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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 12 of 12. This is the beginning of the thread.
Posted by Grouch on August 4, 2001, at 21:26:44
MAOIs (Parnate & Marplan) are the only antidepressants that have been helpful for me. Unfortunately, I'm not able to tolerate them due to numerous side effects, especially sleep problems (insomnia, disrupted sleep cycle).I've tried benzos and trazodone, neither of which worked very well and had side effects of their own.
I haven't been able to find much information on *how* MAOIs actually disrupt sleep. (Is this even known?) Are there other ways to combat this side effect?
Appreciate any info...
Posted by SalArmy4me on August 4, 2001, at 21:50:03
In reply to MAOIs and sleep problems, posted by Grouch on August 4, 2001, at 21:26:44
Things to consider:
You could try adding small doses of atypical neuroleptics like Risperdal (Risperidone) to MAOI's for sleep:
(Stoll, Andrew L. MD 1,2. Haura, Gail MA 1. Tranylcypromine Plus Risperidone for Treatment-Refractory Major Depression. Journal of Clinical Psychopharmacology. 20(4):495-496, August 2000:
All five of the nonpsychotic depressed outpatients in this trial had treatment-refractory and prolonged unipolar or bipolar depression and responded to the combination of tranylcypromine plus risperidone. Four of five patients experienced a dramatic and sustained antidepressant response to the combination. Despite the lack of psychosis and previous MAOI monotherapy (in four of five patients) that was less than successful, these patients responded to the combination of tranylcypromine and risperidone. Further studies are required to determine whether the risperidone alone or the combination of tranylcypromine and risperidone was responsible for the antidepressant effects observed in these patients. All patients, except for one who experienced overwhelming sedation, tolerated the medications well. Although not necessarily causal, the tranylcypromine and risperidone were started simultaneously in the three patients with the most dramatic responses...").You could switch to Moclobemide:
(Magder, David M. MD. Tolerability and Efficacy of High-Dose Moclobemide Alone and in Combination With Lithium and Trazodone. Journal of Clinical Psychopharmacology. 20(3):394-395, June 2000.
"Moclobemide is a selective reversible inhibitor of monoamine oxidase-A that is reported to have comparable efficacy and a safer side effect profile compared with traditional irreversible monoamine oxidase inhibitors (MAOIs).1, 2 Furthermore, numerous studies have demonstrated that moclobemide is as effective and tolerable as selective serotonin reuptake inhibitors and tricyclic antidepressants.3-5 In all instances, the dose range of moclobemide reflected standard prescribing recommendations, not to exceed a dose of 600 mg/day. However, when higher doses were used (750 mg/day), moclobemide was judged to be tolerable and effective in the treatment of dysthymia and double depression...")You can switch to Selegiline:
(Sunderland, Trey MD. High-Dose Selegiline in Treatment-Resistant Older Depressive Patients. Archives of General Psychiatry. 51(8):607-615, August 1994:
"Selegiline appears to be an effective antidepressant in older patients with treatment-resistant depression. While low-dose selegiline (10 mg/d) may have some mood-lifting effects in nondepressed subjects, such as patients with Parkinson's disease or Alzheimer's disease [12,76], or when low-dose selegiline is given in combination with phenylalanine [17], our data suggest that higher, non-MAO-B selective doses of selegiline may be required to reverse moderate to severe depression in the elderly. In fact, the data from our study of high-dose selegiline (60 mg/d) support earlier data from our laboratory indicating that MAO-A inhibition and the subsequent consequences of this inhibition rather than MAO-B inhibition alone may be required for antidepressant efficacy [77,78]. Data from our study combined with those from a previous study involving younger adults [11] suggest that nonselective MAOI dosages of selegiline between 30 and 60 mg/d are required for adequate antidepressant response, much more than the 5- to 10-mg doses of selegiline recently suggested in the American Psychiatric Association's practice guideline for major depressive disorder in adults [79]. In fact, because the CSF MHPG values were reduced only by 50% with selegiline compared with previous reports of 80% to 95% reduction with clorgyline and other mixed MAO inhibitors [62], it is possible that selegiline doses higher than 60 mg/d would provide even better antidepressant responses..."You could try something like (Sonata) zaleplon, or zolpidem (Ambien).
