Tuesday, March 25, 2008

Why This Shrink Doesn't Prescribe MAOI's

Graham wrote in a question:

OK, so since it was a pretty generic post, I'm going to ask a question of you three that's pretty far off topic. Why do you think MAO inhibitors are so infrequently used in psychiatric practice today? Besides dietary/drug interactions, their safety profile is good. There are masses of studies showing efficacy. Why switch patients from one SSRI/TCA to another to another instead of trying a MAO inhibitor. Do you think MAOI's have a place as second line agents in certain circumstances?

What a great question, I've been thinking about this one for a bit and this is what I've come to. I don't use Monoamine Oxidase Inhibitors (MAOI's) to treat depression or anxiety, though from time to time, I think about it. Why not? It's a really good question, they are really good medications, sometimes helpful when other meds don't work, and lore has it that they are helpful with "rejection sensitivity" in patients with borderline personality disorder.

So Why Don't I use them?

1) They are dangerous in combination with a bunch of foods-- aged cheeses, certain red wines, fava beans, and I'd have to look up the rest of the list. It includes medications, even some over-the-counter medicines. Accidental or purposeful ingestion of these substances in combo with MAOI's can lead to hypertensive crises-- think stroke and death. This makes me a little wary.

2) Pure gut bad association-- at the hospital where I went to medical school, the young daughter of a New York Times editor died-- the combination of MAOI's and prescribed Demerol were thought to play a role in her death.

3) I don't like to give patients medicines that they can easily fatally overdose on.

4) My own naivete. By the time I started residency training in psychiatry, SSRIs were hot. Many patients were on TCA's (tricyclic antidepressants, and you can OD on these, too). I saw two patients in my residency on MAOIs. I've worked in 3 different clinics, each with an active caseload of about 1,000 patients. There was one patient in the first clinic I worked in (1992) on an MAOI. I've never seen the chart of any other patient treated at any of these clinics with an MAOI. Okay, I haven't seen any patient's chart, but the point here is that I'm just not familiar with them, so they aren't my first/second/third/fourth choices for treatment. Should they be?

5) Once you've used an SSRI, you have to wait weeks to use an MAOI, not always an easy prospect for a depressed patient.

Thanks Graham, I'm running my next sidebar poll in your honor!


DK said...

MAOIs scare me, primarily because they just impose so many lifestyle restrictions on patients. And then there's the narrow therapeutic window thing. Honestly, I have enough trouble prescribing TCAs because of the potential for overdose.

My current supervisor is always on us, residency is the time to use the meds that are out of vogue, to get experience with things like MAOIs, TCAs, typical antipsychotics, so that you can have them in your arsenal later. He has a really good point, but, I still have trouble reaching for thorazine instead of risperdal, you know? There's a reason whole new classes of drugs have come on the market since the days of Navane (and it's not entirely related to drug company patents...).

Dr. Pink Freud said...

Selegiline (Sinemt) is an MAOI (monoamine oxidase inhibitor) now available in a patch (transdermal) form. It appears to have a very favorable side-effect profile.

A main concern for MAOI use is the dietary restrictions that must be followed. Foods rich in Tyramine (an amino acid) content must be avoided, due to increased risk of a hypertensive crisis (BAD). The new transdermal patch if believed to be much safer because it bipasses MAO-A, located in the GI tract. The manufacuter, Bodkin, asserts that lower doses are necessary with its transdermal formulation, which also decreases the risk of hypertensive crisis. This may be a good option for some people, especially since MAOIs can work well for treatment refractory depression, atypical depression and double depression.

Jessica said...

Your argument that they are too easy to OD on doesn't fly with me... TCAs are also very easy to OD on.

Sarebear said...

There have been times I have wished I was on a TCA or MAOI so I'd have something "easy" to figure out how to OD on. AT least, I'm pretty intellectual, so I'd be able to slog through whatever online medical stuff I could find.

This change in meds is feeling promising (says I after quite a bit of time, but a couple of family deaths kinda mess up one's ability to assess how one is reacting to a med, as the least of what such life events do, as well as often it's more hindsight that will tell anyway) so hopefully I won't go there again, but then again, the nature of my problems is cyclical, so I've learned to never say never. I wish.

Ah, well.

Anyway. That new transdermal thingamajiggy sounds promising.

as far as MAOI's go, but I've always been leery, except when lusting after something dangerous.

Self-discipline has never been my strong suit, so an MAOI wouldn't fit anyway irregardless of the other stuff.

Actually, I have a post in mind about assessing efficacy of a med from a patient's point of view, now that I've been through the process of assessing a mood stabilizer several times now, although I am not sure I've ever hit the full jackpot yet (although this "may" be "the one" but I'm trying to just not think about that and go on about stuff anyway. The effects can be startling enough sometimes anyway.)


Well, I digress, but that's not news.

Hope those of you who celebrate it had a nice Easter, and those of you who celebrate other things this time of year, had a nice one or some of those, too. And for everyone else, happy spring.


Anonymous said...

My psychiatrist and I discussed going to the MAOI patch because of the side effects I have with Cymbalta. Ultimately, I decided against it for two reasons. One was the washout period; I was nervous about going completely off everything because I had had a bad experience trying to switch from Cymbalta to Welbutrin. The second was that I break out in a rash anytime I have to use a bandaid, so I wasn't optimistic that the patch would be a long term solution for me. Had the patch not been available, I wouldn't have even considered MAOIs, because of the dietary restrictions.

The Cymbalta side effects aren't life-threatening, but they're annoying enough to keep looking for another solution.

Anonymous said...

Personally, I think if someone has not responded to newer drugs, is in bad shape and has the kind of depression known to respond well to MAOIs, then it's worth considering. Giving up cheese and wine pales in comparison to relieving your intractable depression, right?

They are generally considered the most effective of the antidepressants by far, so it doesn't seem right to toss them on the trash heap.

Lithium also has a narrow therapeutic window, some serious medical risks, and is possible to lethally OD on. Doesn't stop anyone from prescribing it.

I'm not a doctor, just a patient.

DK said...

T, it does actually (re: Lithium's narrow therapeutic window). The Lithium patient these days is usually reasonably compliant, has decent reportability (i.e., they'll call us if they're feeling funny or get the stomach flu or start a new med from their FP), and will come in for occasional levels. Plus, while it's fairly easy to get toxic on Lithium, relative to an MAOI it's much harder to lethally overdose on it.

And I don't know that I would agree that they're the most effective antidepressants out there. But you do raise some good points.

Had vaguely heard of the Selegeline patch. That actually quite useful... In my institution, we're much quicker to go to ECT for refractory depression (and many other things. We have a busye ECT service). I wonder if this might be another option worth considering.

Unknown said...

A friend at the local major medical center uses MAOIs regularly and frequently for the treatment resistant depression patients and finds them very helpful and not hard to use. The friend is always encouraging me to try them for ertain patients. I have not yet because the patients always refuse, scared about the potential risks.

Do our thorough and, I believe necessary, informed consent processes keep people form meds that would truly help their health?

A cardiologist would say to a patient,"Listen, you are under close supervision by a doctor, these medications have been thoroughly tested and work, and you have an illness that can be life threatening if untreated."

Unknown said...

Sorry, I forgot that my pseudonym is also your blog name. Disclaimer: I am not the shrink rap of this web site.

Roy said...

I will sometimes offer an MAOI, and inform the pt of the risks/benefits/side effects/alternatives. Not only the diet, but I also tell them of my limited experience with these drugs. This typically results in declining this option. I don't think it is the OD concern that is of major importance. And the comparison to lithium is useful. The difference re:toxicity is that with lithium, you can check a level and know in hours if that is the problem. There is no such simple check with MAOIs.

