half century (going on longer now, if you count iproniazid and isoniazid, millenia if you could the harmala alkaloids, which are RIMAs, but hallucinogenic) and something that's been on the market for 5, I'd go with the one with the track record any day. This is also why, IMHO, taking opium is a better idea than taking acetaminophen or propoxyphene or meperidine.
Despite what anyone tells you, they're clueless if they assert that anyone really has any idea of the effect that these new drugs with molecular weights of 400+ (many atypicals, etc) have on human tissue. Nobody does, and if I had the money and were a betting man, I'd bet you that at least 20% of these drugs will be off the market in 20 years, and the MAOIs will still be around. Phenelzine and tranylcypromine are simple molecules that are analogous to endogenous amines. They are not completely innocuous--phenelzine causes serious hepatic issues for a very small number of people--but at least their effects on human tissue have been well-studied and documented. They therapeutic index is much higher than most people think; people can survive a a dose of 4g tranylcypromine if they make it to the hospital for supportive care in the ICU.
The danger of the tyramine pressor response is also wildly exaggerated. The incidence of hypertensive crises--if you are also counting people who _disregard the diet_--is something like 10%. If you control for those who follow the diet, the figure is much lower. I have been on MAOIs since August of 2004, and have never had a hypertensive crisis--and I will begrudgingly admit for the sake of argument that I have used intravenous cocaine and methamphetamine while taking an MAOI. While I do not recommend this practice, it goes to show you that the reality is not nearly as bleak as you'd be led to believe.
Currently, I take d-amphetamine (45mg/day) with phenelzine (105-120mg/day) and routinely consume certain foods on the "no-no" list; my doctor knows about this. The only things I avoid are soy sauce, fava beans (l-dopa content), tap beer from dive bars, very heavily aged cheeses in large quantities, and nasal decongenstants (which are WAY more dangerous than psychostimulants in this regard). Oh, and dextromethorphan. Don't take that with an MAOI. There are even reports in the literature of combination _SSRI_ and MAOI treatment (do not do this yourself)!
IMHO, _ANYONE_ who takes a medication for a phobic anxiety disorder or depression who hasn't tried an MAOI is missing out. They are the only drugs on the market classified as antidepressants that actually elevate mood. The side effects of MAOIs tend to lessen with time, whereas the side effects of SSRIs tend to increase with time. For instance, the sexual problems I had with Nardil started to lessen after 7 months and were gone after 12 months. This is a very short period of time to wait if you've been suffering from dysthymia since age 12 and social phobia since birth.
MAOIs are the only medications I can say have had any lasting therapeutic effect whatsoever on my mood disorder and social phobia. The d-amphetamine is just for energy and focus, really.
The "gold standard" for the treatment of depression is bilateral, high-amplitude ECT. Despite what anyone has to say about it, this is pretty much undisputed. Beyond that, MAOIs are the most effective treatment, especially in combination with psychostimulants, tricyclics, etc. I'd bet, also, that most people would feel better on a low dose of Nardil + low dose of a benzodiazepine than on a benzodiazepine alone.
In short, the "something special" is that they actually work. IMHO, the main reason people don't get relief from taking them is inadequate dosing.
The psychiatrists at the clinic I go to will prescribe up to 120mg phenelzine or tranylcypromine without much hesitation. I was taking up to 200mg/day of tranylcypromine. With phenelzine in particular, if you're not taking 1mg/kg of body weight, you haven't given it a fair shot.
Posted by Chairman_MAO on February 20, 2007, at 14:27:31
In reply to Re: Are MAOIs ever ineffective?, posted by Quintal on February 20, 2007, at 9:36:57
Diphenhydramine is safe. Cyproheptadine can be used to treat serotonin syndrome.
You are quite correct about meperidine, dextromethorphan, and tramadol, though. Those are the big ones to watch out for, aside from centrally-acting decongestants.
Posted by Chairman_MAO on February 20, 2007, at 14:32:24
In reply to Re: Are MAOIs ever ineffective?, posted by halcyondaze on February 19, 2007, at 17:22:11
Is that study a joke? The full therapeutic dose of tranylcypromine is no less than 0.8mg/kg/day, and can be 1.5-2mg/kg/day. The 60mg/day maximum dose is a fiction. It's really around 120-200mg/day, and any competent psychiatrist knows this.
A non-blinded study of antidepressants is also intrinsically worthless.
Posted by Chairman_MAO on February 20, 2007, at 14:35:21
In reply to Re: Are MAOIs ever ineffective? » UgottaHaveHope, posted by Ken Blades on February 20, 2007, at 5:41:11
Your story breaks my heart. Indeed, Brofaromine is probably the only RIMA that could've had efficacy approaching that of traditional MAOIs.
Honestly, though, I have no interest in trying the RIMAs because I have no issues taking phenelzine (except weight gain).
Posted by Chairman_MAO on February 20, 2007, at 14:36:21
In reply to Re: Are MAOIs ever ineffective? » lcat10, posted by UGottaHaveHope on February 19, 2007, at 22:36:13
I would also add that buprenorphine + MAOI is a very worthwhile combination.
