![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 13 of 13. This is the beginning of the thread.
Posted by RetiredYoung on July 24, 2004, at 10:02:37
I've been diagnosed with depression and been on anti-depressants for over 15 years now. I'm currently taking Lexapro 30mg, Surmontil/Trimipramine 25mg, generic Adderal 15mg - the cocktail is having diminishing effectiveness this year. I've been doing some net research which leads me to believe that, more precisely, I have atypical depression. What's interesting is that MAOIs seem to be much more effective for this particular type of depression.
Despite the dietary restrictions, I'd like to switch to an MAOI. However, some sites I've read indicate that you must be off SSRIs (and TCAs?) completely for two weeks before starting. Just going down on Lexapro would be hard enough, but completely withdrawing would be next to impossible.
Have others gone down this route? Advice would be greatly appreciated.
Posted by cybercafe on July 24, 2004, at 10:39:59
In reply to Switching to MAOI??? Please advise.., posted by RetiredYoung on July 24, 2004, at 10:02:37
> I've been diagnosed with depression and been on anti-depressants for over 15 years now. I'm currently taking Lexapro 30mg, Surmontil/Trimipramine 25mg, generic Adderal 15mg - the cocktail is having diminishing effectiveness this year. I've been doing some net research which leads me to believe that, more precisely, I have atypical depression. What's interesting is that MAOIs seem to be much more effective for this particular type of depression.
>
> Despite the dietary restrictions, I'd like to switch to an MAOI. However, some sites I've read indicate that you must be off SSRIs (and TCAs?) completely for two weeks before starting. Just going down on Lexapro would be hard enough, but completely withdrawing would be next to impossible.
>
> Have others gone down this route? Advice would be greatly appreciated.
>i would recommend it from personal experience... SSRIs definately only did 30% of the job for me (though they were definately a lot better than nothing!!) but parnate is really a miracle drug for me ... YMMV ... yes the washout period wasn't much fun... but if you really can't bear it... i'm sure there are other drugs you can take to help you with it (i.e. clonazepam really helps SSRI withdrawal, etc) ...
don't think you'd be able to get away with Adderall and parnate at the same time though... i do take parnate + ritalin .. but my doc says amphetamines are a big no-no .... YMMV
Posted by SLS on July 24, 2004, at 10:42:02
In reply to Switching to MAOI??? Please advise.., posted by RetiredYoung on July 24, 2004, at 10:02:37
Hi.
Waiting 14 days after taking your last dose of Lexapro before starting an MAOI is the only way to guarantee that you won't experience a serious reaction. You might hear stories of people making the switch between drugs successfully without waiting, but the risk does exist. The most immediate risk is of a reaction known as serotonin syndrome. It can occur when an MAOI is combined with any drug that blocks the reuptake of serotonin (5-HT), such as Lexapro. It can be fatal. The reaction can include severe mental confusion and incoherency, coma, hypertension, hyperpyrexia, tachycardia, myoclonus, hyperreflexia, muscle rigidity, and a bunch of other nasty things. Believe it or not, the waiting period recommended for Prozac is 5 weeks. I really don't know how far it makes sense to push things. I wouldn't go any sooner than one week, though.
Parnate might be a good choice for you. It has amphetamine-like properties, and is usually more tolerable with respect to side effects than is Nardil. In addition, it is easier to work with if you want to add things like tricyclic antidepressants. I have combined Parnate + desipramine + amphetamine + thyroxine. There is also the opportunity to use a high-dosage Parnate strategy that is sometimes effective in difficult cases that involves dosages above 100mg.
Good luck.
- Scott
Posted by King Vultan on July 24, 2004, at 10:49:43
In reply to Switching to MAOI??? Please advise.., posted by RetiredYoung on July 24, 2004, at 10:02:37
The Surmontil is okay (it is a TCA but has nearly zero effect on amine reuptake and IMO is completely safe to use with an MAOI), but it is absolutely essential that the Lexapro be tapered down and eliminated. There is simply no way to combine an SSRI with an MAOI because of the likelihood of serotonin syndrome occurring. I am not an expert on amphetamines--there are people here who are, though--but the books say that these are also contraindicated. If it were me, I would also drop the Adderall.
You also do need some kind of washout period after completely discontinuing the Lexapro. Two weeks is the standard amount because it's long enough for every antidepressant I can think of except for Prozac and Vivactil, but the actual amount of time needed to completely clear a particular drug is five half lives. My "Mosby's 2004 Drug Guide" lists Lexapro as having a mean half life of 27-32 hours. Taking 32 x 5 = 160 hours or about one week. The metabolites of Lexapro do not appear to have any real SSRI activity, so for most people, waiting one week should be a sufficient amount. My pdoc is conservative and cautious enough so that he would probably make me wait the two weeks, anyway, but I think other doctors might see this differently.