Shrink Rap: Thank you for clarifying that you are not one of us Shrink Rappers. I was wondering who that came from and your profile is turned off.

imPRESsed1 said...

Dinah, thanks for turning my question into a post. It was a self-serving question, because after riding the med merry-go-round, I begged my psychiatrist to let me try Nardil. He did so somewhat hesitantly as he said he hadn't prescribed a MAOI since his residency, and was unaware of a single doctor in the area using MAOIs. Anyways, to make a long story short, Nardil did what no other antidepressant has done for me; it essentially cured my depression. Side effects are minimal, and the diet becomes second nature after a few weeks. Lifestyle restrictions are a fairly small downside when compared to severe depression.

I would ask that psychiatrists reconsider MAOIs as a legitimate and relatively safe treatment option for treatment resistant depression. Their reputation as dangerous drugs is mostly unfounded, especially in the case of a very med compliant patient. (I am not aware of the small therapeutic window which is being discussed; Nardil can produce results anywhere from 30mg to 90mg per day, and toxicity is reached only with much higher doses.) Their good efficacy is very well proven with 50+ years of research and clinical use.

Anyways, thanks again for expressing your views, Dinah, I really appreciate it!

Anonymous said...

Have any of you heard of a study looking at SSRI or other antidepression meds absorption issues in patients who've had gastric bypass surgery? I'm currently a little of a year out from my RNY gastric bypass surgery (153 pounds GONE) and have found that I need double the normal Cymbalta dosage to get the theraputic effect. I'm taking 120mg a day, but am now fighting with my insurance over them not being willing to cover more than 60 mg per day. BTW, I'm dysthmic with cycles of full-blown depression a couple of times a year. I've been under the care of a psychologist for many years now.

Anonymous said...

The Libby Zion case of 1984 was complicated and had as much to do with poor supervision by overworked docs as it did with the potential dangers of the drug. Any drug can be lethal in right, make that wrong, circumstance.

Anonymous said...

I have never taken an anti-depressant, but based on reading everything posted here would be willing to take an MAOI if I had depression that warranted it, and I CERTAINLY would prefer an MAOI to Electroconvulsive Therapy which is well know to cause memory loss both short and long term in many patients. I'd have NO problem with the dietary restrictions. Bear in mind that MANY medications have dietary restrictions of one sort or another. My thyroid meds are supposed to be taken on an empty stomach in the morning and no food or beverage other than water for an hour after taking them. Many drugs carry a warning to drink no alcohol. My Dad was on Coumadin and had to abstain from alcohol and dark green vegetables. Diabetics need to forgo sweets. Cardiac patients are asked to limit saturated fats and sodium. If I were given an ACCURATE, COMPLETE typed sheet with what food and drugs to avoid, I as a patient would have NO trouble following it. I ALREADY eat no aged cheese and no wine so the restrictions would be a piece of cake for me.

Regarding Sarebear's comment that at times she WANTED an MAOI as a way to commit suicide easily, my comment would be that if I DID want to commit suicide it would not require that I be on an MAOI to do it. That being said it would be prudent of a psychiatrist to make an attempt at assessing a client's ability to comply with medication instructions and food restrictions before prescribing, but MAOIs sound like a good option.

NeoNurseChic said...

I took Parnate for awhile. I came off of Prozac and Pamelor in order to go on the Parnate, so I did have to wait the necessary time between drugs. I took all of these for headache, though, and not for depression. I do know that Prozac and Cymbalta are the only antidepressants I've ever taken where I noticed an effect on mood - not necessarily a good effect, but an effect nonetheless. So I answered your poll in that I did take an MAOI, I did not have any side effects, but honestly I don't know if it helped with depressive symptoms because I honestly wasn't paying attention to those symptoms with it - I was paying more attention to the headache effects.

The hospital where I go for treatment is not very strict in dietary restrictions for either headaches or for MAOIs. They do give a list of foods you must avoid with an MAOI: your aged cheeses and meats, wine, non-domestic and tap beers, banana peels (Who eats banana peels?) and a few other things. However, I've read some lists that were much more strict than that. Some headache centers require that patients cut out an entire huge list of foods just for the treatment of headache, but the only thing the center I go to requires is that you cut out caffeine, and everything else is left up to the individual. I realize I'm talking about 2 different things, but I always felt that my hospital is a little less strict with dietary restrictions, and this allowed me to be more compliant with the meds and treatments.

Nardil is used for headache more often than Parnate, but because I have ADD, the center psychiatrist thought that perhaps the parnate would have some stimulant benefits.

I didn't have any problem with the dietary restrictions, but med restrictions were difficult. When I had a bad cold, the only thing I was allowed to use for it was saline nasal spray, which was not realy helpful. None of the doctors wanted to take responsibility for telling me what OTC meds I could take while on the MAOI. However, I survived the cold, and had the parnate worked for the headaches, I wouldn't have cared what I had to do for it.

I basically cut out all cheeses, and I didn't realize how much I missed cheese until I couldn't have it anymore! Then all I wanted was cheese! haha When I came off the med and waited the necessary time limit, I ate like 6 servings of cheese in one day! lol...

But all in all, parnate did not have side effects for me. Unfortunately it was not the headache helper I was looking for. I wish I could go back and evaluate what effect it had on my mood. During the earlier years of my headaches, I was so focused on headache treatments that I never even looked at what other effects meds might be having on me.

Glad you posted on this. I don't think MAOIs are really to be feared - but definitely need to be respected!

Take care,
Carrie :)

jcat said...

Ok..on this one I can reasonably speak knowledgably from experience and research.

I have somewhat treatment-resistant depression, have gone thru the entire f-ing shopping list of a/ds of every kind in the past 15 years, mixed with just about everything else, including ECT, including nothing, including TCAs and SSRis and MAOIs and and and....

My pdoc will prescribe MAOIs for people he knows are desperate enough to comply with ANYTHING - if it only would work. Just for a while.

So far of the MAOIs, I've tried Parnate (up to 170mg), Nardil (up to 120mg), and Eldepryl/selegiline twice (up to 90 mg). BTW, selegiline at anything over 10mg/day, including the transdermal, has the full range of dietary restrictions. The distinction between MAO-A and MAO-B only applies at dosage way lower than anyone with TRD would be responding to.

The selegiline gave me 6 weeks of feeling good at 60mg the first time, then wipe-out. None of the others have ever done anything good. Side-effects have been minimal until super-high dosage, although there's been a bit of high BP with all. Have canned all of them after 12-16 weeks due to lack of result rather than any S/E profile.

Only adverse reaction has been the 2nd try with the selegiline, when at 70mg I had a small amount of soy sauce with sushi. Not fun. Pdoc does give a detailed list of what to avoid, and seriously, it really is hard to stick to unless - as I replied to Graham prev - you are already a clean-living vegetarian. It's not so much the cheese and red wine bit, but basically avoiding anything that is processed/ canned/ smoked/ cured/ aged/ sauced.... It makes almost any restaurant meal impossible - and believe me, I have tried. You can't even have a decent salad...no avocado, no ripe tomatoes, no cheeses, no caesar or ranch or blue cheese or 1000 island dressing or even a decent olive oil, no crispy bacon bits or anchovies or any of the nice things!

In spite of that, if they had shown results, I'd happily give up every food that I like for eternity. Pdoc has TRD patients who have responded really well, and stayed on MAOIs for years, which is why he tries them. As Graham comments here though, only with patients who are seriously med-compliant, and who are really TRD.

