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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 sowhysosad on April 14, 2009, at 16:10:11
Just wondered what NHS pdocs' attitude towards MAOI's is. Have you ever been given a scrip for phenelzine or tranylcypromine in the UK? What was your diagnosis?
Did they prescribe an MAOI only as a last resort? Did they - as I suspect - massively overstate the risk of the "cheese effect"?
As I wean off a tricyclic the atypical features of my depression (over-sleeping, binge eating) are becoming more prevalent, so my best bet for remission would either be fluoxetine or an MAOI like phenelzine or tranylcypromine.
According to the NICE guidelines they prefer phenelzine over tranylcypromine for some reason, which is odd given that phenelzine is hepatoxic AND causes weight gain. Maybe because tranylcypromine is more likely to cause a hypertensive crisis?
Posted by sowhysosad on April 14, 2009, at 23:14:13
In reply to Anyone been described an MAOI in the UK?, posted by sowhysosad on April 14, 2009, at 16:10:11
Helps if the subject makes sense! I blame depression-induced brain fog.
> Just wondered what NHS pdocs' attitude towards MAOI's is. Have you ever been given a scrip for phenelzine or tranylcypromine in the UK? What was your diagnosis?
>
> Did they prescribe an MAOI only as a last resort? Did they - as I suspect - massively overstate the risk of the "cheese effect"?
>
> As I wean off a tricyclic the atypical features of my depression (over-sleeping, binge eating) are becoming more prevalent, so my best bet for remission would either be fluoxetine or an MAOI like phenelzine or tranylcypromine.
>
> According to the NICE guidelines they prefer phenelzine over tranylcypromine for some reason, which is odd given that phenelzine is hepatoxic AND causes weight gain. Maybe because tranylcypromine is more likely to cause a hypertensive crisis?
>
>
Posted by jms600 on April 15, 2009, at 6:40:52
In reply to Anyone been described an MAOI in the UK?, posted by sowhysosad on April 14, 2009, at 16:10:11
My doctor is very much against prescribing an MAOI (I too live in Britain). From what I have read and heard phenelzine would really help my severe anxiety but my doctor doesn't want to go near MAOIs. Saying that, he has tried on other patients - and said he would consider using - moclobemide which is a reversible MAOI. It's not as effective as drugs such as Parnate or Nardil, but it still may be worth considering - especially as it's dietary restrictions aren't as bad.
I read about Symbyax just being licensed for treatment resistant depression the other day. It's basically a mix of Prozac and Zyprexa. What it's like for atypical depression I don't know, but it may be worth considering.
Posted by sowhysosad on April 15, 2009, at 14:06:36
In reply to Re: Anyone been described an MAOI in the UK? » sowhysosad, posted by jms600 on April 15, 2009, at 6:40:52
Thanks jms. I've heard moclobemide is pretty useless compared to the irreversible MAOI's, so I probably wouldn't bother trying it even if offered.
The latest NICE guidelines say there's not enough evidence for SSRI's+atypical antipsychotic combos, so I can't see them suggesting Symbyax either.
Looks like fluoxetine's my best bet then, but I'll mention phenlelzine to the junior pdoc for what it's worth. Sadly he knows less about meds than I do...
> My doctor is very much against prescribing an MAOI (I too live in Britain). From what I have read and heard phenelzine would really help my severe anxiety but my doctor doesn't want to go near MAOIs. Saying that, he has tried on other patients - and said he would consider using - moclobemide which is a reversible MAOI. It's not as effective as drugs such as Parnate or Nardil, but it still may be worth considering - especially as it's dietary restrictions aren't as bad.
>
> I read about Symbyax just being licensed for treatment resistant depression the other day. It's basically a mix of Prozac and Zyprexa. What it's like for atypical depression I don't know, but it may be worth considering.
>
Posted by jms600 on April 15, 2009, at 16:36:39
In reply to Re: Anyone been described an MAOI in the UK? » jms600, posted by sowhysosad on April 15, 2009, at 14:06:36
It may be worth giving the SSRI + Zyprexa a go. I took Zyprexa with Effexor and lithium and it had a noticeable antidepressant effect on me. Weight gain was an absolute nightmare though. What the combo would be like on atypical depression I really don't know.
