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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 16 of 16. This is the beginning of the thread.
Posted by Adam on September 28, 1999, at 0:30:01
Ah, progress.
The last decade has seen an incredible increase in the number and kind of antidepressant medications. Today we have SSRIs, NARIs, SNRIs, RIMAs, alpha-adrenergic receptor agonists, serotonin receptor antagonists, anticonvulsants, and heavens knows what else. And of course there are the old tricyclics and the MAOI inhibitors, classes of drugs that, serendipitously, were found to relieve depression. The newer drugs, sought out specifically for their potential antidepressant effects, have promised to meet or exceed the efficacy of the old with fewer/no side effects, and one cannot help but be struck by the hype surrounding Prozac and its siblings at the beginning of the decade to see how perilously attractive such promises have been.
But it seems to me that the hype has largely belied the real value of the newer drugs when compared to the old, and with many American doctors now embracing polypharmacy, when such a short while ago laser-guided monotherapies were all the rage, I can’t help but think we are largely trying to mimic with lots of new drugs what was done very effectively with the old ones. And not always with much success, or at least, when the possible drug interactions and side effects start piling up, with fewer clear advantages than one would hope.
Prozac once seemed like a miracle. Now, as reboxetine nears approval, I’ve read many articles where doctors have disparaged the SSRIs for their lack of robustness in treating severe depression, and how a safe NARI is thus so eagerly awaited here. SSRIs often deaden peoples emotions, they say, while reboxetine improves drive, social functioning and so on. Hopefully the future rush to prescribe NARIs will prove to be more than a giant fad.
There is little that is alluring about, say, an MAOI. A host of possible side effects, and, of course, the dietary restrictions and the potential for lethal drug interactions. Yet they are still prescribed, and, it would seem through my conversations with some pdocs old enough to remember the days when the MAOIs and tricyclics were all there really was, pack more of an antidepressant punch than anything available today. I am currently enrolled in an MAOI study, and have had a chance to talk to the principle investigator, who, not being one to mince words, has described a full response to an MAOI as feeling “fantastic” in a way that no other antidepressant can match. I’ve read with interest the stories of the first patients in a VA hospital being treated for tuberculosis with iproniazid who were literally described by one doctor as “dancing in the aisles”. It’s hard to argue with such observations, especially when they are so unexpected. I find the results of Eli Lily-funded studies less compelling. I am disconcerted by meta analyses of recent antidepressant clinical trials that estimate the placebo effect to account for around 80% of the therapeutic effect.
Like I said, I’m currently in a study where an MAOI (in this case selegiline, perhaps a more dubious MAOI in terms of efficacy in treating depression) is being delivered via a transdermal “patch” system to get around dietary restrictions. I’m hoping that this idea shows promise and can be applied to other MAOIs, if not ones currently available, then ones to be developed in the future. It seems in the hopes of avoiding the adverse effects of this old class of drugs, many have abandoned it altogether, and nearly all the research out there is on the newer classes. Maybe if the transdermal system works it will help revive some interest in the MAOIs, even if a transdermal system cannot always be used. If selegiline doesn’t work for me, chances are I will try Parnate, and sadly bid good-bye to pepperoni pizzas and a good pint of Guinness. Such has been the vain pursuit of real help from the newer meds that I didn’t make this transition long ago, and I may have suffered needlessly in the interim because none of my prior doctors even considered an MAOI, or saw the possible advantages.Well, those are my thoughts. What are yours?
Posted by JohnL on September 28, 1999, at 3:35:23
In reply to All that's old is new again..., posted by Adam on September 28, 1999, at 0:30:01
Adam. Hagop Akiskal, a noted guru in psychiatry, describes in his book reasons for antidepressant failures. He speaks of patient-related reasons and physician-related reasons. For physician-related reasons, he cites the underuse of MAOIs as the main reason. I have no expereience with MAOIs, a little with TCAs, but I agree with you. I think the older stuff has merits overshadowed by the marketing hype of current-day drugs. Newer alternatives that attempt to mimic olden day methods, except with diminished side effects, are certainly welcome in my book! Reboxetine, patch-delivery MAOIs, and who knows what else aren't coming down the pike fast enough. Bring em on!
Posted by Noa on September 28, 1999, at 7:03:52
In reply to Re: All that's old is new again..., posted by JohnL on September 28, 1999, at 3:35:23
Adam and John, thanks for the thoughts. John, I have read a lot of abstracts on Hagop Akiskal's work, as well as in textbooks citing his work, and I am impressed. Which book of his are you referring to? I would like to see it. Thanks.