Have also been thru just about the full range of TCAs, also up to many times PI-max. Currently, have had the best 2 weeks in the last 4 years on Tofranil, a few days at 125mg followed by a dive, and now again at 150mg. YAY! YAY! YAY!

And in all honesty, as someone who hoards past meds for the endgame, if you look seriously at the LD50 quantities for all the TCAs and the MAOIs, and work out what you'd need compared to a lab rat, the chances of successfully ODing on almost all of them is very very slim unless you have pre-existing conditions. The chances of having a stroke or stuffing up your kidneys and liver past all usefulness are very very good. There is more chance of dying with a couple of boxes of aspirin. Not trying to give ideas here, but really, never mind having enough of them on hand...it's kind of hard to swallow as many as one would need to guarantee death rather than disability. I'm not denying the potential for an OD, but even with two weeks worth at 15times PI-max, it's not enough anyway. Sorry Sarebear... they aren't an 'easy' way out.

But for the right patients, with the right illness...they can be a miracle, and I'd agree that it's unfortunate that they are so often ignored.

Medicoglia, RN said...

While I do understand what wxchick is saying, I wonder about how well a person already on other dietary restrictions would handle the added restrictions of an MAOI. I am diabetic...I already cannot eat most grains, all starches, several fruits, no juice, and of course no obvious sugar either. I have to eat protein with any meal that has any carbs what-so-ever. What are my protein options? Eggs (not good to eat all the time (cholesterol already an issue for diabetics), cheese, nuts (don't like most of them), nut butters, and meats (cholesterol issues again). What meats and cheeses taste the best? The aged ones of course! So add an MAOI and my diet would basically be chicken breasts and salad (but not my favorite dressing...roquefort), and occasionally a bit of boring cheddar. I don't think I would be able to do it.

I suppose I am pretty lucky that wellbutrin is very effective for me!

Medicoglia, RN said...

OOPS...that should have said that I understand what Therapy Patient is saying...not wxchick.

Anonymous said...

There was a murder mystery, years ago, Table D'Hote by Douglas Clark, where the method of murder was to invite the victim, who had just started a course of MAOIs, to a dinner that featured Chianti, broad beans, old Cheddar cheese, and liver.

The victim had been sent the standard "Don't drink the Chianti!" instructions, but the murderer had stolen them before he ever saw them.

Gerbil said...

Wow. Think of how different Silence of the Lambs would have been if Hannibal Lecter were on an MAOI.

Anonymous said...

Aren't there selective MAOIs available in the USA? They are far better tolerated than the classical ones, and patients don't need to follow the restrictive diet necessary with unselective MAOIs.
Here in France we have moclobemide (MOCLAMINE). Nevertheless, it's rare I prescribe it. But I've never prescribed classical MAOIs.

Roy said...

The best we have is selegeline. I can't recall why moclobemide didn't make it here.

imPRESsed1 said...

dr m,

In my personal experience, moclobemide is vastly inferior to the classical MAOI's. Also, there is very little data to support the efficacy of moclobemide. One study from Brazil (I believe) shows efficacy, and other than that, there isn't much data out there. It's approved in Canada, but not in the US.

Sarebear said...

I think my remarks were taken the wrong way. I'm certainly not looking for a way out. In the past I have.

I didn't say MAOI would make it the easiest way, or EASY at all. It was one thing that passed through my mind, as anything does in that state of mind of desperately seeking something.

But that is in the past. I chose to comment, with that past experience regarding the subject of MAOI's in mind/at hand.

I feel I've been attacked a bit, but I also know I'm overly sensitive and all that, so I'll just go read Harry Potter 7 which I've just started and never read although some of the stuff has been spoiled for me by now because, well, it's been a year, how could it not?

Carrie, sign up for Ravelry!!! Oh email me bout the preemie hats to knit, I could and should knit some for local area, but I want to knit some for the benefit of someone I know, and that's YOU (your workplace and the babies who you care for so expertly from your descriptions of it in the past).

a psychiatrist who learned from veterans said...

Emsam has rather brought the MAOIs back a bit for me. As psychiatric medication is to a lay person, MAOIs are to the psychiatrist, a bit of a Gothic topic. I've never had any trouble with them. I had a patient come to me once who had been on Parnate or Nardil for over a dozen years, the only time she had any trouble was when she ate Stilton cheese in London. The only thing I ever learned from a JCHO reviewer was about MAOIs; what do you give somebody who has a hyperensive reaction to an MAOI? Answer: 2 vitamin C 500 mg tablets which they are to chew. The food items are really gourmand items, and I want an investigation of the prison you work in if they are served there! Pizza from Pizza Hut doesn't qualify. Another odd fact. I had an alcholic PTSD patient who benefited from MAOI. He told me American beer was no problem but you couldn't drink Canadian beer. Currently we would give a patient EMSAM but pharmacy blocked us saying there might be a seroetonin syndrome with his fentanyl patch. How many patient's have I seen on SRIs on Duragesic? We tried to contact BMS on Friday but it was Good Friday which is a bad Friday to call BMS. Since then I was on call so haven't gotten back to it; like I say, Gothic.

NeoNurseChic said...

As I was told - you can drink American bottled beer, but no tap beer or foreign beers, as they contain higher or unknown amounts of tyramine.

Sara - I've gotten a bit away from knitting of late. Have had so much else going on these days and haven't been feeling very well lately, so I haven't had much energy even for fun/quiet stuff like knitting!

If you want to make preemie hats, let me know - do you need a pattern? Or just an address for where to send them? Do let me know - and I appreciate you doing it!!

Take care,
Carrie :)

Anonymous said...

I don't have much time, and as a result this will have to be a fairly short post. There are a couple of points I'd like to hit upon. First off let me say that I have absolutely no medical training, all of these comments will be from a personal patient experience point of view.

I also had a bit of an alcohol problem in my teenage years, extending from about 18 to 23 years of age I am currently 27 and have been sober for a little over three years. And to cut to the chase I was apperently self cognizant enough to realize that by brain wasen't functioning properly. In effect I just didn't feel like "me" anymore. While living in the united states they tried me on the whole gambit of antidepressents (except MAOIs), everyone of those experiences worse than the last. One of the main things I notices with both the SSRIs and tricyclics was the almost complete inability to laugh, as if the reflex was completely inhibited for some reason. I also felt sluggish and somewhat dumbed-down.
Then, a miracle. A physician in mexico perscribed me selegiline 40mg daily, all my symptoms began to subside, everyone around me even noticed how much more relaxed and like my old self I had become. Laughter comes quick, my word association seens to have improved and I'm even much more goal oriented. Sorry this is running long by I urge more people to experiment on patients that are truely suffering, as this brand of drugs seems more to give lost life back instead of simply numbing down the shambles that remain.
Also, has anyone ever had the laughter complaints with the non MAOIs.

Anonymous said...

Another deeply satisfied MAOI user here, to plead with you to consider them more! I took various different combinations of SSRIs, SNRIs, antipsychotics both old-style (extrapyramidal effects - yuck) and new-style (diabetic blood-sugar levels - double yuck), mood-stabilisers, drugs to control Parkinsonian effects, and a lot of other stuff PRN, such as benzodiazepines and, when hospitalized, major tranquillisers like haloperidol. Nothing did much other than stabilise me at a cognitively and affectively low level.

After over seven years of that, starting at age 14, including three hospitalisations, I was assigned to a new shrink (the old one moved to within another NHS trust), who gave me phenelzine. Wow. It worked, incredibly well and almost instantly (though with a few alarming rapid moodswings from hypomania to occasional severe depression, which was 100% sorted with lamotrigine). This guy (this angel!) looked at my past medications, my symptoms, my family history, and prescribed an MAOI straight away, first session.