Also, have you tried some of the more stimulating tricyclics such as desipramine or imipramine? Saying that, atypical depression responds less well to tricyclics than MAOIs so it may well be best sticking with the Parnate route.
Posted by bleauberry on April 15, 2009, at 17:48:49
In reply to Anyone been described an MAOI in the UK?, posted by sowhysosad on April 14, 2009, at 16:10:11
This might help.
Go to pscychotropical.com. Scroll around and click on information about MAOIs. These are writings of a Dr Gillman, in which he describes the great usefulness of the MAOIS, why they are incorrectly seen as risky, why they are ignored, why doctors are unknowledgeable of them, why the diet restrictions are much less than previously thought, why other antidepressants don't work well, and why he has treated over 950 patients with Parnate and 50 with Nardil. Anyone who has an argument against MAOIs would lose the argument big time, knock out in the first round, going up against the awesome information given by Dr Gillman. No contest.
Print out this article and bring it with you. Maybe even have Dr Gillman's phone number and challenge your care provider to call him. The article will arm you with all the knowledge you need to blow out of the water any false information or hesitation your care provider may have.
Someone must be using MAOIs in UK, because I ordered mine overseas mailorder and it came from UK.
You could also go to askapatient.com. Check the overall rating by patients for Effexor, Prozac, Lexapro, whatever. They are all in the low to mid 3's, on a 1-5 scale. Now check the overall rating for Parnate and Nardil. Both are in the mid 4's. Now print out the actual comments and stories of those patients on Nardil and Parnate. Bring those stories with you for your care provider to see. And the ratings.
Do the same at revolutionhealth.com.
If the care provider will take a few minutes to read the stuff, they will see that they are the exact duplicate copies of all the other nonsense doctors that allowed patients to stay sick for 10 years, 20 years, 30 years, when all they had to do was say, "Ok, let's try the MAOIs for a couple months and see what happens. Got nothing to lose at this point." But no, let the patient stay sick. Let them read the stories of real people like you who were denied full care.
If you go Prozac, and if you are interested in Symbyax, get the Prozac and Zyprexa separately. That way you can juggle the doses of each individually, instead of being tied to fixed proportions. The only benefit of Symbyax over the two drugs individually is that it would have the real Lilly brand prozac, not a generic fluoxetine. Which brings me to the next point...
Insist on brand Prozac. Do not accept generic unless you want to increase the odds of failure, which we all know are already high enough.
I was on 20mgProzac+5mgZyprexa for, oh I forget, something like 6 to 8 years. They were decent very productive years. I had some anhedonia and social shyness the whole time, but zero depression, excellent performance at work, healthy, active. A third add-on that really helped was Adrafinil, similar to Modafinil, except better in my opinion.
Hopefully if you go in fully armed, knowledgeable, and quick to the punch with expertise on MAOIs, and everything you printed out, you might just win. You should win. Just your efforts alone would show you would have made a great attorney preparing for an important trial. You should win.
Posted by sowhysosad on April 15, 2009, at 19:52:37
In reply to Re: Anyone been described an MAOI in the UK?, posted by jms600 on April 15, 2009, at 16:36:39
Thanks for the tips jms. Are you bipolar, or did you manage to get a scrip for Zypreza for normal (unipolar) depression?
I'm weaning off imipramine at the moment and I can say categorically that it's useless for atypical depression, and has made me feel worse if anything. Based on my experience I'd say that adage about tricyclics and atypical is 100% on-the-money.
> It may be worth giving the SSRI + Zyprexa a go. I took Zyprexa with Effexor and lithium and it had a noticeable antidepressant effect on me. Weight gain was an absolute nightmare though. What the combo would be like on atypical depression I really don't know.
>
> Also, have you tried some of the more stimulating tricyclics such as desipramine or imipramine? Saying that, atypical depression responds less well to tricyclics than MAOIs so it may well be best sticking with the Parnate route.
