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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. Copyright © SLACK Incorporated