With this post, we continue our sort-of-biweekly series on medications used to treat bipolar disorder and related symptoms. Two weeks ago, we covered an older class of antidepressants that are still sometimes used – Tricyclics. This week, we turn our attention to another older classes of antidepressants – Monoamine Oxidase Inhibitors or MAOI’s, for short.
Medications in this group work differently from SSRI’s(including Prozac and Paxil), SSNRI’s(including Effexor and Cymbalta), and Wellbutrin. While MAOI’s have fallen out of favor since the introduction of the newer generation of antidepressants, they remain effective and may be useful alternatives in some cases.
Monoamine Oxidase Inhibitorsare the earliest antidepressants, developed in the 1950s. They work by preventing the action of an enzyme that breaks down norepinephrine, serotonin, and dopamine, along with a number of related brain chemicals, resulting in an increase in the levels of these chemicals in the brain. MAO inhibitors include the following:
Emsam is a second generation MAOI that has been released in recent years. The other formulations are much older and have fallen out of favor with most prescribers. Emsam is provided as a skin patch that you apply to your arm, torso, or thigh. The medication passes slowly and gradually through your skin into your bloodstream. By absorbing the medication more slowly, patients may be able to avoid some of the dietary restrictions that often accompany MAOI’s (as explained later in this post).
The main benefit of MAOI’s is the fact that they boost the three main neurotransmitters that affect mood – serotonin, norepinephrine, and dopamine. They may work more effectively on “atypical” types of depressions, as well, and can be powerfully effective antidepressants for some people. They actually have a strong track record specifically with bipolar depression that has not responded to other interventions.
The restrictions on their use over the years have been due primarily to the following three reasons:
Like all antidepressants, MAOI’s carry a risk of manic switching and of agitation and/or suicidal ideation.
The side-effect profile for MAOI’s dwarfs that of even the tricyclics. Possible side effects include the following:
MAOI’s can have dangerous interactions with certain foods and beverages, which may result in a spike in blood pressure, possibly causing a stroke. If you take medications in this class, you may face some serious dietary restrictions and have to avoid any foods that contain a high concentration of tyramine, including the following:
Serious interactions may also occur with certain medications or herbal remedies, including…
Caution: Consult your doctor prior to adding any medications or herbal remedies to your regimen, even commonly used over-the-counter medications. This is true for all medications but especially critical if you are taking an MAOI.
I have not used MAOI’s in my practice for many years. I have not found the need to go to this level of medication given the many other choices available. MAOI’s, at this point in time, are mostly used in academic settings that handle the most complex kinds of mood disorders.
If you’ve taken any MAOI’s for bipolar depression or other conditions or are a doctor who has prescribed any of the older antidepressants in this class, please share your experiences, insights, and observations.
You can leave a response, or trackback from your own site.
amanda j deweese at 7:48 pm on
November 25th, 2009I was diagnosed bipolar 21 years ago. I am a 39 year old female who in the past few months has been prescribed the MAOi Nardil. I was extremely upset with the idea knowing the many restrictions that go along with these types of drugs. I have had too many suicide attempts to recount except for two seperate attempts in 2003 that each landed me in the ICU for a week and further hospitalizations months after. My doctor at the time put me on almost all “new” anti-depressants with no positive outcomes or severe allergic reactions. Finally there was the answer! Tegretol, effexor, paxil, seroquel, buspar & klonipin as needed. The magic mix! The gift from God! I was well until this year 2009. Things started to go South and I was back to daily fights with suicidal ideations. So having gone through ALL “new” antidepressants my doctor gave me the news – MAOi was going to be the next step. I was very resistant knowing how old these medications are and knowing the many restrictions that go along with these meds. The weeks I had to be off all meds in order for my body to rid itself of all other medications before taking the MAOI were scary, and reminded me of just how thankful I should be that there are doctors and medications (no matter how old or new)that are available to help me with my illness. I am now up to the maximum dosage of 90mg Nardil per day. Other than being a diligent watchdog about what goes in my mouth, the side effects have almost been unbearable. Much more so than any “new” drugs. I have blurred vision (enough to make driving out of the question), dizziness, DRY MOUTH(!), extreme fatigue and slight weight gain. So I have been told my options – if the MAOi medications aren’t effective, I am facing ECT (electro-convulsive therapy.) I wish I new someone who has been given this option, and had a story to share both of long-term MAOi drug therapy & then compare that to ECT therapy. If there is anyone with any personal knowledge of this, maybe you could post your story too. Stay positive my friends…
bob at 6:43 am on
December 15th, 20091. Conside Depakine / Depako
2. drug “mixes” are the WORST thing doctors can do.. 1-2 bipolar drugs + sleep-drug is the max. amount to go with
consider consulting another doctor
john at 5:39 am on
January 26th, 2010I had tried everything as you had. The answer came for me even after ECT. I’m doing really well on EMSAM the transdermal MAOI patch 12mg/24hours. I also take lamictil 200mg twice a day. and 2mg. of klonopin twice a day. I was having problems w/ sleep and I’m also taking 400 mg. of Seroquel now which not only helps w/ sleep but mood stabilization. I have to say I have a high tolerance for medications, but, this has been a life saving combination for me. none of the ssri’s or tricyclics i tried in the past were effective. nardil and parnate were somewhat effective but, not nearly as effective as the emsam! good luck and god bless!