My life was changed, and from being a no-hope, chronic, severe, psychotic depression sufferer, I am now entirely discharged from psychiatric services and have a good life, with a mood that reacts appropriately to the circumstances and isn't just flattened. I can laugh, cry, enjoy sex, enjoy food, leave the house, speak to strangers, and feel all the other things normal people are able to feel.

And the suicide risk? The time since I started on phenelzine is the first time since I was 14 that I *haven't* wanted to commit suicide; IMO (tho I am only a patient), even though it's not usually a great idea to give a dangerous drug to a suicidal patient, it's far more risky suicide-wise to have a patient who is depressed and suicidal but on "safe" drugs than a patient who is non-depressed on "risky" drugs. People can always find suicide methods other than their prescription drugs.

I know it's not a wonder-drug for everybody, but was it ethical that, for those seven years I was being treated with ineffective drugs, nobody tried MAOIs (or even tricyclics) to treat my depression? They were willing to give me Stelazine, Haldol, Zyprexa, Depakote, etc., but MAOI is such a dirty word to psychiatrists that I'm very lucky I happened to see a psychiatrist who prescribed phenelzine for me.

Whew - didn't mean to write that much in a comment (that likely won't be read) to an archived post. Sorry :-)

Dinah said...

We read all the comments. Thanks for your input!

Roy said...

And great comments, too. I've had 2 pts in the past month where I've recommended MAOI. They should be considered when other classes and modalities don't work, so I still see them as 3rd line treatments, in general.

Anonymous said...

I'm impressed you read comments to old posts, and reply to them - thanks! I'm a bit of an evangelist when it comes to MAOIs, what with having had such a good response to them personally, so if I came across as hectoring, I didn't mean to. I don't mean to hijack your comments thread for a discussion, but just thought I'd post this.

I know cost comes into the equation in the States, especially for people with bad or no insurance, so maybe phenelzine (and other MAOIs, possibly) is too pricey. Here, the cost to the NHS is about £220 (nearly $440) for a year's treatment at 45mg a day (the price would be lower or nothing for patients; I don't know what the heck goes on in Scotland, but in Wales drugs are free to everyone, and in England most are free but around 12% of prescriptions are charged at £7.10 ($14.11) an item, because the patient does not have reasons for exemption from the charge - those people can buy a "season ticket", currently £102.50 ($203.77) for a year, if they need a lot of drugs). At the cheapest price I can find on the net in the US, for a year's phenelzine at 45mg a day a patient would pay about $560.

Arrgh, wrote a lot again. Please don't feel the need to reply to this comment.

I'm enjoying reading more of the blog, too.

Anonymous said...

I would encourage all psychiatrists to seriously consider MAOIs for treatment resistant depression. I was on SSRIs (Zoloft, Effexor)and combinations of lamotrigin and various others whose names I forget for 7 years. But none of them worked. At the beginning of this year I was on 600mg of Effexor, my mood was low and worsening, my executive and cognitive functionning were abysmal. Unfortunately, I went off the Effexor cold-turkey "as it wasn't working" and suffered my first ever anxiety attack, which lasted weeks and I ended up in Emergency. It took 5 weeks for Parnate 50mg to really kick in - until I felt life was worth living. Since then, I can only say the results have been fantastic. I've even dropped down to 30mg now...What a life saver! I admit that information on food restrictions IS patchy at best. And you mustn't believe anyone re over the counter medicines until you have checked it out...I've learnt a bit tonight - I have been drinking decaf everything, but eating chocolate with impunity... and bacon... But I don't go near yeast extract or any foods that contain it, nor any cheeses or red wine. I have had a few glasses of white wine and seem OK.
And I have had gastric surgery - so I understand what one of the bloggers said about this. It is hard, but it's worth it. Think fresh food. Cereals or toast and jam or honey for breakfast. Egg and salad sandwich for lunch, and meat and 3 veg for dinner. It's really a very healthy diet - the way we used to eat before flavorings and fast food became staples. And most cakes, slices and sweet biscuits are fine.

I carry largactil tablets in my bag at all times in case my blood pressure goes up. My only concern is that people in Australia are parlously ignorant about MAOIs - even in the psychiatric hospitals, they have no idea...
Good luck, and to all you psychiatrists who keep on trying new "safe" drugs on interminably miserable patients... give up, and try an MAOI. "It's better to die on your feet (from accidentally eating cheese) that live on your knees" (Apologies to Midnight Oil)

Anonymous said...

I took Nardil for pretty bad social anxiety and atypical depression and it worked like nothing else before or since. In the end I just became tired of the food restrictions and there were a lot of weird side effects - plus I was probably too disinhibited for my own good. So I stopped.

Now that my problems have come back full force and I've finally broken down and turned to medication again, I decided to try another SNRI. But definitely if that doesn't work I'll go back on an MAOI, and I'm glad I have a psychiatrist who's OK using them. My time on Nardil had its problems, but it probably was the most functional I've been in my life, so really the cheese restrictions are nothing.

On the other hand, I'd have *more* problem being the prescribing physician than being the patient. As a patient you know you can control how safe you're going to be on an MAOI. The psychiatrist basically has to hope that their patient is pretty responsible and not impulsively risk-taking or suicidal.

Kimberley cameraman said...

There is one main problem with nardil that seems to exist across the whole medical community. I have had doctors refuse to give it to m e where others havent even heard of it. The one problem that nardil causes and please listen up those disheartened sufferes of depression and anxiety/social phobia. the one problem is......it works and it works better than many other SSRI/SNRI/TCA/SNDRI. It took me 10 years to find it and thanyou doctors for wasting my time on your drug company pushed SSRIs that treat one chemical in the depression family. You have to treat as many as possible to get rid of symptoms of depression. I was an alcoholic at 14 years of age got sober at 25 and found nardil at 37. I believe i know more about depression, types of treatment for than most Gp's. I dont even need to go to AA anymore. i used to go twice a day. Now i exercise and love it. i tried all know alternative treatments including St john, inositol, Same, Fish oil, vitamin B, Kava kava, SSRI and SNDRI. together which is almost not researched at all. All these had demostrated studies on depression.
One pysch said you have to be your own doctor. Damn right. Coffee is a Mao too and has shown a 30% reduction in suicide amongst 10000 nurses. Not a bad study size. Screw the blodd pressure problem when your dead from illegal drug overdose or suicide your pulse isnt going to be a problem anyway. Dont give up you will eventrually find your way out of pain. you must want to live and want to not die. Did you know a walk around the block 5 days a week for half an hour is equivalent to prozac for depression. Why dont doctors make exercise as important as giving a pill. Combined benefits know one knows. With billionjs of dollars spent on R and D know one knows cause you cant sell a walk

Anonymous said...

Clients, doctors: use logic to battle fear (emotions) and get the facts: MAOIS save many lives every year.
They are vastly under utilized, when they could be helping many folks regain their mental health.
I have taken Nardil now for almost 30 years and am professional therapist.
I eat well, but make sure I check new medications for existing contraindications.
Doctors, if you refuse to educate yourself about the benefits of MAOIs and believe all the scare tactics, you need to get out of the field.
Update your knowledge but of course continue to be careful: there will be clients who cannot safely use MAOIs.
Don't throw the baby out with the bath water though or generalize.
That is a sign one has not done adequate research and is using personal "filters" when evaluating a situation.
Talk to many of us whose lives have been normalized again, thanks to MAOIS. THAT Is where the truth lies.

Unknown said...