Posted by Noa on September 28, 1999, at 7:07:59
In reply to Re: All that's old is new again..., posted by JohnL on September 28, 1999, at 3:35:23
Question for both of you: Would the transdermal patch system eliminate problems with taking decongestants, etc.? This is my problem. I could give up the various cheeses, etc. but because of my sleep apnea, I can't see giving up the occasional use of decongestants because if I can't breathe through my nose, I can't breathe at night, and therefore would not be able to sleep at all. My pdoc has mentioned MAOIs as a possibility, and I have read that they are effective with difficult to treat, atypical chronic depression.
Posted by Sean on September 28, 1999, at 12:18:16
In reply to All that's old is new again..., posted by Adam on September 28, 1999, at 0:30:01
> Ah, progress.
>
> The last decade has seen an incredible increase in the number and kind of antidepressant medications. Today we have SSRIs, NARIs, SNRIs, RIMAs, alpha-adrenergic receptor agonists, serotonin receptor antagonists, anticonvulsants, and heavens knows what else. And of course there are the old tricyclics and the MAOI inhibitors, classes of drugs that, serendipitously, were found to relieve depression. The newer drugs, sought out specifically for their potential antidepressant effects, have promised to meet or exceed the efficacy of the old with fewer/no side effects, and one cannot help but be struck by the hype surrounding Prozac and its siblings at the beginning of the decade to see how perilously attractive such promises have been.
> But it seems to me that the hype has largely belied the real value of the newer drugs when compared to the old, and with many American doctors now embracing polypharmacy, when such a short while ago laser-guided monotherapies were all the rage, I can’t help but think we are largely trying to mimic with lots of new drugs what was done very effectively with the old ones. And not always with much success, or at least, when the possible drug interactions and side effects start piling up, with fewer clear advantages than one would hope.
> Prozac once seemed like a miracle. Now, as reboxetine nears approval, I’ve read many articles where doctors have disparaged the SSRIs for their lack of robustness in treating severe depression, and how a safe NARI is thus so eagerly awaited here. SSRIs often deaden peoples emotions, they say, while reboxetine improves drive, social functioning and so on. Hopefully the future rush to prescribe NARIs will prove to be more than a giant fad.
> There is little that is alluring about, say, an MAOI. A host of possible side effects, and, of course, the dietary restrictions and the potential for lethal drug interactions. Yet they are still prescribed, and, it would seem through my conversations with some pdocs old enough to remember the days when the MAOIs and tricyclics were all there really was, pack more of an antidepressant punch than anything available today. I am currently enrolled in an MAOI study, and have had a chance to talk to the principle investigator, who, not being one to mince words, has described a full response to an MAOI as feeling “fantastic” in a way that no other antidepressant can match. I’ve read with interest the stories of the first patients in a VA hospital being treated for tuberculosis with iproniazid who were literally described by one doctor as “dancing in the aisles”. It’s hard to argue with such observations, especially when they are so unexpected. I find the results of Eli Lily-funded studies less compelling. I am disconcerted by meta analyses of recent antidepressant clinical trials that estimate the placebo effect to account for around 80% of the therapeutic effect.
> Like I said, I’m currently in a study where an MAOI (in this case selegiline, perhaps a more dubious MAOI in terms of efficacy in treating depression) is being delivered via a transdermal “patch” system to get around dietary restrictions. I’m hoping that this idea shows promise and can be applied to other MAOIs, if not ones currently available, then ones to be developed in the future. It seems in the hopes of avoiding the adverse effects of this old class of drugs, many have abandoned it altogether, and nearly all the research out there is on the newer classes. Maybe if the transdermal system works it will help revive some interest in the MAOIs, even if a transdermal system cannot always be used. If selegiline doesn’t work for me, chances are I will try Parnate, and sadly bid good-bye to pepperoni pizzas and a good pint of Guinness. Such has been the vain pursuit of real help from the newer meds that I didn’t make this transition long ago, and I may have suffered needlessly in the interim because none of my prior doctors even considered an MAOI, or saw the possible advantages.
>
> Well, those are my thoughts. What are yours?In general, I agree with everything said here. But
I think we might all accept that having more drugs
in the pharmacopia is better than fewer, and, the
side effects of TCA's and MAOI's were for some
people, very problematic compared to SSRI's.One theory I have about AD's (which is probably
totally wrong, but based on personal observations
of my own affect and perceptual acuity while on
various meds) is that the AD prescribed is not
directly causing the effect. To me it *feels*
like a secondary reaction to the drug is what
eventually causes the relief. Also, I have noticed
that I actually feel best right as the AD is
having an effect - AND - right after I stop it.Maybe drug poop-out is simply a re-establishment
of the primary dysfunction after the brain has
a chance to adjust to the new chemical environment.