Posted by shelliR on August 4, 2001, at 22:38:01
In reply to MAOIs and sleep problems, posted by Grouch on August 4, 2001, at 21:26:44
>
> MAOIs (Parnate & Marplan) are the only antidepressants that have been helpful for me. Unfortunately, I'm not able to tolerate them due to numerous side effects, especially sleep problems (insomnia, disrupted sleep cycle).
>
> I've tried benzos and trazodone, neither of which worked very well and had side effects of their own.
>
> I haven't been able to find much information on *how* MAOIs actually disrupt sleep. (Is this even known?) Are there other ways to combat this side effect?
>
> Appreciate any info...Hi Grouch.
When I took nardil, I also had severe sleep problems. I started to take atarax (hydroxyzine) 150mg as well as 2mg of klonopin before bed and that did the trick for a 30-45 mg. dose of nardil. Over 45mg, nothing seemed to help with sleep. I had no trouble falling asleep but I wake up every three hours: Really wake up and it would take more benzos to finally fall asleep. You might try augmenting the MAOI and trying a smaller dose. My best combination was nardil and lamictal, but I gained a lot of weight on lamictal, so I choose to go off. By the way, that is not a common side effect of lamictal.On Monday I am going to start parnate and am hoping not to have the same sleep problems as on the higher dose of nardil. Your post is not encouraging :-).
Shelli
Posted by Elizabeth on August 5, 2001, at 8:12:07
In reply to MAOIs and sleep problems, posted by Grouch on August 4, 2001, at 21:26:44
> MAOIs (Parnate & Marplan) are the only antidepressants that have been helpful for me. Unfortunately, I'm not able to tolerate them due to numerous side effects, especially sleep problems (insomnia, disrupted sleep cycle).
That was a problem for me with MAOIs too. Their widespread effects on aminergic systems seem to blow the whole circadian cycle to bits. I have a book somewhere that discusses their effects on sleep in depth, but I'd need to dig around to find it (I moved recently).
Adding Ambien to the MAOI was somewhat helpful for me, and I didn't grow tolerant to it.
One thing that's sometimes suggested is melatonin. I'm not too sanguine about adding that to MAOIs, though: when I tried a small amount, it kept me up all night (even with Ambien), I was sweating excessively, and my pupils were very dilated.
-elizabeth
Posted by Grouch on August 5, 2001, at 21:30:29
In reply to Re: MAOIs and sleep problems » Grouch, posted by SalArmy4me on August 4, 2001, at 21:50:03
Hi Sal. Thanks for the input. Unfortunately, I've tried a number of these already w/o success. Both the typical and atypical anti-psychotics (Risperdal & Zyprexa) that I've tried don't agree with me. On the other hand, I wasn't on an MAOI when I tried them, so they might have different effects in that combo. I believe Dr. Stoll is currently doing a larger study of the Parnate/Risperdal combo which could prove interesting.I've tried moclobemide and selegiline... they don't hold a candle to the non-reversible MAOIs IMO.
Never tried Sonata or Ambien so that might be worth a shot.
Posted by Grouch on August 5, 2001, at 21:43:35
In reply to Re: MAOIs and sleep problems » Grouch, posted by shelliR on August 4, 2001, at 22:38:01
> Hi Grouch.
> When I took nardil, I also had severe sleep problems. I started to take atarax (hydroxyzine) 150mgHi Shelli. Am not familiar with atarax... is that an antihistamine?
>I had no trouble falling asleep but I wake up every three hours: Really wake up and it would take more benzos to finally fall asleep.
Similar experience for me... no trouble falling asleep, but would wake up after a couple of hours and be awake or semi-awake for the rest of the night, sometimes managing to get a couple of hours in towards late morning. The weird thing for me during the "wake" time is that I still felt dead tired but couldn't fall asleep. My sleep schedule also became skewed such that I was going to bed as late as 3 AM and getting up as late as 3 PM!
>You might try augmenting the MAOI and trying a smaller dose.
That's a possibility.