This is to Carol concerned about the dental problems after long term use of Nardil. I to have been on Nardil off and on for 23 years. I do know one thing when on the Nardil I grind my teeth VERY bad.I do not when not taking Nardil.Grinding your teeth erodes the enamel on your teeth which can certainly lead to dental problems the only other possible reason i can think of is if your get dry mouth (i don't) you don't have the protective properties that saliva provides Hope you still read this post being yours that i read was over a year old Lynn luvslittlecreatures@gmail.com let me know if you got this

Unknown said...

Its Lynn again. Another MAO patient I have recently moved and have been waiting over a month to see a physiatrist.Iam off my Nardil and have been binge drinking which got me arrested. Which was a good thing because the alcohol/drug counselors are pushing me to get back with a physiatrist among other things that i have neglected.anyway I finally get to see a physiatrist and he wont give me the Nardil. Like alot of other people on here we have been on LOTS of other meds.For me also Nardil is the ONLY med that has helped.The doctor would not listen to me I even told him I abuse benzodiazepine He says the Nardil is old and dangerous Well he gives me Wellbutrin(been there done that) I know one thing I am alot more dangerous when I am drunk (risky behavior) and add some Ativan NOT GOOD! If I wasnt so depressed I would of maybe been a little more assertive but it would of probably not done any good. I will find another doctor who will hopefully give me my Nardil back Thanks for reading

kasmin said...

I’ve been taking Nardil for the last 40 years (I’m 71 years old). In my twenties I started getting intermittent bouts of depression, which gradually increased in severity and length through my thirties. I eventually asked to see a psychiatrist, who started me on a range of tricyclics. All to no avail. He tried me on ECT, without effect. I tried homeopathy for a year, again without result. I went back to the psychiatrist without much hope. He gave me Nardil.

At the age of 41 I got my life back and haven’t had a relapse since. At first there was a bit of hypotension, excessive sweating when performing anything energetic, and loss of libido, but eventually things worked out and I’ve been able to do things that I’d never have thought possible before.

I was, of course, warned about the Chianti and cheese. In fact the list of foodstuffs that contain appreciable amounts of tyramine is very long, and makes you wonder if there is anything at all that you can safely eat. I’ve been happily eating lots of prohibited items such as chocolate, pork, soy sauce and fruit, but in the last 40 years I’ve never once had any adverse reaction as a result of ingesting something I shouldn’t have.

The one food item that I have always scrupulously avoided is cheese. However, I now find, from various internet sites such as www.linkpharma.com.au/util/doc.jsp?i=570&f=blob6&c=20
that not all cheeses are as dangerous as cheddar, for instance, and that cream cheese and cottage cheese, for instance, are devoid of tyramine. This makes me wonder if my total ban on eating cheese is too restrictive.

I think I also read recently that pizzas from the large pizza chains are safe too. I’d be interested in any comments.

Anonymous said...

31 year male under psych care since 16 for tentative DSM-IV dx including anxiety, depression, bipolar disorder, borderline personality disorder. Shifting therapy included anti-psychotics, lithium, epival, benzos, SSRIs and SNRIs, without recognized response.

Patient drank; stopped marijuana upon paranoia; LSD; coke, ecstasy caused foot paraesthesia. ER exposures to anti-psychotics. Got akathisia.

On Zyprexa energy surges dismissed as panic attacks. In mid-20s stopped benzos X2. Put on Gabapentin & Zyprexa. Found Nardil,convinced new psych.

Tapered Zyprexa fast. Life back @60 mg. Nardil after 10 yrs. But in wks myoclonic jerks to multi-focal, intractable musculo-skeletal pain. Psych recanted tent dx of tardive dyskinesia but rx Hydroxyzine.

Strained patient-psych relp fractured. Nardil mtce for mos while sought cause of syndrome. Tapered Nardil, myoclonics gone, pain remained.

Now 6yrs musculoskeletal pain, NSAIDs, muscle relaxants, opioids & benzos. Dr, Neur, Psych, pain Drs, - unabated.

In six years, relief only 4X. 2X with temp reintro of MAOI. Relief faded in weeks. 3rd. post- hosp for self-inflicted trauma.
The last interval <wk post Suboxone. Suffers undiagnosed musc-skel pain & GI impacts of opioid therapy.


1. Does the history of repeated exposure to typical anti-psychotics and the akathisia they induced, followed by protracted Zyprexa and the concurrent energy rushes dismissed as panic attacks suggest the development of a tardive dystonia which expressed about a month following truncation of Zyprexa therapy ? The young man has experienced panic attacks and distinguishes between them and the energy rushes. Psychiatrist Peter Breggin has emphasized the painful CNS trauma induced by the anti-psychotic classes.

2. Does the arrival of the musculo-skeletal syndrome about a month into MAOI therapy suggest a condition attributable to Nardil itself ? Note its temporary remission on two occasions upon reinstitution of MAOI therapy. Does one place credence in the documented albeit paradoxical relationship in which the offending medication, upon reintroduction, masks the syndrome which it itself evoked ? Again, psychiatrist Peter Breggin has emphasized the CNS and peripheral NS side-effects which might follow MAOI therapy.

3. Given the young man`s history, the medical profession is prone to consider an underlying psychiatric disorder, including somatization, as driving the musculo-skeletal pain syndrome. Certainly all ranges of therapy have failed to elicit more than partial mitigation of pain. Benzodiazepines have achieved as much relief as any other medication. In the presence of psychiatrists, the young man focuses on descriptions of the pain syndrome and his researched theories as to its origin.

4. Are there objective, quantifiable means of discriminating among 1-3 and any other differentials the readers might contribute ? Psychiatrist Peter Breggin has referred to the CNS imaging studies which have shown the sequelae of anti-psychotic therapy.

Your insight is sought by the young man`s father.

Anonymous said...

I like the honesty of your response. I think they can be useful and there are some very good materials out there on them (e.g. Stahl's work), but they are dangerous. I've seen almost miraculous responses to them, but I've always referred to a psychopharmacologist when I thought an MAOI was the best approach.

Anonymous said...

I am 70 and have been on nardil 25 years. I do not , nor have I ever, had to adhere to the food restrictions.biggest problem is the effect even at 60-75 mg is not consistent. still bouts of recurring depression just not usually as severe

Anonymous said...

I have been on MAOIs since 2005 and I have not followed the food restrictions. I have normal blood pressure when sitting and become dizzy when I start walking after sitting a prolonged period of time.

The only problem I had was the massive weight gain; I initially lost ~26lb after starting the Nardil and then gained over 100lb. A friend who was on Parnate gained well over 50lb, despite walking over 5 miles a day.

My mood is not at its ideal but it's a whole heckuva lot better than it ever was.

oc1dean said...

A friend from the stroke group I go to used MAOIs and was compliant with the dietary restrictions. He took 1 herbal energy pill and had a bleeding stroke.

Anonymous said...

I started on Emsam 2 months ago. Was just increased to 12/24mg and I want to know how long I should give this to work? I have good days and then I have these days where I want to do nothing but cry. Is this normal?

Anonymous said...

I had major depressive disorder. Bottom line - 30mg/day Parnate cured me within a few weeks.

We had tried ALL the other antidepressants except the TCAs (contraindicated for an existing eye pressure problem) before I went on Parnate. These other meds included nearly all the SSRIs (including lithium and ATA augmentation), Remeron, Cymbalta, Wellbutrin, Effexor, Prisiq. Probably forgot a couple.

