This is one of the few class of meds with which neither Mouse nor I have had any personal experience. If all else fails, medication-wise, there are the MAOIs. Although I think they should be considered before the TCAs. Outside of the US you can find things like MAOI type B meds, reverse MAOIs and the MAOI patch, all of which deal in one way or another with the overwhelming lifestyle changes that come with MAOIs. The MAOIs work by inhibiting monoamine oxidase at your cerebellum, hence their name, as well as concentrating serotonin and norepinephrine in certain parts of the brain. For some forms of depression that’s just all that is going to work. When the terms “atypical depression” and “treatment resistant” come up, the MAOIs are the drugs that break through that resistance. So why aren’t they prescribed more often? Because they interact with a vast number of foods, prescription and non-prescription drugs, and often in a deadly way. So why aren’t the other forms available in the US? Because the patents have expired, and enough money isn’t to be made to please the shareholders. Maybe. There is testing of an MAOI patch in the US, so we’ll see if anything comes of it. But if you’re desperate and disciplined enough to exchange pizza, wine, coffee, chocolate, kim chee, sauerkraut, avocados, fava beans, aged cheeses, especially ripe bananas, practically every OTC medication and a host of other foods and prescription drugs, for potentially the only solution for otherwise insoluble depression, the MAOIs might be your last horsie on the med-go-round. Just be sure to wear a MedAlert bracelet noting that you’re on an MAOI in case you’re hospitalized, because no painkillers for you until the MAOI is out of your system, otherwise you too may wind up in a nineteen-day long coma. Then again, you may not be lucky enough to wake up. On top of that, the common side effects are similar to the SSRIs, in addition to dizziness being really popular. Plus you stand a chance freaky side effects like the TCAs, although the odds are a lot higher (i.e. it’s less likely). And the MAOIs have their own discontinuation syndrome. But they really do work for some people when everything else fails, especially if Remeron worked for you before then pooped out. If only other options are wild experimentation with off-label meds of last resort and ECT give the MAOIs some decent consideration.
I’m just going to cover the basics for now and where to get more information, if available. I’ll update these meds to the new format after I deal with other meds, as these aren’t prescribed very often, even though they probably should be prescribed more often. If and when that MAOI patch comes out we should see a lot more MAOI action, as the patch takes care of a lot of the problems associated with MAOIS.
If you’re down to the MAOIs, you need long talks with your doctor and a thorough reading of the patient information sheets. These drugs are not to be taken lightly. But in reading the experiences of people who have taken them, and comparing them with Mouse’s experiences with the TCAs, if you have gone through all of the standard antidepressants and even some of the off-label medications, you’re much better off giving the MAOIs a shot before the TCAs.
Antidepressant Comparison Chart by Loren Regier and Brent Jensen of Queen’s University School of Medicine, Kingston Ontario. Of course it applies only for meds available in Canada, eh. But it does cover SSRIs, TCAs, MAOIs, Multiple Reuptake Inhibitors and whatever else they have in the Great White North. Which means all sorts of varieties of MAOI you can’t find in the US, but might get a doctor to prescribe for you through a Canadian Pharmacy.
You’ll also want to check Nom de Plum’s Summary of Psychotropic Medications for lots of information on the old-school meds like TCAs and MAOIs and how they are used for things like atypical depression.
For now, a glimpse of what the old Poppin’ Zits! Consumers’ Guide to Psychiatric Meds used to look like:
Marplan (isocarboxazid). Dosage should be started with one tablet (10 mg) of Marplan twice daily. If tolerated, dosage may be increased by increments of one tablet (10 mg) every 2 to 4 days to achieve a dosage of four tablets daily (40 mg) by the end of the first week of treatment. Dosage can then be increased by increments of up to 20 mg/week, if needed and tolerated, to a maximum recommended dosage of 60 mg/day. Daily dosage should be divided into two to four doses. After maximum clinical response is achieved, an attempt should be made to reduce the dosage slowly over a period of several weeks without jeopardizing the therapeutic response. Beneficial effect may not be seen in some patients for 3 to 6 weeks. If no response is obtained by then, continued administration is unlikely to help. No half-life data are provided. Hoffmann-La Roche.
Nardil (phenelzine sulfate ) Initial dose: The usual starting dose of Nardil is one tablet (15 mg) three times a day. Early phase treatment: Dosage should be increased to at least 60 mg per day at a fairly rapid pace consistent with patient tolerance. It may be necessary to increase dosage up to 90 mg per day to obtain sufficient MAO inhibition. Many patients do not show a clinical response until treatment at 60 mg has been continued for at least 4 weeks. Maintenance dose: After maximum benefit from Nardil is achieved, dosage should be reduced slowly over several weeks. Maintenance dose may be as low as one tablet, 15 mg, a day or every other day, and should be continued for as long as is required. No half-life data are provided. Parke-Davis.
Parnate (tranylcypromine sulfate). The usual effective dosage is 30 mg per day, usually given in divided doses. If there are no signs of improvement after a reasonable period (up to 2 weeks), then the dosage may be increased in 10 mg per day increments at intervals of 1 to 3 weeks; the dosage range may be extended to a maximum of 60 mg per day from the usual 30 mg per day.