The November issue of Psychiatric Annals focused on some basic aspects of monoamine oxidase inhibitors (MAOIs). Now, in Part 2, Edward H. Tobe, DO, DLFAPA, enlisted a group of outstanding clinicians to bring us a second set of articles that capture the clinical data on the use and effectiveness of this treatment therapy. These articles are valuable, and I hope that the result will be an increase in the use of MAOI medications in patients with a range of treatment refractory conditions from depression to anxiety disorders. There is a great deal at stake here— allowing a patient with a severe refractory condition to go untreated is essentially increasing the risk of suicide for that patient. A slightly higher level of treatment risk is certainly justified in these treatment refractory cases as opposed to the consequence of patient death due to suicide.
The issue starts with a scholarly review of the concept of atypical depression and a discussion of how it relates to MAOIs by Jonathan W. Stewart, MD. I have not seen such a historical and clinically analytic discussion of this topic before. Then, there is a review of the history of MAOIs written by one of the fathers of modern psychopharmacology, Donald F. Klein, MD, DSc, and Peter C. Arden, BA. This is followed by a review of the efficacy studies of “Monoamine Oxidase Inhibitors for Various Psychiatric Disorders and Conditions” by Arden, Penchaya Atiwannapat, MD, and Stewart.
As a Feature article for this issue, Tobe leads a discussion with the clinical authors in addition to Jeffrey P. Staab, MD, and John M. Zajecka, MD, dealing with the aspects of clinical MAOI use, including patient concerns, diet issues, medication interactions, and the management of rare hypertensive crises. To put the dietary issues into focus, I recommend a paper by Stahl and Felker.1 The article explores the dietary issues in relationship to MAOIs in an up-to-date perspective. I tell my residents that the information presented is equivalent to 5 years of clinical experience.
One issue in using MAOI medications I find particularly ironic is that with all the concern about hypertensive crises, the greatest problem requiring clinical skill is the management of orthostatic hypotension, particularly in female patients who often have lower baseline blood pressures. I advocate the frequent checking of sitting and standing blood pressures as the dosage is increased to a level resulting in clinical response. In some cases, I have had to add sodium chloride tablets and fludrocortisone to maintain an adequate blood pressure. There’s no doubt that using MAOIs successfully requires clinical skill and close attention—that’s appropriate because psychiatrists are supposed to be specialists. It’s our job, and it’s a great opportunity to help people who are struggling just to stay alive.
- Stahl SM, Felker A. Monoamine oxidase inhibitors: a modern guide to an unrequited class of antidepressants. CNS Spectr. 2008;13(10):855–870.