Magazine article Clinical Psychiatry News

MAO Inhibitors Enjoy Resurgence of Interest, Use. (MAO Inhibitors Revisited)

Magazine article Clinical Psychiatry News

MAO Inhibitors Enjoy Resurgence of Interest, Use. (MAO Inhibitors Revisited)

Article excerpt

Fueled by diagnostic clarifications and improved recognition of patients who will benefit from therapy, monoamine oxidase (MAO) inhibitors have experienced a resurgence of clinical interest and increased worldwide use as antidepressants, including use as first-line therapy in selected patients.

MAO inhibitors have much clearer indications for use in the treatment of depression, especially for patients who have atypical features or treatment-resistant illness, said Jay D. Amsterdam, MD, professor and director of the depression research unit at the University of Pennsylvania in Philadelphia. With improved understanding of the clinical pharmacology and risk-benefit ratio of the drugs, use of MAO inhibitors could expand even further.

"Most of us think of using MAO inhibitors for treatment of major depression with atypical features," said Dr Amsterdam. "However, when we loo bac over the literature on the use of MAO inhibitors in major depression, there is no doubt that these drugs are highly effective in patients who have major depression with melancholic features, psychotic features, bipolar I and II depression, and more recently, patients with treatment-resistant depression."

The concept that MAO inhibitors are most useful in patients who have milder or atypical forms of depression is unfounded, he continued. Moreover, a substantial body of literature supports the effectiveness of MAO inhibitors in chronic forms of depression.

First Effective Antidepressants

In scientific fact, MAO inhibitors were the first drugs that wored consistently in treatment of depression, said Dr Amsterdam. Physician enthusiasm for the agents waned with recognition of the "dar side" of MAO inhibitors, the tyramine interaction, or so-called "cheese reaction." In some patients, MAO inhibition can elicit tyramine reactions to aged, smoed, or fermented foods, leading to hypertensive crisis.

Fear of a cheese reaction liely was out of proportion to the actual ris, leading to better documented problems associated with use of tricyclic antidepressants and selective serotonin reuptae inhibitors (SSRIs).

"As psychiatrists, we will go to great lengths to avoid using MAO inhibitors in our patients," said Dr Amsterdam. "As a result of this avoidance, tricyclic antidepressants enjoyed almost 20 years of unbridled prescription writing. Tricyclics were prescribed in such quantities that they finally emerged as the leading cause of death in overdose with alcohol. Yet we continued to prescribe them, The second leading cause of death in overdose was tricyclic antidepressants without alcohol."

"More recently, the SSRIs have come under fire," he continued. "Many people feel these drugs are not as potent as the earlier tricyclic antidepressants and the MAO inhibitors. On top of that, there are some data from our group and others of a therapeutic decrement, Patients who are repeatedly treated from one depressive episode to the next--or within the same episode, from one SSRI to the next-developed a gradual resistance at a rate of about 20% with each prior antidepressant."

Superior to Comparators

In clinical trials of major depression with atypical features, MAO inhibitors "invariably have been superior to the comparator drug, usually a tricyclic," he said. MAO inhibitors also have proven useful in the treatment of patients who have bipolar disorder with depressive variants (Am I Psychiatry. …

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