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Re: TCA/SSRIs Vs MAOIs -- VERY long, even for me

Posted by Racer on November 29, 2007, at 11:04:36

In reply to Re: TCA/SSRIs Vs MAOIs, posted by mav27 on November 29, 2007, at 8:35:43

As Mav27 mentioned, SSRIs are not considered more effective than the TCAs in treating depression. In fact, none of the anti-depressant classes are considered more effective than the other classes -- they're all about as effective, but they have different benefits and drawbacks.

The biggest reason SSRIs are so popular is that they're easier to take -- fewer and generally milder side effects, and safe in overdose. They can cause apathy in some people, which doctors sometimes use to advantage -- for some people, that emotional blunting can be an improvement, such as those with OCD. They can cause sexual side effects, which for many people can be mitigated. Despite what we read here, SSRIs are also very effective for many people who take them. This board is not populated with the typical person treated for depression, so we don't often hear about the successful use of SSRIs, so I think it's easy to forget that fact. For some people, the emotional blunting can improve the symptoms of social phobia, and combined with therapy such as CBT, they can be used quite successfully for it.

TCAs are cardiotoxic in overdose, and their side effects tend to be much more extreme than SSRIs. Anti-cholinergic side effects, such as urinary retention, constipation, blurred vision, increased body temperature, photo-phobia, hypotension etc, can be much more difficult to cope with than the relatively milder side effect profile of SSRIs and other newer antidepressants. Many of the TCAs target a broader range of receptors, and many work primarily on the dopamine/norepinephrine system, rather than serotinergically. Insomnia, weight gain, and sometimes some cognitive impairment are other possible side effects. They're worth trying, but due to the danger of overdose, they're not first-line drugs anymore. "Atypical" depression is so-named because it doesn't typically respond very well to TCAs.

MAOIs are the last line of treatment, because of the dangers posed by their side effects. The dietary restrictions are difficult for many people to cope with, and the side effect profile includes circulatory problems, urinary retention, constipation, lowered blood pressure, orthostatic hypotension, hyperreflexia, and others. Atypical depression -- which is the most common form of depression -- is said to respond best to MAOIs, and a lot of people here on this board have found Nardil particularly helpful for social phobia. The hypertensive crisis is, of course, the most dangerous of the possible side effects with MAOIs. Dietary restrictions can help avoid this reaction, although there have been reports of idiopathic hypertensive crisis, as well. More frequently, hyPOtension is a problem, especially for those who've experienced hypotension from other drugs. The dietary restrictions make MAOIs a last choice for those with eating disorders, especially anorexia nervosa, and their cardiac effects make them even less appropriate for those with eating disorders, which may have compromised cardiac functioning. Atypical depression is said to respond particularly well to MAOIs, which isn't surprising since responding to MAOIs is what makes it "atypical" in the first place... (Historically, that's where the name came from. TCAs were considered the gold standard of early anti-depressants, and doctors noticed that some clusters of depressive symptoms predicted better response to the MAOIs -- therefore, it was not "typical" or melancholic depression. And again, atypical depression is the most common variety.)

The other, newer, anti depressants all fall into various other groups, with various other benefits and drawbacks.

Generally speaking, while there are some guidelines that you can use -- "MAOIs are often more effective in Atypical depression, and I have primarily atypical features" -- it's not really possible to say that any one drug, or class of drugs, will be more successful than any other for any given person. After trying a ton of anti-depressants over the years, I can say very generally that more noradrenergic medications are more often helpful for me, but that's only a general trend, and doesn't really offer more than a very broad guideline. MAOIs, due to their mechanism of action, are probably the most broadly targeted antidepressants -- they should help maintain the ratios of the major neurotransmitters, while increasing their potential activity. Tyramine, the compound in foods that triggers the hypertensive crisis, is found in many foods, is synthesized from tyrosine, and may be a neurotransmitter in its own right. Since tyramine is derived from tyrosine, a non-essential amino acid -- that is, an amino acid which the body can synthesize from others -- restricting dietary sources probably isn't a problem from a health standpoint. On the other hand, most pork products contain a fair amount of tyramine, which could be a problem if you really like pork. (And soy-based products, like soy sauce, teriyaki sauce, and miso, are entirely off limits. In fact, the pressor action of tyramine may be why teriyaki causes severe headaches in some people.)

OK, I'm done exposing my inner dork. That's my nutshell version, without too terribly many tangents, and I'll go away and be quiet now. I hope it was helpful.




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