Corinne Byers at 10:35 am on
December 19th, 2010I’m a 59-year-old female and have had problems with depression since I was 14 or so. More often than not I’d go to bed wishing I wouldn’t wake up in the morning. During my working years, getting up in the morning was like facing the gates of hell. Never have made a suicide attempt though — too cowardly.
Didn’t get any treatment to speak of until my 40′s. Therapy was too expensive, and I hated the idea of being dependent upon a drug that messed with my head. When I finally started seeing a therapist regularly, she persuaded me to start taking an antidepressant. My GP prescribed imipramine (Tofranil), a tricyclic. It did help, but I was taking high doses of thyroid at the time. I’d started taking the thyroid in my mid 30′s for my PMS (It’d gotten so bad I was only ‘normal’ for one week out of four) and found it helped me tremendously. I was, however, taking more thyroid than is considered physically healthy, and my doctor took me off it. Then the imipramine made me so sleepy it was unsafe to drive, and difficult to work. I got off it.
Eventually my depression got bad enough that I had to try again. I went through the gamut of all the SSRI’s and SNRI’s. Some helped, but I had to keep raising the dosage until side effects became too much of a problem (painful neuropathy, having diarrhea accidents in my car — stuff like that). Most resulted in my sleeping more hours than people on death row. Finally I tried an MAOI — Nardil.
Nardil has its problems. I have sexual side-effects, some neuropathy, some joint issues, I can get hypomanic, anxious, and I have sleep problems. Fortunately, if I take trazodone at bedtime I can get to sleep. Not getting enough sleep is probably the biggest threat, but it’s manageable with proper use of trazodone. Every couple of years, the benefits have gradually faded to the point where I have to take a drug vacation for a couple of months. I try to be alert to when it’s happening so I don’t have to do it in the dead of winter when I’m at my worst. I’ve often tried another anti-depressant during these vacations in hopes of finding an alternative, but I always come back to Nardil.
While I’m taking Nardil, I have a life. I’m kinda goofy and absent-minded, but I’m out there doing things. Without it, I might as well be dead. The dietary restrictions are a small price to pay in my opinion.
Ally at 10:20 pm on
August 19th, 2011After about 2 years of trial an error with medications, my doctor suggested trying an MAOI. I was so surprised. I’m a student and at the time I was studying psychology; all they ever teach you in school about MAOIs is that they’re ancient and dangerous. I thought my doctor must be joking or something, but I was so desperate.
My doctor prescribed Parnate and within a week I was so much better (actually a bit on the manic side). I have spent more than half of my short life depressed on the edge of suicide. I’ve tried it twice (one attempt being very serious and nearly succeeding). All I can say is that I miss cheddar like you wouldn’t believe, but I’d give up nachos for the rest of my life if I can actually feel what it is to be happy (at least much of the time–my doctor and I are frustrated at the recurring “breakthrough depressions” and know we can do better, so we’re still ironing out some kinks).
I also take a mood stabilizer. Parnate is very activating, so I’ve had issues with sleep that we’ve dealt with by occasionally adding a benzodiazepine or sleep med like Ambien, but other than that I have had no apparent side effects. It’s wonderful really.
Medication For Bipolar Depression (August 25, 2009)
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