by Harvey Widroe, M.D.
American Reporter Correspondent
November 15, 2007
HOPE FOR THE HOPELESS
ORINDA, Calif. -- Albert described himself. "I'm a hopeless case.
"I've tried every antidepressant, and none of them works for me." Yet he had never taken an MAOI antidepressant drug. He knew almost nothing about them. Many depressed patients feel that they have become hopeless cases. They present a long list of antidepressants which have failed completely or else produced only partial or transitory relief from severe, long-lasting depression.
The vast majority of these patients have never taken so-called MAOI antidepressants, a family of very powerful and effective drugs that may very well help them. Most of these "hopeless" patients are surprised when I first mention them.
The odds are that the only place they ever encountered the term MAOI was on some medication instruction sheet. They had been struck by a bold warning that said (in capital letters) "Do not use along with MAOIs." They may have wondered briefly what a MAOI actually was, if only to reassure themselves that they weren't taking it. The very expression MAOI brings on a twinge of dread in most of us. Doctors have been scared off, too. Most doctors have never prescribed an MAOI antidepressant. And very few doctors have had any training in how to use them, because their medical school faculty members under age 65 hadn't prescribed them either. It is safe to say that a whole generation of physicians has never been taught anything about MAOI antidepressants except for being warned not to use them. Now, despite all the admonitions about MAOIs, a new drug, Emsam, a MAOI antidepressant given by skin patch, has been approved by the FDA and is being marketed. So what is going on? Aren't all MAOIs supposed to be killer drugs? In the late 1950s and early 1960s, long before the Prozac era, a number of MAOI drugs were introduced as a family of powerful psychiatric drugs for depressions. Reports soon began to surface that some patients who took MAOI antidepressants had suffered strokes following a sudden increase in blood pressure, a so-called "hypertensive crisis." A hypertensive crisis with an ensuing stroke was like blowing up a balloon or over-inflating a bicycle tire until it popped. On the basis of these catastrophic reports, the FDA quickly banned the further sale of MAOIs.
Within a year the FDA again approved the sale and prescribing of MAOI antidepressants, but this time with a serious warning that included a list of dietary restrictions required to avert sudden jumps in blood pressure. This grave warning, combined with the prospect that patients might not adhere to the dietary restrictions and possibly suffer fatal consequences, made the vast majority of physicians reluctant to prescribe them.
Instead, for their depressed patients, they prescribed other newly developed drug: members of the tricyclic family of antidepressants. But all of these antidepressants had serious side effects, too. Overdose all too often was lethal. And 2000 suicidal patients each year died of tricyclic antidepressant overdose. Nonetheless the tricyclic antidepressants' side effects, when used as prescribed, did not seem nearly as dangerous as having a patient blow a hole in an artery that supplied blood to the brain. When the Prozac group of antidepressants became available a decade later, there no longer seemed to be a pressing need for either the MAOIs or even the tricyclics. And the Prozac-like antidepressants could be easily administered by any physician with a fair prospect that a depressed patient was going to get some relief with relatively few serious side effects. There was no apparent effect on the heart or blood pressure. Even overdose was no longer to be feared. Prozac soon made it to the cover of Newsweek magazine. It was the new miracle drug.
Prozac and its relatives are can be wonderful drugs, but there are many instances in which users grew worse than ever when they are stopped. But for many depressed patients these antidepressants don't do as good a job as we had earlier thought. Tricyclic antidepressants seem to help a large number of patients who don't respond well to the Prozac group or those for whom the Prozac-like antidepressants seem to have lost effectiveness.
Another group of these drugs, Effexor and Cymbalta, help some patients for whom Prozac-like drugs don't seem to work. But they, too, have their own limitations and side effects. Other antidepressants such as Wellbutrin, Serzone, Remeron all work some of the time for many patients. Each in its own way has side effect problems and varying effectiveness. For the significant number of depressed patients for whom all the other antidepressants don't do an adequate job, a MAOI can help.
So how safe is it to take an MAOI? They are safe if prescribed by a psychiatrist experienced in their use. The psychiatrist will ask that the patient follow a small list of dietary restrictions. All of the foods on the forbidden list contain a particular amino acid, tyramine, which in itself can drive up blood pressure.
Aged cheeses and red wine are the big problems for most people. Processed cheese is safe. Other foods high in tyramine content that most of us can live without include pickled herring, sauerkraut, liver, dry sausages such as salami, pepperoni, bologna, broad beans, and cubes of brewer's yeast. Many other foods contain some tyramine, but in amounts so small that they don't pose a hazard. Foods with a low tyramine content, such as chocolate, turn out not to be dangerous.
Certain other medications are deservedly in the prohibited list for someone taking a MAOI antidepressant. Decongestants, most other cold medicines, antidepressants and diet pills all may elevate blood pressure because of the presence of an MAOI.
Patients usually can spot a hypertensive crisis, should it appear. They develop a severe headache in the back of the head radiating down into the neck. I advise them to immediately take a blood pressure lowering medication such as Inderal, 20 or even 40 mg. and then visit a local ER for further evaluation and treatment. Any patient who is taking an MAOI antidepressant should be given a few Inderal tablets to be kept right at hand at all times for emergency use.
Avoiding the foods or medications on the "No" list usually makes use of MAOI antidepressants quite safe.
Another important factor is that there really are two types of MAOI drugs. One does not seem to cause blood pressure elevation at all despite what we eat or drink. Selegiline and Emsam (the patch version of Selegiline) or St John's Wort appear not to increase blood pressure even after a cheese sandwich and a glass of red wine.
The recent release and marketing of Emsam is encouraging physicians to take another look at all of the MAOIs as a powerful and effective antidepressant treatment option. If used properly under the guidance of an experienced psychiatrist, they are safe. Many patients, whose lives are miserable because of severe depression that has not responded to most other antidepressants, may come to lead normal lives with the help of MAOIs.
Harvey Widroe M.D. is author of the Smart Dieter's Cheating Guide (Outskirts Press, 2007), with Ron Kenner.