Then, when you go off the AD, this state is
disrupted and you have a brief AD effect.Why am I rambling on about this? All these drugs,
old and new, generally operate on the three
amine systems: serotonin, dopamine, and
norepinephrine. The subjective "quality" of the
response to perturbing one or more of these
systems is what differentiates the "feel" of the AD.
BUT, none of these drugs really get to the root
of the problem (in my opinion). They simply jar
the brain for a while and then you wind up back
where you started.What these drug company people need to do (again
in my likely ridiculous opinion!) is to look more
at the process of *reaction* to the various drugs
and why such different substances can cause a
similar change in mood. I think the current AD's
are probably operating like a scaled-down form
of ECT.The delay in AD response seems to be linked to
the necessity of the brain to literally change
certain genes in the cells that create transmitters
and receptors. A drug that had a direct effect on
these transcription processes would likely have
a quick onset and lasting result.In conclusion (hee hee hee!) I'm kind of sick of all
the available drugs because they still do not
deal with depression directly. This makes all the
maketing hype particulary offensive. I mean,
come on Pfizer, Lilly, and Merck: wake up and smell
the genome...Sean.
Posted by Adam on September 28, 1999, at 13:17:13
In reply to Re: MAOIs, posted by Noa on September 28, 1999, at 7:07:59
JohnL,
Hi, John. Unfortunately, the restictions on decongenstants still apply, even with the transdermal
delivery system. Such drugs, like pseudoephedrine, pass right through the gut with little or no
alteration, and thus a delivery system that bypasses the gut is of no help. I just had one of the
worst colds in my life, and not being able to down a Theraflu or somethingwas definitely a major drag.> Question for both of you: Would the transdermal patch system eliminate problems with taking decongestants, etc.? This is my problem. I could give up the various cheeses, etc. but because of my sleep apnea, I can't see giving up the occasional use of decongestants because if I can't breathe through my nose, I can't breathe at night, and therefore would not be able to sleep at all. My pdoc has mentioned MAOIs as a possibility, and I have read that they are effective with difficult to treat, atypical chronic depression.
Posted by Noa on September 28, 1999, at 20:48:46
In reply to Re: MAOIs, posted by Adam on September 28, 1999, at 13:17:13
Thanks for the info on decongestants. What about nasal spray versions of decongestants, prescriptions such as Atrovent (ipatropium bromate)?
Posted by Adam on September 29, 1999, at 13:43:07
In reply to Re: MAOIs, posted by Noa on September 28, 1999, at 20:48:46
Hey, Noa,
Um, I have no idea. I think the packaging might say if the drug X/MAOI combo is
dangerous or not, but absence of info. is not evidence of absence, as they say.
Your doctor might know, or know where to look. Dr. Bob?> Thanks for the info on decongestants. What about nasal spray versions of decongestants, prescriptions such as Atrovent (ipatropium bromate)?
Posted by ryan_s on February 12, 2000, at 23:40:46
In reply to Re: All that's old is new again..., posted by Sean on September 28, 1999, at 12:18:16
i have suffered from severe depression for about two years and have not found any relief from the ever crippling symptoms of depression. prozac, paxil, buspar, remoron, celexa, zyprexa, and seroquel have not done the trick. i am fed up with the drugs. all of the antidepressants take away the emotion that was once in my life. all that i want is a general sense of well being
the solution in my opinion is to try the older maoi inhibitors, but there is a problem. the problem is that my doctor will not perscribe me any maoi's in fear of liability. the depression has been so horrible that i do not want to wake up in the morning and face life. i want to call local pdocs and ask directly "do you perscribe maoi's?" or is there a better way, other than asking a question. please help.looking for happiness,
ryan
Posted by jd on February 13, 2000, at 4:36:04
In reply to Re: All that's old is new again..., posted by ryan_s on February 12, 2000, at 23:40:46
Ryan,
I can sympathize with your frustration. Shy of a point-blank question "Do you prescribe MAOIs?", you might consider this one: "Do you have much experience in treating refractory depression."
Most any doctor who can truthfully answer yes to this question have used MAOIs in his or her practice. This is not to say that all such doctors would agree that you should try an MAOI first-off: they will want to make sure that the other easier possibilities really have been explored. (For example, you don't mention whether you've tried wellbutrin, effexor, or tricyclics--these might merit a trial first.) But at least you'll be working with someone who understands MAOIs as a viable (if complicated) treatment option rather than simply being afraid of them like many less experienced MDs.Best of luck to you,
jd
> i have suffered from severe depression for about two years and have not found any relief from the ever crippling symptoms of depression. prozac, paxil, buspar, remoron, celexa, zyprexa, and seroquel have not done the trick. i am fed up with the drugs. all of the antidepressants take away the emotion that was once in my life. all that i want is a general sense of well being
> the solution in my opinion is to try the older maoi inhibitors, but there is a problem. the problem is that my doctor will not perscribe me any maoi's in fear of liability. the depression has been so horrible that i do not want to wake up in the morning and face life. i want to call local pdocs and ask directly "do you perscribe maoi's?" or is there a better way, other than asking a question. please help.
