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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 13 of 13. This is the beginning of the thread.
Posted by Amigan on November 29, 2007, at 7:31:09
Hello.
I would like you to inform me about the pros and cons of the "classic" anti-depressants TCA/SSRI versus MAOIs.
In which conditions the first group of meds is most effective and in which conditions the MAOIs are preferred?Also, i read somewhere that according to a clinical study, the SSRIs gave dissapointing results on the treatment of social phobia, while the MAOIs gave good results. Is this true?
Posted by mav27 on November 29, 2007, at 8:35:43
In reply to TCA/SSRIs Vs MAOIs, posted by Amigan on November 29, 2007, at 7:31:09
MAOI's are still much more effective in treating social phobia than ssri's and tricyclics. And after being on all 2 for my social phobia i can see why it's true by a long way. Nothing has compared to Nardil in my case.
SSRi's are also said to be no more effective in treating depression than tricyclics, the ssri's just have more tolerable side effects, as well as being safer as tricylics can be toxic if you overdose.
Personally i prefer the trycyclics over ssri's, the constipation and dry mouth can be annoying, but the complete sexual dysfunction and blunting of all emotions the ssri's caused me were far harder to live with and the tricyclics actually did a better job at helping my depression.
Overall though nardil is miles ahead of anything else i have taken, it's treating both my depression and social phobia and the only side effect i notice is insomnia.
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.
Posted by Phillipa on November 29, 2007, at 12:17:05
In reply to Re: TCA/SSRIs Vs MAOIs -- VERY long, even for me, posted by Racer on November 29, 2007, at 11:04:36
Thanks Racer very important. I do think or feel that some come here for general advise on antidepressants if this board is only for treatment resistant patients shouldn't there be a support board also for them? Just a question. Phillipa
Posted by gardenergirl on November 29, 2007, at 14:52:29
In reply to Re: TCA/SSRIs Vs MAOIs -- VERY long, even for me » Racer, posted by Phillipa on November 29, 2007, at 12:17:05
> Thanks Racer very important. I do think or feel that some come here for general advise on antidepressants if this board is only for treatment resistant patients shouldn't there be a support board also for them? Just a question. Phillipa
This board isn't only for treatment resistant depression.
gg
Posted by Phillipa on November 29, 2007, at 18:41:57
In reply to Re: TCA/SSRIs Vs MAOIs -- VERY long, even for me » Phillipa, posted by gardenergirl on November 29, 2007, at 14:52:29
GG thank's for clarifying. Phillipa
Posted by bleauberry on November 29, 2007, at 18:49:20
In reply to TCA/SSRIs Vs MAOIs, posted by Amigan on November 29, 2007, at 7:31:09
Basically TCAs are viewed as having the most side effects. MAOIs probably second behind that. And then SSRIS being easiest on side effects. But that often does not pan out. I've heard people tolerate TCAs much better, and vica versa. I've heard people call TCAs rat poison, but also the same has been said of SSRIs. I've heard people with no side effects on MAOIs, and others with tons of side effects.
No way to predict.
Basically speaking, if you want a real authentic antidepressant with a high chance of working, it would be an MAOI. After that, it is a roll of the dice with a TCA or SSRI similar to placing bets at Las Vegas. Trial and error is the only way to find out. For the best odds of winning, MAOIs. However, thousands of people have found total cure or incredible relief with SSRIs. And some prefer TCAs.
Like I said, no way to predict.
Too bad there isn't just some way to look into the nervous system and see exactly what is wrong so you would know ahead of time how to fix it. Dreaming.
Posted by Phillipa on November 29, 2007, at 18:58:04
In reply to Re: TCA/SSRIs Vs MAOIs, posted by bleauberry on November 29, 2007, at 18:49:20
Agree now where is the inventor of the scan we need? Phillipa
Posted by DStupid on November 30, 2007, at 22:14:21
In reply to Re: TCA/SSRIs Vs MAOIs -- VERY long, even for me, posted by Racer on November 29, 2007, at 11:04:36
Thank you very much for your post. In your opinion, which of the MAOI has the least cardiac side-effects, assuming proper diet? By cardiac side effects, I mean rapid pulse, angina, palpitations, low blood pressure.
Posted by Racer on November 30, 2007, at 23:47:49
In reply to Re: TCA/SSRIs Vs MAOIs -- VERY long, even for me » Racer, posted by DStupid on November 30, 2007, at 22:14:21
> Thank you very much for your post. In your opinion, which of the MAOI has the least cardiac side-effects, assuming proper diet? By cardiac side effects, I mean rapid pulse, angina, palpitations, low blood pressure.
I don't know. I'm not by any manner of means any sort of expert on MAOIs -- they're contraindicated for me, for a number of reasons (except EMSAM), so they're the class of drugs I know least about.
Good luck. I'm sorry I couldn't help.
Posted by Sigismund on November 30, 2007, at 23:56:20
In reply to Re: TCA/SSRIs Vs MAOIs -- VERY long, even for me » Racer, posted by DStupid on November 30, 2007, at 22:14:21
Generally speaking the line is to start Parnate first because the side effects are more bearable than with Nardil.
Though in your case this may not apply.
Parnate can do funny things to your blood pressure quite independent of the tyramine thing.
Not just low BP, but spikes, for reasons unexplained.
I don't know specifically about rapid pulse rate.Then of course there is Emsam, which would be my choice if it was available here, so long as I could deal with the insomnia.
Posted by amigan on December 1, 2007, at 10:15:07
In reply to Re: TCA/SSRIs Vs MAOIs -- VERY long, even for me » DStupid, posted by Sigismund on November 30, 2007, at 23:56:20
Thank you for your replies. I should have noted that i don't suffer from depression, though.
Anyway, I have been taking Prozac and i don't think that i does much for my condition so i thought to switch to a MAOI.
I have social phobial, plus other phobias and i am dysthymic. I know that Nardil is the best medicine for me, but it is not available here. I have to decide from either Moclobemide (Aurorix) or Selegiline. Which one is the most effective for phobias?Also which of the 2 is the more stimulating med? I'm taking a benzo with Prozac for my condition and i could use some up-lifting. I suspect that it's Moclobemide, as it's a MAOI-A and it boosts Epinephrine+ NorEpinephrine+ Dopamine, while Selegiline only boosts dopamine.. Am i right on this??
On the other hand, Selegiline is metabolized into L-(meth)amphetamine but... I read that the L isomer is not psychoactive at all.
Posted by Phillipa on December 1, 2007, at 17:18:59
In reply to Re: TCA/SSRIs Vs MAOIs -- VERY long, even for me » DStupid, posted by Sigismund on November 30, 2007, at 23:56:20
You could take the patch off at night or add something like klonopin which is what most users added if adding a benz. PJ
This is the end of the thread.
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