Patch Raises New Hope for Beating Depression
It was the first type of antidepressant, and for many people the monamine oxidase, or MAO, inhibitor remains the best hope for relief from major depression.
The trouble is that the side effects can be so serious that MAO inhibitors are rarely prescribed. When taken with certain foods, for example, they may bring on sudden and severe hypertension.
The problems, however, may soon be resolved.
A study reported in November in The American Journal of Psychiatry suggests that by administering the MAO inhibitor selegiline in patch form, patients can receive the antidepressant benefits of the drug without the usual side effects. NY Times
Even without the patch formulation, the MAO inhibitors remain a woefully neglected powerful class of antidepressants. Both clinical lore and my own experience suggest they are useful for types of depression (more ingrained or severe; with ‘atypical’ features or comorbid with other conditions) which have not responded to more ‘modern’ (post-Prozac) agents. The risk of hypertensive reaction is highly overrated if the medication is given to patients who are competent to understand and motivated to comply with the dietary restrictions, and these restrictions (the so-called “MAO Inhibitor Diet“) are less draconian than the hysterics usually make them out to be.
True, a medication that involves “active” participation by prescriber and recipient will be inconvenient to some in comparison with the SSRIs (Prozac etc.), which have supplanted all other antidepressants due to the marketing claims that prescribing them requires “no muss, no fuss.” As readers of FmH know (because I hammer this point home whenever I have the opportunity), the well-publicized complications of rampant SSRI use (including successful litigation against the manufacturers for acts of violence, suicidality and discontinuation syndromes about which I’ve written here) result in large measure from the illusion that they are so easy to prescribe that they require no art to manage and thus may be given with less supervision than previous antidepressants, and often by nonpsychiatric prescribers. A further consequence of the ascendency of the SSRI and post-SSRI antidepressants may be an overall decrease in antidepressant effectiveness, both because of the lax supervision of their use; and (as readers of FmH may recall I and other psychiatrists suspect) because they are probably “watered-down” antidepressants which do not attack the ‘core symptoms’ of a depressive disorder but rather make sufferers feel better by controlling ‘downstream’ epiphenomena, symptoms which accompany depression. I don’t mean to be a psychopharmacological Calvinist, but sometimes I wonder if that isn’t precisely why they are so much easier to give. They have fewer side effects than older, more robust antidepressants because there is no free lunch, you get what you pay for.
My viewpoint may be jaundiced because, as a consulting psychopharmacologist and a hospital-based psychiatrist, I see the most truly ill of the depressed patients, the patients in whom I am concerned about the reduced efficacy of the SSRIs, rather than the ‘walking wounded’ who form so much of the modern market for antidepressants for whom an SSRI may be effective enough. (At one extreme, this latter class, of course, blend into those for whom psychopharmacology has famously been called “cosmetic” rather than therapeutic; another consequence of the scourge of the SSRIs.) So, in a number of senses — increased efficacy, mindful prescribing, the participation and responsibility of the recipient, filtering of recipients, etc. — the return of the MAOI is a welcome development, if the patch facilitates it. For technical reasons, however, selegiline, the MAOI about which they are talking here, is not the only one upon which I believe we should focus, however. Other, perhaps better, MAOIs go by the names of tranylcypromine (Parnate), phenelzine (Nardil), and isocarboxazid (Marplan). Selegiline, however, as the newest MAOI, still ‘belongs’ to a pharmaceutical company and generates profits, whereas the other, older agents are in the public domain and nobody’s cash cow. So industry interest in further promoting them is not as likely. Trivia: while this is still an unresolved point, (weak) MAO inhibition may in fact be the mechanism of action for St. John’s Wort‘s putative antidepressant effects.