> On Monday I am going to start parnate and am hoping not to have the same sleep problems as on the higher dose of nardil. Your post is not encouraging :-).
Heh. Actually it's ironic because I've been considering retrying Nardil, so your post isn't so encouraging to me either! :) (First time I tried Nardil it had no effect, but I didn't push the dose very high.)
Posted by Grouch on August 5, 2001, at 21:59:07
In reply to Re: MAOIs and sleep problems » Grouch, posted by Elizabeth on August 5, 2001, at 8:12:07
Hi Elizabeth. I'm glad you answered since you seem to be the resident MAOI guru around here.> That was a problem for me with MAOIs too. Their widespread effects on aminergic systems seem to blow the whole circadian cycle to bits.
They sure do. See my previous post.
>I have a book somewhere that discusses their effects on sleep in depth, but I'd need to dig around to find it (I moved recently).
That would be great if you can find it. Even if you can just get the title & author I may be able to find it at my local medical library.
> Adding Ambien to the MAOI was somewhat helpful for me, and I didn't grow tolerant to it.
>
> One thing that's sometimes suggested is melatonin. I'm not too sanguine about adding that to MAOIs, though: when I tried a small amount, it kept me up all night (even with Ambien), I was sweating excessively, and my pupils were very dilated.I tried melatonin once with Marplan. My former pdoc suggested it, though I'm pretty sure the potential risk didn't even occur to him at the time (he didn't warn me about it). Anyway, I didn't have any serious adverse effect, but I felt really hung over the following day, and I can't recall if I slept any better or not.
Posted by Elizabeth on August 6, 2001, at 12:10:49
In reply to Re: MAOIs and sleep problems » SalArmy4me, posted by Grouch on August 5, 2001, at 21:30:29
> I've tried moclobemide and selegiline... they don't hold a candle to the non-reversible MAOIs IMO.
Selegiline is an irreversible MAO-B inhibitor that inhibits MAO-A at higher doses. It also has amphetamine metabolites
There is an irreversible MAO-A inhibitor, clorgyline, but as far as I'm aware it has never been used clinically.
> Never tried Sonata or Ambien so that might be worth a shot.
I think so.
BTW, the book I referred to in my previous post is _Clinical Advances in Monoamine Oxidase Inhibitor Therapies_, Kennedy ed. (1994).
-elizabeth
Posted by Grouch on August 7, 2001, at 20:56:13
In reply to Re: MAOIs and sleep problems » Grouch, posted by Elizabeth on August 6, 2001, at 12:10:49
Posted by michael on August 8, 2001, at 21:09:35
In reply to Re: MAOIs and sleep problems » Grouch, posted by Elizabeth on August 5, 2001, at 8:12:07
Fwiw - I've read that melatonin is not a good idea when one is taking stimulants, because it sort of joins them, or prolongs their effects - or something like that... Sorry I can't quote something more authorative on this. In any case, the point is that rather than having its usual sleep-inducing effect, it has the oppisite effect, like additional amphetimines.
My point is that perhaps something similar occurs when one is taking MAOI's (since they, like amphetimines, act to increase dopamine/norepinephrine/seratonin - I think?)...? I want to stress that I don't know that to be a fact - this is purely something that crossed my mind when I read the previous post.
Anyway, I appologize if the above doesn't make sense... michael
> > MAOIs (Parnate & Marplan) are the only antidepressants that have been helpful for me. Unfortunately, I'm not able to tolerate them due to numerous side effects, especially sleep problems (insomnia, disrupted sleep cycle).
>
> That was a problem for me with MAOIs too. Their widespread effects on aminergic systems seem to blow the whole circadian cycle to bits. I have a book somewhere that discusses their effects on sleep in depth, but I'd need to dig around to find it (I moved recently).
>
> Adding Ambien to the MAOI was somewhat helpful for me, and I didn't grow tolerant to it.
>
> One thing that's sometimes suggested is melatonin. I'm not too sanguine about adding that to MAOIs, though: when I tried a small amount, it kept me up all night (even with Ambien), I was sweating excessively, and my pupils were very dilated.
