Download Monoamine Oxidase Inhibitors— Are We Missing Something?

editorial
Monoamine Oxidase Inhibitors—
Are We Missing Something?
Jan Fawcett, MD
T
his issue of Psychiatric Annals, guest edited by Edward
H. Tobe, DO, DLFAPA,
is the first of two that will present
a comprehensive series of articles
on monoamine oxidase inhibitors
(MAOIs). In this first issue, we feature a discussion about “The Role of
Monoamine Oxidase in Human Organism and Its Metabolism” by Dagmara Mirowska-Guzel, MD, PhD,
DSc, and Ewa Bałkowiec-Iskra,
MD, PhD, DSc, which describes the
function of monoamine oxidase-A
and monoamine oxidase-B enzymes.
The next article, “Moclobemide—A
Reversible Inhibitor of Monoamine
Oxidase-A,” by Janusz K. Rybakowski, MD, PhD, gives us more
perspective on possible new forms of
MAOIs with greater safety (that are
not available in the US). Next comes
an article on a relatively rare topic
of discussion, “Revisiting the Role
of Monoamine Oxidase Inhibitors
in Pediatric Pharmacology,” by Andres J. Pumariega, MD, and Basant
K. Pradhan, MD. John M. Zajecka,
MD, and Alexa M. Zajecka provide a
clinical overview of MAOIs. The final article is by Tobe, who discusses
Jan Fawcett, MD, is a Professor with
the Department of Psychiatry at the
University of New Mexico School of
Medicine. He was chairperson of the
DSM-5 Mood Disorders Task Force.
Address correspondence to Jan Fawcett, MD, via email: [email protected].
doi: 10.3928/00485713-20141106-01
488
the oversimplification of the catecholamine hypothesis of depression.
Why feature MAOIs when they
are barely used? We know that they
are used infrequently by psychiatrists.
In fact, I worry that MAOIs may go
out of production due to the paucity
of their use. The reason to focus on
MAOIs is that selective serotonin
reuptake inhibitors (SSRIs) and related new-generation antidepressants
(like bupropion) have shown limited
efficacy. The STAR*D (Sequenced
Treatment Alternatives to Relieve
Depression) study found that 33% of
patients did not reach remission after
four consecutive treatments and the
4.5-month relapse rate was 40% for
first-line citalopram remitters ranging up to 70% for patients requiring
four treatment steps.1 There is now
a serious question whether the new
generation of medications are effective in bipolar depression—they
were never approved by the US Food
and Drug Administration for bipolar
disorder; we just assumed that they
would work.
We were set up for this by the discovery and deployment of SSRIs.2
With very few toxicities and side
effects compared to tricyclic antidepressant medications (TCAs) and
MAOIs, SSRIs became the standard
for the depression and anxiety disorders treatment. Clinicians no longer
had to be nervous about lethal overdoses and multiple side effects. At
the time, TCAs were first line with
MAOIs being used, more frequently
than presently, in treatment-resistant
cases. We somehow forgot about the
efficacy of MAOIs, and focused instead on concerns about side effects
and dietary and other medication interactions.
Now, with primary care physicians, and in some states nurse practitioners and psychologists prescribing antidepressants, psychiatrists are
seeing an increasing numbers of patients presenting with severe symptoms who have failed to respond to
the new-generation marvels.
There is evidence suggesting that
we should consider using MAOIs
in treating refractory depressions as
well as early evidence that MAOIs
might help in bipolar depressions
that are treatment resistant. With this
issue and the second, we are raising
awareness of the value of MAOIs,
particularly in patients who have not
benefited from multiple prior treatments.
I want to personally thank Dr.
Tobe for making this series of articles possible. I believe we need to
consider MAOI therapy for many of
our treatment-resistant patients.
REFERENCES
1. Rush AJ, Trivedi MH, Wisniewski
SR, et al. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: A
STAR*D Report. Am J Psychiatry.
2006;163(11):1905-1917.
2. Cohn JB, Wilcox CA. Comparison of
fluoxetine, imipramine and placebo in
patients with major depressive disorder.
J Clin Psychiatry. 1985;46(3):26-31.
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