Posted by Quintal on February 20, 2007, at 15:27:25
In reply to Re: Are MAOIs ever ineffective? » Quintal, posted by Chairman_MAO on February 20, 2007, at 14:27:31
>Diphenhydramine is safe.
I've read reports to the contrary, and the patient information leaflet 'Nytol One-a-Night' (diphenhydramine 50mg) clearly warns against concomitant use with MAOIs.
>Cyproheptadine can be used to treat serotonin syndrome.
Yes, due to its 5-HT2 antagonism; but Piriton (I guess you were thinking of Periactin?) isn't cyproheptidine, it's chlorpheniramine, which is contraindicated with MAOIs for the reason I stated.
>Those are the big ones to watch out for, aside from centrally-acting decongestants.
I thought these were more likely to cause hypertensive crises than serotonin syndrome?
I agree especially with most of the points in your first post to the thread. I'll reply in more detail soon.
Q
Posted by halcyondaze on February 20, 2007, at 15:34:30
In reply to Re: Are MAOIs ever ineffective? » halcyondaze, posted by Chairman_MAO on February 20, 2007, at 14:32:24
> Is that study a joke? The full therapeutic dose of tranylcypromine is no less than 0.8mg/kg/day, and can be 1.5-2mg/kg/day. The 60mg/day maximum dose is a fiction. It's really around 120-200mg/day, and any competent psychiatrist knows this.
>
> A non-blinded study of antidepressants is also intrinsically worthless.Agreed. The STAR*D depression trial, which took a large population through several stages of medications, with those deemed non-responsive moving onto the next stage, is fast becoming a classic. All parts were published in the Am J of Psychiatry and unfortunately, many people do not take the time to read the methodology before taking for granted the conclusions drawn in studies such as these. So now the idea of Parnate being the "drug of choice for tx-resistance" is being questioned, due to the dubious methods of the trial.
I personally saw no effect at 60 mg/day and I was at a very low weight for my height then, suffering with anorexia nervosa. As the AN remitted and we got a better idea of what was the depression vs. the anorexia, 60 mg still wasn't enough. Now, at 5'2 and 110 lbs, 120 mg is an ideal dose.
Posted by Quintal on February 20, 2007, at 15:57:10
In reply to Re: Are MAOIs ever ineffective? » UgottaHaveHope, posted by Chairman_MAO on February 20, 2007, at 14:25:28
>Given the choice of taking something that's been around for a half century (going on longer now, if you count iproniazid and isoniazid, millenia if you could the harmala alkaloids, which are RIMAs, but hallucinogenic) and something that's been on the market for 5, I'd go with the one with the track record any day.
I agree. That's why I think that Gillman is unfair to dismiss the entirety of herbal medicine by comparing and extrapolating toxicity during the use of Foxglove digitalis extracts in heart disease to herbs like St. John's Wort used to treat emotional problems. I don't think that level of precision is as important when using herbal medicines for this purpose, and most herbal medicines are now available as standardised forms anyway.
I have in my possession samples of Psychotria viridis and B.cappi. I'd be interested to hear your experiences with them (assuming you have used them?). I think it would be better to take them in ritual setting the first time, rather then alone or with a sitter (my choice of sitters are limited), though my social phobia is a barrier to attending such rituals.
>I will begrudgingly admit for the sake of argument that I have used intravenous cocaine and methamphetamine while taking an MAOI. While I do not recommend this practice, it goes to show you that the reality is not nearly as bleak as you'd be led to believe.
I used illicit amphetamine paste myself while taking Parnate. I took it sublingually in tiny amounts at first. It's refreshing to hear someone else who has done similar. I've been reluctant to post here telling people of that because of the reactions I suspect it might provoke.
>This is a very short period of time to wait if you've been suffering from dysthymia since age 12 and social phobia since birth.
Which MAOI do you find most effective? Nardil is as yet the only one I haven't taken. I might be able to get my GP to prescribe it for me if I am persuasive enough. Have you tried cyproheptadine to see if reverses the sexual dysfunction caused by Nardil? That's the one side effect I cannot tolerate.
Q
Posted by Quintal on February 20, 2007, at 16:03:47
In reply to Re: Are MAOIs ever ineffective? » halcyondaze, posted by Chairman_MAO on February 20, 2007, at 14:32:24
>The 60mg/day maximum dose is a fiction. It's really around 120-200mg/day, and any competent psychiatrist knows this.
Oh how I wish I could convince my arrogant young pdoc of this. He steadfastly refuses to raise the dose above 30mg, and hoped I would be satisfied with 10mg as a maintenance dose after the first month. I found that I needed *at least* 80-120mg to achieve a good therapeutic response. I am 5'9 and around 140lb. I've had people tell me here that I risked killing or poisoning myself with such a dose. In fact the reverse was true - 30mg agitated my suicidal depression and I was only safe at the higher doses.
Q
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