Thank God my doctor and nurse finally have me Parnate. Parnate works. Period. Acts on all three brain NTs. Every study I have read (dozens) have found find that it is highly effective for MDD. It has a rating of like 4.5/5.0 on askapatient.com (higher than any other antidepressant). Read the history from the VA hospital on how they these drugs were first noticed as antidepressants.

Once remission is achieved, Parnate dose can be decreased from 30mg (or above) down to 10mg or even 5mg for maintenance.

The food restrictions are not as bad as people make them out to be, unless you can't control yourself and must drink a lot of alcohol and eat "aged" foods. In any case the restrictions are trivial compared to MDD itself, which of course can be deadly.

Obviously patients should wear a medical alert bracelet or neck chain in case of emergency hospitalization and carry a wallet card, since interactions with anesthetics and other meciations are the only major concern. Again, this is manageable compared to MDD. Wash out the small maintenance dose for 10 days prior to elective surgery. (Obviously, should be using CBT or other therapy methods for these times.)

I always remember reading one physician who wrote, "Parnate always works." Can you say that about the weak SSRIs? Especially considering the findings showing that they are not much more effective than placebo?

Any doctor who won't use them is probably concerned about their personal liability in the case of patient non-compliance (which I understand). But if you want to CURE your MDD patients, get a signed informed consent document and give them the diet and medication cautions. Q.E.D. baby.

Anonymous said...

I had major depressive disorder. Bottom line - 30mg/day Parnate cured me within a few weeks.

We had tried ALL the other antidepressants except the TCAs (contraindicated for an existing eye pressure problem) before I went on Parnate. These other meds included nearly all the SSRIs (including lithium and ATA augmentation), Remeron, Cymbalta, Wellbutrin, Effexor, Prisiq. Probably forgot a couple.

Thank God my doctor and nurse finally have me Parnate. Parnate works. Period. Acts on all three brain NTs. Every study I have read (dozens) have found find that it is highly effective for MDD. It has a rating of like 4.5/5.0 on askapatient.com (higher than any other antidepressant). Read the history from the VA hospital on how they these drugs were first noticed as antidepressants.

Once remission is achieved, Parnate dose can be decreased from 30mg (or above) down to 10mg or even 5mg for maintenance.

The food restrictions are not as bad as people make them out to be, unless you can't control yourself and must drink a lot of alcohol and eat "aged" foods. In any case the restrictions are trivial compared to MDD itself, which of course can be deadly.

Obviously patients should wear a medical alert bracelet or neck chain in case of emergency hospitalization and carry a wallet card, since interactions with anesthetics and other meciations are the only major concern. Again, this is manageable compared to MDD. Wash out the small maintenance dose for 10 days prior to elective surgery. (Obviously, should be using CBT or other therapy methods for these times.)

I always remember reading one physician who wrote, "Parnate always works." Can you say that about the weak SSRIs? Especially considering the findings showing that they are not much more effective than placebo?

Any doctor who won't use them is probably concerned about their personal liability in the case of patient non-compliance (which I understand). But if you want to CURE your MDD patients, get a signed informed consent document and give them the diet and medication cautions. Q.E.D. baby.

Anonymous said...

So Emsam at it's lowest dose does not have any dietary restrictions AND it comes in a patch form so there is no risk of overdose. In addition, if a patient is not taking any other medications there is no risk of a med interaction. Your old school thinking baffles me and it makes me SO angry that doctors are not willing to prescibe the ONLY medication that has worked for me in the past.

Dinah said...

Anon: I will prescribe Emsam. It costs $900/month and not all insurance companies will cover it.

Dave B said...

I suffered for some ten years with severe depression and tried every medication on the market with no relief. Finally a doctor told me about one more, MAOI's. At first I declined because I was so sick of the trial periods that never worked. He pressed me, and I took Parnate. After about a week, I opened my eyes one morning and realized that I was not depresssed. I have now taken MAOI's for some 25 years. I started first with Parnate and then was shifted to Nardil. (On one occasion I mistakenly asked the pharmacist for Parnate after I had switched to Nardil. I was given the Parnate from an old prescription still in RXX history, took the Parnate, and had a major epiosode that put me in the hospital).

Nardil has given me the opportunity to live a normal, fulfilled life. I have tried 2 or 3times to go off the Nardil, but each time spiraled back into the depression.

I read somewhere that MAOI's are the first line of defense for depression in Europe.

I would encourage you not to be dissuaded from prescibing Parnate or Nardil. It literally saved my life.

John Rausch said...

If anyone know a doctor who will prescribe MAOIs practicing in SW Ohio, please let e know at John at johnrausch dot com.

Anonymous said...

I have been on Nardil for 15 years and it saved my life! I have tried every medication on the market and Nardil was the only medication that worked for me. I have never had a problem with foods, some of the foods on the list doesn't affect me and the ones that do I simply exclude. I am a veteran and the V.A. Refuses to prescribe Nardil for me so my cost out of pocket is very high. I can not live a normal life without this medication and the V.A. Has no right to deny me a medication I have been using for 15 years without any problems.

Anonymous said...

Part of your job as a physician is to educate yourself, yes? Acknowledging your ignorance doesn't help anyone. With depression being the rampant, devastating, and sometimes fatal condition that it is, don't you owe it to your patients to be informed as to even the less popular treatments? Ironically, MAOIs are helpful for treatment-refractory depression; so if you have a patient with whom you've explored many options unsuccessfully, they could be the thing to finally help. I didn't go to med school--I'm "merely" a patient, but I read journals to be able to be an informed part in my own care. Fortunately, my dr. is willing to think outside the box. I'm appalled by your own self-admitted *willful* ignorance on such a crucial subject. "Do no harm" does not mean "don't at the very least educate yourself as to the risk-benefit ratio of a treatment and simply allow your patient to suffer".

Dinah said...

Last Anon, I agree, in the 6 years since I wrote this post, I have had a number of patients who have not responded to other medications and I now use MAOIs. They remain difficult for the reasons mentioned above, patients don't want to try and give me a lot of hassle about the diet (which makes me anxious that they won't fully comply), and stopping medications for weeks remains hard. There have then been issues with needing to stop the medications for weeks for surgeries. Emsam in a low dose that does not require a low tyramine diet has made this easier, but it is unbelievably expensive and some people have not tolerated the adhesive. One person got manic on them. I don't believe I ever said I was "willfully ignorant", I simply said that I did not have much exposure, and these medications are difficult to use (they remain so), but given the fact that I've had patients where I have exhausted other options, and the availability of Emsam has made the use of MAOIs more feasible (I've also now used Nardil, Parnate, and oral selegeline), I've expanded my repertoire.

Anonymous said...

I would be willing to place my life savings on the fact that many more people have died by NOT having access to a doctor that is courageous enough to prescribe MAOIs than deaths from eating cheese.

Unknown said...

I've been on Parnate for a decade. After 27 drugs it was my miracle pill. With intracranial hypertension ECT or TMS are not options for me.

