Re: Feeling better during Nardil taper-off?

> Hi PB,
> I'm on the process of switching to Parnate after 2+ years on Nardil. I have been dreading the transition since my mental health is bad even when on the Nardil. I've now reached 15mg a day of Nardil by decreasing 15mg a week from 45mg (note that I was on 90mg for the majority of the 2 years).
>
> However, I am finding that my mood has stabilised and overall improved over the last 2 weeks. Does anyone have a good feel for why this might be? In theory, there's not enough active metabolite in my system to effect sufficient MAO inhibition and so I should be feeling rotten. Don't get me wrong, I plan to enjoy it while it lasts but I know things can change radically and rapidly for the worse.

What you are experiencing is called a withdrawal-rebound-improvement. I believe it occurs more often with TCA and MAOI than it does with other classes of antidepressants. In my experience with Nardil, this improvement can last for 2-3 weeks. Mania can sometimes be triggered as a result of this phenomenon.

J Psychopharmacol. 2011 Mar;25(3):306-13. Epub 2010 Feb 15.
Antidepressant discontinuation manic states: a critical review of the literature and suggested diagnostic criteria.
Narayan V, Haddad PM.
Source

We critically appraised all published reports of hypomania and mania following antidepressant termination. To increase reliability and validity we devised diagnostic criteria for an antidepressant discontinuation or withdrawal 'manic state' based primarily on the Diagnostic and Statistical Manual of Mental Disorders, 4th edition substance withdrawal criteria. A systematic literature review identified 24 reports meeting our criteria. Mean age was 39 years (range 18-74), men and women were approximately equally represented, and more cases involved people with unipolar (n = 19) than bipolar disorder (n = 4). The median duration of preceding antidepressant treatment was 12 weeks (range 4 weeks-12 years). All major antidepressant classes were involved (tricyclic antidepressants = 13; selective serotonin reuptake inhibitors = 5; monoamine oxidase inhibitors = 3; selective serotonin-norepinephrine reuptake inhibitors = 2; miscellaneous = 1). More cases followed abrupt antidepressant withdrawal (n = 11) than a tapered withdrawal (n = 6). Six cases appeared to meet the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition for a manic episode, with two cases requiring inpatient admission. Of the 24 cases, nine resolved spontaneously without treatment (median duration = 25.5 days), six responded to antimanic drugs, four resolved following antidepressant reinstatement, and treatment was unclear in five cases. We conclude that antidepressant discontinuation hypomania/mania is a valid syndrome. It should be added to the differential diagnosis of hypomania/mania. The clinical implications and possible mechanisms are discussed.

J Clin Psychiatry. 2004 Jul;65(7):987-93.
Antidepressant-withdrawal mania:a critical review and synthesis of the literature.
Andrade C.
Source

Department of Psychopharmacology, National Institute of Mental Health and Neurosciences, Bangalore, India. andrade@nimhans.kar.nic.in
Abstract
BACKGROUND:

Hypomania or mania have rarely been reported to develop shortly after the discontinuation of an antidepressant drug. The true incidence of this discontinuation syndrome is unknown because it may be underreported as a consequence of underrecognition or misattribution. This article examines the possible etiology, nosology, mechanisms, and other aspects of the syndrome.
DATA SOURCES AND STUDY SELECTION:

A PubMed search was conducted in May 2003 and repeated in January 2004 using the search terms antidepressant and mania. Relevant articles containing adequate descriptions for presentation were retrieved, and their reference lists were hand-searched for further pertinent material. Hand-searches of the indexes of leading psychiatry journals were also performed for the years 1998-2003. Twenty-three articles were identified for review.
CONCLUSIONS:

Antidepressant-withdrawal hypomania or mania may occur rarely with almost any antidepressant drug after sudden withdrawal, tapered discontinuation, or even merely a decrease in dose. The syndrome may be self-limiting, may abate with the reinstitution of the antidepressant drug, or may require specific anti-manic treatments; mood stabilizers do not necessarily protect against the syndrome. The true incidence of the syndrome is unknown. Narrow and broad diagnostic criteria are proposed for the syndrome, and a synthesis of literature is provided.

Can J Psychiatry. 1987 Dec;32(9):764-7.
Transient mood elevation associated with antidepressant drug decrease.
Corral M, Sivertz K, Jones BD.
Source

Department of Psychiatry, UBC Health Sciences Centre Hospital, Vancouver.
Abstract

The development of hypomania, mania and transient mood elevation within 2-3 days of antidepressant discontinuation, and lasting days to several weeks has been reported in unipolar depressed patients. Imipramine and desipramine are the antidepressants most frequently associated with the above phenomena. A reported case of transient mood elevation following abrupt reduction but not discontinuation of desipramine therapy in a woman with unipolar depression is described. The phenomenon was observed and documented on two separate occasions. Mood elevation occurred despite decreased plasma levels of the drug. Relapse followed despite maintenance of dose and similar drug plasma levels. Factors which could account for the transitory improvement of mood are examined. It is suggested that the patient's improvement in mood may have occurred due to a rebound paradoxical therapeutic effect. The features of the presented case history which appear to support this hypothesis are discussed. Also the clinical implications of this phenomenon are reviewed.

Some see things as they are and ask why.
I dream of things that never were and ask why not.

- George Bernard Shaw

Re: Feeling better during Nardil taper-off?

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