>
> looking for happiness,
> ryan
Posted by harry b. on February 13, 2000, at 12:07:09
In reply to Re: All that's old is new again..., posted by ryan_s on February 12, 2000, at 23:40:46
looking for happiness,
ryan
ryan, I can't help with your meds question or ways
to approach pdocs. Just wanted to say that I have
long ago given up on my quest for happiness. Now,
I'm -just- searching for some kind of contentment,
and to be at peace with myself.Be well
Posted by torchgrl on February 13, 2000, at 14:48:20
In reply to Re: All that's old is new again..., posted by ryan_s on February 12, 2000, at 23:40:46
> i have suffered from severe depression for about two years and have not found any relief from the ever crippling symptoms of depression. prozac, paxil, buspar, remoron, celexa, zyprexa, and seroquel have not done the trick. i am fed up with the drugs. all of the antidepressants take away the emotion that was once in my life. all that i want is a general sense of well being
> the solution in my opinion is to try the older maoi inhibitors, but there is a problem. the problem is that my doctor will not perscribe me any maoi's in fear of liability. the depression has been so horrible that i do not want to wake up in the morning and face life. i want to call local pdocs and ask directly "do you perscribe maoi's?" or is there a better way, other than asking a question. please help.
>
> looking for happiness,
> ryanYou may not want to pose the question that directly; maybe stating that you're interested in working with someone who is open to using the full spectrum of meds currently available, including MAOIs... However you put it, you owe it to yourself to find a doctor who's willing to use ALL the options that you have, not just the "safest" ones. As you can see from this board, many people are using the older medications with considerable success; just because SSRIs etc are newer, doesn't mean they're better for everyone. MAOIs and tricyclics can be the answer for many people--plus, they're much less expensive!
Good luck!
Posted by SIGOLENE on February 14, 2000, at 15:12:04
In reply to Re: All that's old is new again..., posted by torchgrl on February 13, 2000, at 14:48:20
I tried MAOI's 2 years ago. And I had to stop them because It was really impossible to sleep with it. It's worse than SSRI's for sleep. So if you are already someone with sleeping difficulties it's better to forget MAOI's because you can't take an other sedating AD with it, like Desyrel for sleep.
Sigolene.
Posted by Scott L. Schofield on February 15, 2000, at 20:14:14
In reply to Re: All that's old is new again..., posted by SIGOLENE on February 14, 2000, at 15:12:04
> I tried MAOI's 2 years ago. And I had to stop them because It was really impossible to sleep with it.
This is not an uncommon side-effect, especially early on in treatment. I think insomnia is more frequently associated with Parnate than with either Nardil or Marplan. However, it does occur with all three frequently. Interestingly, several people have posted here recently stating that they actually found Parnate to be sedating. Making broad generalizations can often be counterproductive when evaluating the pharmacotherapy of affective-disorders.
> It's worse than SSRI's for sleep. So if you are already someone with sleeping difficulties it's better to forget MAOI's because you can't take an other sedating AD with it, like Desyrel for sleep.
Competent psychiatrists can treat MAOI-induced insomnia. Since so many people can claim that an MAO-inhibitor has saved their life, and that so many of these same people have had insomnia as a side-effect, it seems that treatment-emergent insomnia is not so great a concern as to warrant avoiding MAOIs. And again, one's experience with the side-effects of one drug cannot be extrapolated to all others.
Finally, the use of Desyrel (trazodone) to treat MAOI-emergent insomnia has been the first choice of many psychiatrists for nearly a decade.
- Scott
Posted by Sigolene on February 17, 2000, at 14:18:13
In reply to Re: All that's old is new again..., posted by Scott L. Schofield on February 15, 2000, at 20:14:14
> Finally, the use of Desyrel (trazodone) to treat MAOI-emergent insomnia has been the first choice of many psychiatrists for nearly a decade.
>
Dear Scott,
I have just read again the paper in the Desyrel box, and it's written on it that it shouldn't be taken togother with an MAOI absolutly counterindicated. But it's the European version of Desyrel (called here Trittico). Is that not written in USA?
Sigolene
Posted by Sigolene on February 17, 2000, at 14:22:06
In reply to Re: All that's old is new again..., posted by ryan_s on February 12, 2000, at 23:40:46
I would like to know if someone is taking together an MAOI AD and Desyrel. Because I thought it was forbidden ? and I would like to try this myself.
Thanks Sigolene.
This is the end of the thread.
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