Posted by sowhysosad on April 15, 2009, at 20:12:35
In reply to Re: Anyone been described an MAOI in the UK? » sowhysosad, posted by bleauberry on April 15, 2009, at 17:48:49
Funny you should mention that bleauberry - I have a Ken Gillman article printed in a folder in my bag, albeit from his site psychotropical.com!
I'll certainly give him the article next time I see him. I fear it'll be an uphill struggle though. I actually see a very inexperienced junior pdoc who then consults with the qualified doc. She then makes a decision based on the notes he's taken. He seems to know next to nothing about meds, having to consult a reference tome for even the most basic information any layman on this forum would know.
I mentioned phenelzine to him last time I saw him, and he gave me some speech about how "not all medications are available in the UK". Felt like saying "Yeah, you might've heard of phenelzine. It's quite a new drug. It was only licenced about 55 years ago".
With regard to branded Prozac, unfortunately the UK health service ALWAYS uses generics for off-patent drugs to save money. I suppose the upside of this arrangement is that no prescription will ever cost me more than about $11 (US) for a month's supply. I had great results with generic fluoxetine liquid before though.
Posted by jms600 on April 16, 2009, at 16:29:34
In reply to Re: Anyone been prescribed an MAOI in the UK? » jms600, posted by sowhysosad on April 15, 2009, at 19:52:37
My main diagnosis is severe anxiety with moderate unipolar depression. My psychiatrist prescribed Zyprexa off label with an SSRI.
As Symbyax has been licensed in the US for treatment resistant depression - and you are considering Prozac - you could speak to your doctor about a Zyprexa + Prozac combo. Not sure how effective it would be against atypical depression alone - I guess it's a suck it and see approach.
Posted by sowhysosad on April 16, 2009, at 17:34:04
In reply to Re: Anyone been prescribed an MAOI in the UK? » sowhysosad, posted by jms600 on April 16, 2009, at 16:29:34
Great idea jms. I'll keep that in mind.
It's also great to see a UK psychiatrist thinking outside the box and not sticking slavishly to the NICE guidelines.
I'd be a bit nervous about taking an AP because of the risk of TD, but I assume it's very low with a modern med like Zyprexa.
> My main diagnosis is severe anxiety with moderate unipolar depression. My psychiatrist prescribed Zyprexa off label with an SSRI.
>
> As Symbyax has been licensed in the US for treatment resistant depression - and you are considering Prozac - you could speak to your doctor about a Zyprexa + Prozac combo. Not sure how effective it would be against atypical depression alone - I guess it's a suck it and see approach.
Posted by jms600 on April 17, 2009, at 16:18:23
In reply to Re: Anyone been prescribed an MAOI in the UK?, posted by sowhysosad on April 16, 2009, at 17:34:04
TD is not so much of a problem with Zyprexa than with the older typicals. As your diagnosis is atypical I guess the next meds to try would be MAOIs. If they don't do the trick then maybe consider the SSRI + Zyprexa route. I've never tried MAOIs; however, there are few people on here - who have tried them - who say they are completely ineffective.
Posted by sowhysosad on April 17, 2009, at 16:52:02
In reply to Re: Anyone been prescribed an MAOI in the UK?, posted by jms600 on April 17, 2009, at 16:18:23
> If they don't do the trick then maybe consider the SSRI + Zyprexa route.
To be fair, I've not tried an SSRI since October last year. I had akathisia on one then couldn't tolerate a return to Cipralex, no doubt a transient reaction caused by the akathisia (overly elevated serotonin causing anxiety I'd guess). I'm stll hopeful that fluoxetine on its own might help; it's worked miracles for me before when i've had this type of depression.
>I've never tried MAOIs; however, there are few people on here - who have tried them - who say they are completely ineffective.
I wonder if that's a dosing issue - docs reluctant to push the dose to a level where it might work. Some docs swear by higher doses of phenelzine. Still, no single med works for everyone, so chances are they'e in the 30% whose depression doesn't respond to MAOI's.
This is the end of the thread.
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