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.
poster:Chairman_MAO
thread:734115
URL: http://www.dr-bob.org/babble/20070219/msgs/734476.html