Posted by Tomatheus on January 11, 2006, at 12:52:56
In reply to Looking for a Diagnosis, Medicine Input, posted by HKristina on January 9, 2006, at 12:57:06
Heather,
You might want to consider trying an MAOI -- if not now, possibly at some point in the future. Let me quickly summarize the extent to which MAOIs have demonstrated efficacy in the treatment of your various diagnoses and primary symptoms.
1) Panic disorder:
Several controlled studies have found MAOIs to be effective in the treatment of panic disorder. According to Liebowitz et al. (1990), several older studies comparing MAOIs with the tricyclic antidepressants in terms of their efficacy in treating panic disorder have found the MAOIs to be superior. The MAOIs Nardil and Parnate have not been approved by the FDA for use in panic disorder, but they are sometimes used (successfully) in treatment-refractory patients.
2) ADD:
MAOIs are not approved by the FDA for the treatment of ADD/ADHD, and they are rarely - if ever - prescribed for this condition. However, in a study that aimed to determine the effectiveness of both dextroamphetamine sulfate (generic for Dexedrine) and MAOIs in the treatment of childhood "ADD with hyperactivity," Zametkin et al. (1985) found that the MAOIs had "immediate, clinically significant benefit and were clinically indistinguishable from dextroamphetamine." All of the participants (14 boys with a mean age of 9.2 years) went through two trials: one with dextroamphetamine, and the other with an MAOI (either Parnate or clorgyline, an irreversible MAO-A inhibitor that has only been used in research studies). Zametkin et al. (1985) concluded that MAOIs may be "useful alternative treatments in selected cases of ADD."
3) Hypochondriasis:
The efficacy of MAOIs in the treatment of hypochondriasis is unclear, largely because no published study that I am aware of has specifically attempted to examine the nature of the relationship between hypochondriasis and MAOI responsiveness. I was able to locate a research article on a controlled study that measured the effectiveness of the MAOI Nardil on several measures of depression and anxiety. One of these measures was "hypochondriasis-agitation." The study, conducted by Ravaris et al. (1976), found that participants who were given 60 mg/day of Nardil showed greater improvement in their hypochondriasis-agitation scores than those who were given either 30 mg/day of Nardil or a placebo. Although data on the relationship between hypochondriasis and MAOI responsiveness are largely lacking, the possibility that MAOIs may be effective at treating the symptoms of hypochondriasis seems to be at least somewhat likely.
4) Depression:
The MAOIs Nardil and Parnate are FDA-approved for the treatment of depression and are believed to be of particular value in the treatment of patients with "atypical" features, bipolar depression, and treatment-refractory depression (Fiedorowicz & Swartz, 2004). In a meta-analysis (a research article that summarizes and analyzes the findings of multiple clinical trials) on the efficacy of MAOIs in depression, Thase et al. (1995) found that MAOIs tend to be less effective than tricyclic antidepressants in inpatients, but tend to be more effective than the tricyclics in patients with atypical depression. Patients with atypical depression must report having a reactive mood and at least one of the four following symptoms: overeating, oversleeping, a "leaden paralysis" feeling, and personal rejection sensitivity (Quitkin et al., 1988). Other researchers have concluded that MAOI responders often experience comorbid symptoms of depression and anxiety and do not show "significant melancholic depressive features" (Liebowitz et al., 1990). So, in a nutshell, MAOIs tend to be relatively comparable to most other antidepressants in terms of their overall effectiveness in the treatment of depression, but they are usually only used as third- or fourth-line treatments (if that) because of their side effects, especially the need to maintain a special diet to avoid experiencing a potentially (but rarely) fatal hypertensive crisis. But for certain depressed patients (e.g., atypical depressives, treatment-resistant depressives, depressives with comorbid anxiety symptoms, and some bipolar depressives), MAOIs are believed to be particularly useful.
5) Excessive alcohol consumption:
MAOIs obviously aren't used to treat substance/alcohol use disorders per se, but I think it's important to note that there is a significant positive relationship between major depression and alcohol use disorders. As Grant & Harford (1995) reported, "comorbidity of alcohol use disorders and major depression is pervasive in the general population." So, even though one cannot say conclusively that depression *causes* alcohol use disorders, or vice versa, it is clear that the two variables are related. It also remains possible (and somewhat likely, in my opinion) that your excessive alcohol consumption during that year or so of your life may have been a manifestation of your depressive and other psychiatric symptoms.
6) Social anxiety:
Even though SSRIs are almost always used in the first-line of treatment of social anxiety disorder because of their favorable safety profile in comparison to the MAOIs, comparative research trials have consistently shown the MAOI Nardil to be the most effective medication for treating social anxiety disorder. According to Aarre (2003), patients with social anxiety disorder should not be considered treatment resistant unless they have been offered a Nardil trial.