>
> -elizabeth
Posted by mdmicky on March 2, 2002, at 14:59:03
In reply to Re: MAOIs and sleep problems » Grouch, posted by SalArmy4me on August 4, 2001, at 21:50:03
try taking the MAOI twice a day with first (and larger) dose in the AM and the second dose before 4 pm. this helps with the sleep continuity disturbance and the restless legs. i had horrendous sleep for years and finally made a commitment to always taking the second dose earlier. my sleep is again quite restful. on the occasion that i take it at 6 or 6:30 (or later), i have another fitful night. i'm certain that the earlier dosing solved the problem for me.
good luck.
Posted by djmmm on March 4, 2002, at 15:34:31
In reply to Re: MAOIs and sleep problems, posted by mdmicky on March 2, 2002, at 14:59:03
Here's some info on MAOIs and sleep problems...
from
http://www.cogsci.soton.ac.uk/bbs/Archive/bbs.vertes.html
Monoamine oxidase inhibitors (MAOIs)
Of the antidepressants, the MAOIs have the strongest suppressive action on REM sleep. A number of early reports using normal and patient populations showed that MAOIs virtually completely (or completely) suppressed REM sleep for weeks to several months. In an initial study, Wyatt et al. (1969) reported that the MAOIs, isocarboxazid, pargyline hydrochloride, and mebanazine, reduced REM from about 20-25% of TST to 9.7%, 8.6% and 0.4% of TST, respectively, and that in one subject REM was virtually eliminated for two weeks.
In a subsequent report in anxious-depressed patients, Wyatt and co-workers (1971a) described the remarkable findings that the MAOI, phenelzine (Nardil), given at therapeutic doses, completely abolished REM sleep in six patients for periods of 14 to 40 days. There was a gradual decline in amounts of REM sleep for the first two weeks on the drug and a total loss of REM after 3-4 weeks. In a complementary study with narcoleptic patients, Wyatt et al. (1971b) reported that phenelzine completely abolished REM in 5 of 7 patients for the following lengths of time: 14, 19, 93, 102 and 226 days. They stated that: "The complete drug-induced suppression of REM sleep in these patients is longer and more profound than any previously described"; and further that "No adverse psychological effects were noted during the period of total rapid-eye-movement suppression".
Several other studies have similarly shown that MAOIs essentially abolish REM sleep. Akindele et al. (1970) reported that phenelzine completely eliminated REM sleep in four subjects (one normal and 3 depressed) for 2 to 8 weeks, and addressing possible behavioral consequences stated that "Far from this leading to disastrous effects on mental functions, as some might have proposed, clinical improvement began". Kupfer and Bowers (1972) showed that phenelzine abolished REM in 7 of 9 patients, and drastically suppressed it in remaining patients from pre-drug values of 23.1% and 24.8% of TST to 1.4% and 0.5% of TST, respectively. Finally, Dunleavy and Oswald (1973) reported that phenelzine eliminated REM in 22 depressed patients.
If REM sleep were involved in memory consolidation, it would seem that the total loss of REM with MAOIs for periods of several months to a year (Wyatt et al. 1969, 1971a, 1971b; Kupfer & Bowers 1972; Dunleavy & Oswald 1973) would affect memory. As indicated above, the loss of REM did not appear to be associated with any noticeable decline in cognitive functions in these largely patient populations. These studies, however, made no systematic attempt to assess the effects of MAOIs on cognition.
Other reports, however, have examined the actions of MAOIs, primarily phenelzine, on cognition/memory and described an essential lack of impairment (Rothman et al. 1962; Raskin et al. 1983; Georgotas et al. 1983, 1989). For example, Raskin et al. (1983) observed no adverse effects of phenelzine on a battery of 13 psychomotor and cognitive tasks in a heterogeneous population of 29 depressed patients. Similarly, Georgotas and colleagues (Georgotas et al. 1983, 1989) reported that elderly depressed patients given phenelzine for 2 to 7 weeks showed no alteration in several measures of cognitive function, and concluded that the lack of adverse effects with phenelzine suggests that it is preferable to TCAs (see below) in the treatment of depression in the geriatric population.
This is the end of the thread.
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