Todd
Posted by flipsactown on July 24, 2004, at 10:56:57
In reply to Switching to MAOI??? Please advise.., posted by RetiredYoung on July 24, 2004, at 10:02:37
I am currently on 30mg Lexapro and have been for 46 days. Yesterday, I started feeling the benefits of Lex in that I have been as depression free as I have been since I was first diagnosed with clinical depression over 14 years ago.
After 10 years on being on mostly SSRI's, Prozac, Zoloft, Paxil, Celexa, Effexor, Remeron and Desipramine, I decided to try Nardil, an MAOI, since the SSRI's I have tried, and were mostly effective in controlling my unipolar depression, have all seemed to have pooped out.
In order to switch from an SSRI to an MAOI, my pdoc had me taper and stop all my AD's for 15 days before I could even start Nardil. Needless to say, those were the longest 15 days of my life.
I was finally able to start Nardil and in 2 weeks my depression seemed to be lifting. However, I had intense insomnia, which I did not mind at first, since I was feeling pretty good and had lots of extra time due to the insomnia to do a lot of my "honey-do's". I was getting less than 2 to 4 hours of sleep and after 6 weeks, of being sleep deprived, I was getting more and more depressed. So, I decided to get off Nardil and try Lexapro, which I have never tried and, like Prozac, the first AD I took over 14 years ago, I am once again, depression free. Yes! Yes! Good luck to you. Nardil would have worked for me if I were able to get some quality sleep, more than a couple of hours at a time. I did take Ambien and Seroquel but was still unable to get any quality sleep.
FST
> I've been diagnosed with depression and been on anti-depressants for over 15 years now. I'm currently taking Lexapro 30mg, Surmontil/Trimipramine 25mg, generic Adderal 15mg - the cocktail is having diminishing effectiveness this year. I've been doing some net research which leads me to believe that, more precisely, I have atypical depression. What's interesting is that MAOIs seem to be much more effective for this particular type of depression.
>
> Despite the dietary restrictions, I'd like to switch to an MAOI. However, some sites I've read indicate that you must be off SSRIs (and TCAs?) completely for two weeks before starting. Just going down on Lexapro would be hard enough, but completely withdrawing would be next to impossible.
>
> Have others gone down this route? Advice would be greatly appreciated.
>
Posted by SLS on July 24, 2004, at 11:21:20
In reply to Re: Switching to MAOI??? Please advise.., posted by King Vultan on July 24, 2004, at 10:49:43
> The Surmontil is okay
I agree.
Unfortunately, I don't feel confident in saying the same thing about Adderall. You will probably experience profound fatigue and even depression for having to stop it, but I would be afraid to recommend its continuation to anyone other than me. On the other hand, those doctors who have combined amphetamines and Parnate in the past have insisted that the amphetamine be started first. I never really saw the wisdom in this, though. However, you can find relevant threads containing conversations between clinicians in Dr. Bob's Psychopharmacology Tips. I can't pull them up right now because the Search function server is busy.
- Scott
Posted by RetiredYoung on July 24, 2004, at 13:00:09
In reply to Re: Switching to MAOI??? Please advise.., posted by SLS on July 24, 2004, at 11:21:20
Thanks to all for the replies so far.
I've tapered on and off the Surmontil and stimulants (the first was Provigil) - it was indeed tough (fatigue and depression) but it did pass after a few days.
I've been continuously on one of the SSRIs at one time or another since 1992 - I'd started ADs in 1990 with Pamelor but had to discontinue because the effective dosage range for me caused tachycardia. I'm terrified of going off Lexapro because I'm nearly certain of how horrible that would be; unfortunately, it's now clear to me that I would have to do this to begin an MAOI, which may or may not provide a lasting benefit for me.
Ugghhh... :(
Posted by bluebird on July 25, 2004, at 17:04:34
In reply to Re: Switching to MAOI??? Please advise.., posted by cybercafe on July 24, 2004, at 10:39:59
> > I've been diagnosed with depression and been on anti-depressants for over 15 years now. I'm currently taking Lexapro 30mg, Surmontil/Trimipramine 25mg, generic Adderal 15mg - the cocktail is having diminishing effectiveness this year. I've been doing some net research which leads me to believe that, more precisely, I have atypical depression. What's interesting is that MAOIs seem to be much more effective for this particular type of depression.
> >
> > Despite the dietary restrictions, I'd like to switch to an MAOI. However, some sites I've read indicate that you must be off SSRIs (and TCAs?) completely for two weeks before starting. Just going down on Lexapro would be hard enough, but completely withdrawing would be next to impossible.
> >
> > Have others gone down this route? Advice would be greatly appreciated.
> >
>
> i would recommend it from personal experience... SSRIs definately only did 30% of the job for me (though they were definately a lot better than nothing!!) but parnate is really a miracle drug for me ... YMMV ... yes the washout period wasn't much fun... but if you really can't bear it... i'm sure there are other drugs you can take to help you with it (i.e. clonazepam really helps SSRI withdrawal, etc) ...