7) Cycling:
Ok, I kind of cheated and found what you wrote in another thread, but I noticed that you wrote that you experienced some "cycling" between depression and euthymia on no meds and then experienced more significant cycling on SSRIs. What I'm about to say comes both from my own experience and from research studies, but basically I do think that there is some evidence that MAOIs tend to be the best antidepressants for patients who rapid cycle in response to SSRIs and/or SSNRIs (and also possibly tricyclics). I can say from my own personal experience that I experienced SSRI-induced cycling, but never experienced any hypomanic symptoms of any sort on Nardil, Parnate, or moclobemide monotherapy. All rapid cyclers may not be able to tolerate MAOIs as well as I have (from the perspective of their tendency to induce hypomania), but there is some evidence that they're less likely to induce cycling than other antidepressants. Furthermore, clorgyline (an irreversible MAO-A inhibitor that has been used exclusively in research) has demonstrated some capacity to prolong the duration and lessen the severity of mood cycles in patients with endogenous rapid-cycling bipolar disorder (Potter et al., 1982).
Well, to sum things up really quickly, there is little doubt in my mind that you fit the profile of a potential MAOI responder. Of course, patients taking MAOIs are required to follow a special diet that restricts foods such as aged cheeses, salami, pepperoni, dried sausages, spoiled meats, fermented soy products, tap beer, sauerkraut, and broad beans. So, you'd have to be willing to make some sacrifices. But in my opinion, refraining from eating the foods on the MAOI diet list is a small price to pay for patients who get clinically significant relief from MAOIs. Of all the MAOIs (Nardil, Parnate, Marplan, selegiline, moclobemide, and a few others -- depending on where you live), I would recommend the "old" Nardil. The problem with this, unfortunately, is that the "old" Nardil was replaced with the new Nardil about two years, so there won't ever be a way to get the "old" Nardil unless those who are in the process of taking action against Pfizer succeed at making the "old" Nardil available once again. But as far as my suggestion, I'm not going to lie; I do think that the "old" Nardil would probably be your best bet. Since you can't take that, though, I guess I'm going to have to suggest that the "new" Nardil is probably your best choice since it generally tends to be the MAOI of choice for patients with symptoms of both depression and anxiety.
Hope this helps. I've technically started a little "Babble break," but I felt that I had to reply to your message first. So, I probably won't be reading the boards much for the next few weeks, but I'll check up on things every now and then, and I'll have my Babblemail on.
Tomatheus
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REFERENCES
Aarre, T. F. (2003). Phenelzine efficacy in refractory social anxiety disorer: A case series. Nordic Journal of Psychiatry, 57, 313-15.
Grant, B. F., & Harford, T. C. (1995). Comorbidity between DSM-IV alcohol use disorders and major depression: Results of a national survey. Drug and Alcohol Dependence, 39, 197-206.
Fiedorowicz, J. G., & Swartz, K. L. (2004). The role of monoamine oxidase inhibitors in current psychiatric practice. Journal of Psychiatric Practice, 10, 239-48.
Liebowitz, M. R., Hollander, E., Schneier, F., Campeas, R., Welkowitz, L., Hatterer, J., et al. (1990). Reversible and irreversible monoamine oxidase inhibitors in other psychiatric disorders. Acta Psychiatrica Scandinavica, Suppl 360, 29-34.
Potter, W. Z., Murphy, D. L., Wehr, T. A., Linnoila, M., & Goodwin, F. K. (1982). Clorgyline: A new treatment for patients with refractory rapid-cycling disorder. Archives of General Psychiatry, 39, 505-10.
Quitkin, F. M., Stewart, J. W., McGrath, P. J., Liebowitz, M. R., Harrison, W. M., Tricamo, E., et al. (1988). Phenelzine versus imipramine in the treatment of probably atypical depression: Defining syndrome boundaries of selective MAOI responders. American Journal of Psychiatry, 143, 306-11.
Ravaris, C. L., Nies, A., Robinson, D. S., Ives, J. O., Lamborn, K. R., & Korson, L. (1976). A multiple-dose, controlled study of phenelzine in depression-anxiety states, Archives of General Psychiatry, 33, 347-50.
Thase, M. E., Trivedi, M. H., & Rush, A. J. (1995). MAOIs in the contemporary treatment of depression. Neuropsychopharmacology, 12, 185-219.
Zametkin, A., Rapoport, J. L., Murphy, D. L., Linnoila, M., & Ismond, D. (1985). Treatment of hyperactive children with monoamine oxidase inhibitors. Archives of General Psychiatry, 42, 969-73.
poster:Tomatheus
thread:597152
URL: http://www.dr-bob.org/babble/20060108/msgs/597933.html