I have encountered your fear from doctors and this has engendered anxiety within me. It is a stressful game of projection and should not be my issue as a patient. I fear, quite reasonably, facing a Dr. who will not write the prescription because of his or her own "issues" rather then the clear benefits to me.
At the same time I spend my medical life hypervigilant and an anxiety disorder has developed. I awoke from back surgery hearing a nurse speak of the Flexeril injection she was preparing to give me. I refuse medications, pain medications, food and have rewritten menus in hospitals in three states because the Doctors were not familiar with my dietary restrictions. Some hospitals did have a "low tyramine" diet, but it included foods that are "forbidden."
I find that "older" doctors respond well to me while younger doctors dismiss my concerns about drug interactions as "anxiety." Sometimes, I believe, this interferes with my ability to receive medical help while facing issues like hypokalemia, high ammonia levels, intracranial hypertension, a thyroid storm etc.
I read the prescribing information and some Doctors do not seem to appreciate the level of proactive interest I take in my health. Last week I was prescribed Linzess. No drug drug interactions were listed or tested for, but while reading the p.i. I noticed that tyrosine is an ingredient. I cannot ingest tyrosine(the amino acid connected to tyramine) and so refused the medication, called the pharma company, reported it to the FDA and my Doctor decided I was unwilling to receive help. I am not interested in risking a hypertensive crisis or serotonin syndrome.
Yes, it is very challenging to "treat" me for medical conditions because I am on an MAOI and this is frustrating, but I am "presenting in pain" and it is complicated. I am a "challenging" case, but this need not be my "issue." My back problems are the most frustrating. I feel denigrated because I struggle managing pain, but doctors and physical therapists generally work with individuals who are on muscle relaxants or pain medications. (I also cannot take steroids.) So I manage acute anxiety, 3 chronic pain conditions, retractable depression and I do that on music, deep breathing, prayer, the love of my friends and family and it is far from easy. I feel and my friends believe that doctors expect me to be superwoman while failing to recognize with compassion and logic the medical dilemma I am in or not wanting to deal with it because of their fear.

I am ideally suited for the restrictions of an MAOI, but right now with experiences with doctors and in hospitals in Maine, New York, Florida I find it necessary to consider discontinuing Parnate not because of my own compliance issues, but because I need to protect myself from doctors and nurses. I find the existence of this dilemma to be intolerable and absurd.

I find that many interaction checkers do not flag pertinent information and the FDA does not regulate these programs in hospitals and doctors offices.
Increased education about MAOI's, special labels for individuals taking MAOIs and other protective measures must be implemented to protect those who need this drug.
I seek any guidance and assistance. I can no longer be silent and it is imperative that I address many of these challenges to help other individuals who need an MAOI.

Anonymous said...

It bothers me so much that psychiatrists are generally under the impression the MAOIs have worse/more dangerous side effects than SSRIs. On SSRIs, side effects make you feel less than human. On MAOIs, you feel like a normal person for the first time in your life. Also, how many American's eat real cheese? (processed cheese and mozzarella are fine on the diet) Cut out large portions of bacon and red wine, and you're fine diet wise. Honestly, there are so few things in a typical American diet that need to be restricted.

And not giving someone a drug that will final cure their depression to prevent them from trying to overdose? You're not going to commit suicide when you finally have hope/proof that a drug actually works.

Please consider using MAOIs more often.

I have extreme social anxiety and Nardil has been a life saver. SSRIs do nothing for social anxiety. Don't just read your text books, read some message boards. Sometimes the patients know best. But on that note, the scientific evidence also shows MAOIs to be superior in treating social anxiety. Particularly Nardil.

Anonymous said...

I have been through virtually all the SSRIs and Tri-cyclics. Prozac, Zoloft, Paxil, Cymbalta, Selexa, Amitrypyline, Lithium (fucked up my liver), Abilify, Effexor, Remeron, Lithium, and on and on. Started MAOI on Emsam transdermal patch. Not real effective and cost me $1200 a month out of pocket. I have settled in on Tranylcypromine and Lamotrigine. Yes, they suck and have side effects and food interaction, and drup interactions with OTC cold medication and such. I have strep right now and I am suffering because I have a Penicillin allergy too. I did ECT for 2 1/2 months and all it did was make me progressively sick and it destroyed way more memory than disclosed. I get by. I am functional on the Tranylcypromine & Lamtrogine. But certainly not well. Not the :old" me although we can debate the relative positives of that as I self medicated as an alcoholic most of those years. My current cocktail is losing efficacy. My suicidal thoughts are daily. I actually ordered potassium cyanide from Cameroon but was scared to pick it up due to terrorist scare. My pills will probably ultimately give me the out. I'm getting there. I have tried hard. I am tired of trying. Suicide is brave. Deciding to stop living a miserable life for whatever peace or lackthereof in the afterlife. Is it more selfish for me to take my life or more selfish of my loved ones to keep me alive while miserable. The MAOI works as long as it can, and then offers a way out. Maybe it is the perfect drug.

Just Some Guy said...

I would like to say that I am extremely frustrated by the majority of psychiatrists for their extreme unwillingness to prescribe MAOI's. Serious long-term treatment resistant depression is one of the most debilitating and unpleasant sickness a person can endure, and I really have to wonder if psychiatrists care. Highly reputable doctors from Mayo Clinic and Harvard Medical School have written well documented highly supportive journal articles as to the great benefit of MAOI's yet the majority of psychiatrists are still unwilling to prescribe them, regardless of whether other meds have of no help to patients nor the years upon years that patients have suffered with depression. Frankly, it makes me angry.

Unknown said...

I was put on Parnate "many moons ago" after trying every other anti-depressant available in Canada. I looked in the CPS under "anti-depressants," and asked, "Why haven't we tried the MAOIs?" He sort of "blew them off" as "inconvenient" because of the dietary restrictions. I looked at him, and said, "Dietary restrictions? That's it - and I could feel better???" Okay, he said. And Parnate was the first one we tried. The very first time I was in hospital, and after taking it for about 2 weeks, I literally woke up one morning "depression-free!" I was discharged later that day. I have read, and read, and read about the dietary restrictions, and I have actually created my own "MAOI Guidelines" that include "Avoid Foods", "Caution Foods" (i.e., can be consumed in small quantities if well before the 'Best Before' date), and "Allowed Foods" - all categorized by food group. I also own a home BP monitor. If I get a headache - and I'm not sure about the cause, I check my BP first - so as not to waste a trip to the ER if it's "just a headache." It has been "just a headache" 100% of the time. I have been on-and-off Parnate at least 6 times - for 2-3 years at a time, and am on it now. Have never once had a hypertensive crisis - but I am ABSOLUTELY FAITHFUL about the diet; not taking ANY OTC meds; etc. I make all of my own food so that I know exactly what is in it. If I go to camp or something, I take all of my own food. If I am even remotely unsure about a food, I simply do not eat it. I live in Edmonton, Alberta, Canada, and I am the only patient in the city who is on Parnate. I have discovered that Psych Residents are not even learning about MAOIs in school. When I say "Parnate" to them, they have no clue what I am talking about. When I have had to be admitted to the hospital, I have to take my own supply because it takes the hospital 3 days to find some. Nurses and even ER Docs know nothing about it. Of all the years I have been on it, I have had only one overdose, which was this past August (that really didn't need to happen), and I had to basically tell the ER Doc to "hurry up and call Poison Control" because he didn't have any idea what the consequences could be. It was a "close call," and, needless to say, I won't be doing that again, but it has been prescribed for me once again. There just isn't anything else that works. Treatment-resistant depression is the worst.

Andrew said...

This was written in 2008- I certainly hope you have reconsidered your position.

MAOI's are the most potent antidepressants available, let there be no doubt about that. They are generally EXTREMELY effective for not only MDD, but for phobic states, GAD etc It's very disconcerting to see these agents are so little used, when they could effectively treat many people who are suffering so greatly. Yet doctors are extolled the never-ending virtues of the SSRI (cash cows), which, are not that efficacious. Let me make clear: these medications are NOT dangerous and ARE very effective!