>
> don't think you'd be able to get away with Adderall and parnate at the same time though... i do take parnate + ritalin .. but my doc says amphetamines are a big no-no .... YMMVI have a question for you. When coming off of the SSRI what dose of clonazepam did you take? I am coming off of Paxil and just going down 5mg gives me the shakes and so forth. I also take clonazepam, did you up your doses as you went down? I am at 75mg on Paxil right now. Just dropped 5mg from 80mg. It just isn't working well. It seemed to work in the 1st year, which was the first time in my life I felt relief at all, although anxiety and depression were still and issue. Plan to switch to MAOI. I think Parnate is the one I want to take. Seeing new Doc soon. Thanks, bluebird
Posted by cybercafe on July 28, 2004, at 10:23:34
In reply to Re: Switching to MAOI??? Please advise..cybercafe, posted by bluebird on July 25, 2004, at 17:04:34
> I have a question for you. When coming off of the SSRI what dose of clonazepam did you take? I am coming off of Paxil and just going down 5mg gives me the shakes and so forth. I also take clonazepam, did you up your doses as you went down? I am at 75mg on Paxil right now. Just dropped 5mg from 80mg. It just isn't working well. It seemed to work in the 1st year, which was the first time in my life I felt relief at all, although anxiety and depression were still and issue. Plan to switch to MAOI. I think Parnate is the one I want to take. Seeing new Doc soon. Thanks, bluebird
gee probably less clonazepam than i'm taking now (2 mg tabs) ... i think i must have taken a .5 mg tab maybe 3 times a day?
i went off effexor really high dose (300 mg?) and had major problems till i took clonazepam, then i felt SO much better... effexor is supposed to be the second worst AD to come off. paxil i believe is the worst. according to my doc.
and since parnate seems to be the right drug for me, i can get away with a low dose even though i've always taken high dosages of other drugs ...
same with abilify
in fact i used to be depressed everyday, now it's been so long since i've been depressed that i find it hard to emphasize with what my bros are going through around here .... what's depression like? i don't remember ....
i am going for med school or at the very least pharmacy college and i'm afraid by the time i graduate i will have zero recollection of what it's like to be depressed/anxious :(
Posted by cirrus6000 on July 28, 2004, at 23:33:33
In reply to Switching to MAOI??? Please advise.., posted by RetiredYoung on July 24, 2004, at 10:02:37
I have gone the MAOI route too, it appears as though I have atypical depression. none of the ssri's worked with me serzone, effexor, remron didnt work. Nardil appears to be what I need thats about all I have for you. I havent changed my diet at all either. I have even gone ahead and taken L-tyrosine pills too and no side effects yet...
Posted by King Vultan on July 29, 2004, at 7:40:54
In reply to Re: Switching to MAOI??? Please advise.., posted by cirrus6000 on July 28, 2004, at 23:33:33
> I have gone the MAOI route too, it appears as though I have atypical depression. none of the ssri's worked with me serzone, effexor, remron didnt work. Nardil appears to be what I need thats about all I have for you. I havent changed my diet at all either. I have even gone ahead and taken L-tyrosine pills too and no side effects yet...
I don't know what your dosage is, but the chances of suffering a hypertensive crisis increase with increasing dosage of the Nardil. I would strongly advise following the dietary restrictions, and I would not be taking the tyrosine if I were in your place, either.Todd
Posted by cirrus6000 on July 29, 2004, at 10:43:00
In reply to Re: Switching to MAOI??? Please advise.. » cirrus6000, posted by King Vultan on July 29, 2004, at 7:40:54
> > I have gone the MAOI route too, it appears as though I have atypical depression. none of the ssri's worked with me serzone, effexor, remron didnt work. Nardil appears to be what I need thats about all I have for you. I havent changed my diet at all either. I have even gone ahead and taken L-tyrosine pills too and no side effects yet...
>
>
> I don't know what your dosage is, but the chances of suffering a hypertensive crisis increase with increasing dosage of the Nardil. I would strongly advise following the dietary restrictions, and I would not be taking the tyrosine if I were in your place, either.
>
> Todd
>My dosage is 15 mg 2 times a day and the tyrosine is to reduce the cravings. So my dosage isn't very high.
Posted by Piquet on July 29, 2004, at 19:09:45
In reply to Re: Switching to MAOI??? Please advise.., posted by cirrus6000 on July 29, 2004, at 10:43:00
> My dosage is 15 mg 2 times a day and the tyrosine is to reduce the cravings. So my dosage isn't very high.
High enough, though. Unless your present diet normally excludes the riskiest foods, you are "playing under the anvil tree" so to speak :)
Believe me, hypertensive crisis -- though rare -- is very painful, very nasty and very scary. Also, sequelae from the crisis could add to your present burden. I don't mean to sound alarmist, but the risks are real and it has happened to me.
Piquet.
This is the end of the thread.
Psycho-Babble Medication | Extras | FAQ
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.org
Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
Copyright 2006-17 Robert Hsiung.
Owned and operated by Dr. Bob LLC and not the University of Chicago.