Posted by ed_uk on October 31, 2004, at 14:07:34
In reply to Nardil or Parnate for Social Anxiety?, posted by Ted Brosnan on October 31, 2004, at 12:45:32
Hello Ted it's me again....
Just to start, I'd like to point out that although you may live in isolation you've always got your friends on psycho-babble :)
If your depression is caused by AvPD, MAOIs are likely to be very helpful, probably much more so than the other antidepressants you've considered such as nortriptyline. Whether the MAOIs are dangerous or not is very much dependent on the way that they are used. If they are prescribed to a patient who isn't well informed about diet/drug restrictions etc. they would clearly be very dangerous. On the other hand, the risks are much smaller when the patient and their pdoc are both well informed about MAOIs. Some pdocs may choose to give the patient a tablet to take to reduce their BP if they do experience a hypertensive crisis. Many people who take MAOIs may decide to buy a machine to monitor their own BP at home, this could be a great reassurance if you thought you might be having a hypertensive crisis. Phenelzine(Nardil) has been carefully studied in social phobia whereas tranylcypromine(Parnate) and isocarboxazid(Marplan) have not. As far as I know, there have never been any double blind placebo controlled studies of Parnate as a treatment for social anxiety. Nevertheless, some people with social phobia do seem to gain substantial benefit from Parnate.
This is the only study of Parnate in SP that I have ever seen. I can give you the full report if you would like.....J Clin Psychopharmacol. 1988 Aug;8(4):279-83. Related Articles, Links
Tranylcypromine in social phobia.Versiani M, Mundim FD, Nardi AE, Liebowitz MR.
Department of Psychiatry, Federal University of Rio de Janeiro, Brazil.
Thirty-two patients meeting DSM-III criteria for social phobia entered a 1-year drug treatment with tranylcypromine(Parnate) in dosages between 40 and 60 mg/day. After exclusion of the early dropouts, improvement was rated as marked and moderate in 62% and 17% of the sample (N = 29), respectively. Alcohol abuse was associated with a poor outcome. Side effects were frequent and in some cases delayed the attainment of efficacious dosages until the third month of treatment. No serious adverse reactions occurred. The findings, relative to efficacy, are in accordance with a previous trial with phenelzine(Nardil) but **need confirmation in double blind controlled studies.**
Theoretically, the GABAergic effect of Nardil may make it superior to Parnate for some patients. This is not a proven fact however, it is just a theory. Nardil inhibits an enzyme in the brain called GABA transaminase which is responsible for the breakdown of GABA. By inhibiting this enzyme, the amount of GABA in the brain is elevated by Nardil. Unlike the benzos (eg. Klonopin), Nardil does not appear to potentiate the effect of GABA at its receptors.
Certain side effects are generally thought to be more common with Nardil eg. sexual dysfuction, weight gain, sedation and probably edema. Parnate has a reputation for causing more insomnia and aggravation of anxiety. Both drugs can cause urinary retention. Parnate is chemically related to the amphetamines and may possess some stimulant properties due to its effects on dopamine.
Considering your depression in isolation, symptoms such as low energy and amotivation might be expected to respond better to the stimulating effects of Parnate. As a psychologist once said to me, however, you might wrongly be led into the belief that you are suffering from anhedonia (ie. the inability to experience pleasure) if you fail to do any of the things that you enjoy. If your anxiety was improved by Nardil (without causing the potentially 'numbing' effect of the benzos) you could well start to enjoy you social interactions. As a result, your motivation and energy levels may increase. After all, there is nothing more effective in draining away your motivation than being bored. If your depression is mainly due to your isolation, the well known anxiolytic properties of Nardil could be of great help in improving your social life. To be fair, psychopharmacology is always a matter of trial and error and you will never find out which MAOI you prefer until you try them both!
In England, Nardil is used much more frequently than Parnate for three main reasons:
1. Parnate may be associated with an increased risk of hypertensive crisis compared to Nardil.
2. Abuse of Parnate has been reported
3. The BNF (The UK drugs bible) states that Nardil is safer.On the other hand many people who have used MAOIs prefer Parnate due to the fact that certain of the side effects tend to be milder.
I have never come across a study which compared the urinary side effects of MAOIs. If Parnate really is more noradrenergic i suppose you might expect it to be worse. Annoyingly, the drugs which are often used to treat the urinary side effects of other ADs (eg. doxazosin) all tend to lower blood pressure, this may be additive with the BP lowering effect of the MAOIs.
Many people on psycho-babble have found the dietary restrictions of MAOIs relatively easy to adjust to. There are many people on babble who can advise you on this.
The new Nardil contains exactly the same drug as the old Nardil in exactly the same dose ie. 15mg phenelzine. The inactive ingredients used in the formulation of the tablets have been altered. Some people claim that the new Nardil has been less effective. It is possible that you will not run into any problems unless you have been on the old Nardil. It has been suggested that the phenelzine from the new tablets may not be as well absorbed as the phenelzine in the old tablets. The manufacturer claims that tests performed show that this is not true however, they say that the bioavailability of the two formulations is the same. Personally, I would try not to worry too much about the change in formulation.
If you are worried about trying a classical MAOI you could always try Moclobemide (a reversible inhibitor of MAO type A). It is not as effective for SP as the traditional MAOIs but has fewer side effects and there is no need for a special diet. Perhaps a very low dose of Klonopin in combination with moclobemide would be sufficient.
All the best.....
Ed :)
poster:ed_uk
thread:409577
URL: http://www.dr-bob.org/babble/20041029/msgs/409620.html