1. The much discussed "lifestyle and dietary restrictions" are VASTLY overstated.
I refer you to http://www.psychotropical.com/maois-introductory-comments

2. Your "Pure bad gut association" is unfounded. Look at that case in detail. It more exemplifies poor management, not any inherent dangerous properties of MAOI's (in this case, Phenelzine)

3. That holds true for the TCA's and a whole host of other medications which are used much more frequently than the MAOI's

4. Residents should be informed more about these agents. It is unethical that doctors are not informed more about them. And yes, I believe they should be first-line treatments in many cases.

This excellent webpage, written by a doctor with decades of experience with them, should quell a lot of doubts and misinformation:


Unknown said...

It's ridiculous that physicians are so afraid of prescribing MAOIS. I've taken Parnate for 7 years and it's vastly superior to any of the newer antidepressants IME. The original food restrictions list is inaccurate and outdated and it isn't that difficult to avoid the ones that do actually do cause problems. Same for the OTC meds, it's quite simple to avoid them all together. I've never had any hypertensive reaction. You really owe it to your patients to become educated on this. Dr Ken Gillman's http://www.psychotropical.com/ is excellent.

LorMek said...

Hi all, I have been on Nardil about 20 yrs. after going through everything else for 2 1/2 yrs. My psychiatrist at the time had no problems w/it as I am a "natural" type person to begin with. My concern is: are there any known physical reasons to not stay on it for a lifetime. Kidney, liver problems possible in the future?

I have searched repeatedly on the internet and have come up empty. I only go to a family doctor now and she knows nothing about it and the psychiatrist retired, plus I live in fairly rural area with not much available.

Any help is much appreciated.

Unknown said...

I have read this entire thread, and I realize, as do you, that people continue to comment without noticing your reply.

I just want to say that I think you are wonderful for expanding your understanding and repertoire. I hope that you've continued to seek to expand all of your personal and professional horizons, and that in doing so, you've inspired colleagues, and restored faith and hope in those for whom all was lost. Bravo!

"DinahApril 06, 2014
Last Anon, I agree, in the 6 years since I wrote this post, I have had a number of patients who have not responded to other medications and I now use MAOIs. They remain difficult for the reasons mentioned above, patients don't want to try and give me a lot of hassle about the diet (which makes me anxious that they won't fully comply), and stopping medications for weeks remains hard. There have then been issues with needing to stop the medications for weeks for surgeries. Emsam in a low dose that does not require a low tyramine diet has made this easier, but it is unbelievably expensive and some people have not tolerated the adhesive. One person got manic on them. I don't believe I ever said I was "willfully ignorant", I simply said that I did not have much exposure, and these medications are difficult to use (they remain so), but given the fact that I've had patients where I have exhausted other options, and the availability of Emsam has made the use of MAOIs more feasible (I've also now used Nardil, Parnate, and oral selegeline), I've expanded my repertoire."

Anonymous said...

Parnate has been helpful to me where as the newer, safer and supposedly better medications failed - SSRIs, SNRIs, Wellbutrin, Remeron, you name it. Parnate has less side effects too.

The difficulty of the MAOI diet is exaggerated and not helped by the amount of misinformation out there claiming far more foods are forbidden than is actually the case. Mistakes on the diet are very unpleasant and have the potential to be dangerous but accidentally eating some forbidden food does not mean certain death!

Yes there are drug interactions but is it really asking too much for psychiatrists to educate themselves on which meds these are and then advise us patients accordingly? My understanding is that means anything with significant serotonin re-uptake inhibition and certain type of stimulant. So that means avoiding other antidepressants, some RX pain meds and some OTC cold remedies.

I question how depressed can somebody be if they are not willing to alter their diet and watch what other meds they take.

Any family doctor can hand out Celexa safely. I fail to see the point of psychiatrists if they are unwilling or unable to use more specialised medications like MAOIs and TCAs in treatment resistant cases.

I'm glad to see the updated post saying you now use these meds.

Anonymous said...

And remember to read this


can´t stress it enough

Busterc said...

I'm successfully on an MAOI - parnate, old school, diet and all) for years (8? More?), and it was a miracle. I can follow the diet. But I had 1 or 2 mishaps over the years, and one day when I was off pills completely and crashed before refilled. Omg, people, it is a painfuk, horrifying reaction, nothing I would ever do on purpose and I've been suicidal in my depression. I would not use this med in a negative way ever! I'd rather starve to death. Throbbing shooting head pains and spins, night terror style blackouts if you fall asleep and feel pulled backward and spun into a black abyss. If you have a boo boo on these, go to the ER. If you need them, they are amazing, especially when 10 years of meds that don't target enough different neurotransmitters has left you desperate. My doctor was a Vietnam vet and published on MAOIs, and I'm a veteran. Even so, not all VA pharmacies have them. But he congratulated me on the hard choice of trying them, and I lost 10 cholesterol points on the diet which is actually easy to follow. No adged meat or cheese, or man made protein, and flat peas. Nothing "past tense," lol, like fermented, pickled. But I can have ham and bacon because tyrosine somehow doesn't build much in them. I can have mozzarella, and cream cheese. And farmer johns sausages, plus now they make "fresh" hot dogs and polish like sausages....

But please don't od or interact on purpose. 1 you'll probably live anyways, 2 you'll probably have a debilitating stroke and get stuck with living with it. Just sayin.
BTW, I have Addison's disease, thyroiditis, take steroids, corticosteroids, synthroid, inhuman doses of benadryl, vitamins, and I tolerate oral vikoden and iv morphine/dilauded just fine. Tested in ER for a couple years. I have all this, Ambien for sleep, benzos for extra anxiety and I tolerate this as well as can be expected. To give my liver a break we might cut out non mission essentials, but it comes right back up.

Busterc said...

I'm on p arnate and I can't have anything with a D for decongestant. Ephedrine would race my heart and make me tachy(weird rhythm) but its in the dentist so I have to have sometimes. But antihistamine is fine. I like Nyquil but it had 4 decongestants. Still I took it n felt icky before figuring it out and I didn't have major side effects. So I can't remember names but a lot of cold and medicines are fine.

Unknown said...

Dear SR, most psychiatrists are misinformed about MAOIs, so the public is going to be even further misinformed. The scares are grossly exaggerated.
1.Food interaction:the dietary restrictions that everyone is familiar with are based on studies done in the 1960's. Food processing has changed in the last 50 years. The tyramine levels are less in these "risky" foods today. You still need to watch what you eat, ie, aged foods and more importantly spoiled foods. If it's past it's sell by date don't eat it. Find a modified dietary list. It is a doable list that includes certain cheeses cheeses even beer and wine in moderation. The advice given me by a psychiatrist with over 50 years experience was to "go low and slow" when trying these foods. Why even risk these foods when you could die? Because low and slow keeps hypertensive crisis's at manageable non life threatening levels. Blood pressure monitoring let's you know what you can or cannot have. Remember, everyone responds differently to these interaction. Some have NO interaction at all. If you do have an interaction, it will subside (because you went low and slow). Remember, exercise and sex also raise your blood pressure, but they are not contraindicated.
2. Med interaction: in particular, seratonin toxicity. Many drugs that were feared have been proven safe (when in doubt, low and slow). Some are absolutely contraindicated.
This is a life saving medication especially for someone who doesn't respond to SSRIs, SNRIs etc...
Are there lagit concerns? Yes. Considering the potential good compared to risk. It is worth the risk. One simply needs to look both ways when crossing the street.
Please Google Dr Ken Gillman.
Thanks for indulging me. This med changed, even saved my life.

Anonymous said...

"I have read this entire thread, and I realize, as do you, that people continue to comment without noticing your reply."

Yes, we have read that comment.

But this "shrink" has to apologize publicly for being so reckless An ammendment in the comments section is not ethical and is NOT enough.

The fact that people do not notice it says it all.