What is the recommended approach for using Monoamine Oxidase Inhibitors (MAOIs) to treat depression, anxiety, and somatic disorders?

Monoamine Oxidase Inhibitors (MAOIs) for Depression, Anxiety, and Somatic Disorders

MAOIs should be considered as third-line or later treatment options for depression, anxiety, and somatic disorders due to safety concerns, dietary restrictions, and significant drug interactions, with specific consideration for patients with atypical depression, high anxiety levels, or treatment-resistant conditions. 1, 2

Indications for MAOI Use

• MAOIs have proven efficacy for treating depression, particularly in patients with atypical depression, high anxiety levels, anergic bipolar depression, and treatment-resistant depression 1, 2
• MAOIs show superior efficacy compared to placebo in treating agoraphobia and mixed anxiety-depressive states 3
• MAOIs may be somewhat more effective than tricyclic antidepressants when phobic anxiety is an important component of a depressive disorder 3
• MAOIs can be effective for social phobia, panic disorder, and other anxiety disorders that have failed first-line treatments 4
• For medically unexplained somatic complaints, psychological treatment based on CBT principles should be considered first for patients who do not meet criteria for depressive disorder 5

Treatment Algorithm for Depression

1. First-line options: Tricyclic antidepressants (TCAs) or fluoxetine for moderate to severe depression 5
2. Second-line options: Other SSRIs, SNRIs, or bupropion 5
3. Third-line options: MAOIs for patients who have not responded adequately to other antidepressants 6

Treatment Algorithm for Anxiety

1. First-line options: CBT-based psychological treatments for anxiety disorders 5
2. Second-line options: SSRIs or SNRIs 5
3. Third-line options: MAOIs, particularly for treatment-resistant cases or those with high levels of anxiety 7, 3

MAOI Selection and Dosing

• Tranylcypromine is a non-hydrazine MAOI that may provide faster response compared to other MAOIs 3
• Recommended daily dosage for tranylcypromine is 30 mg in divided doses 6
• If no adequate response, increase dosage in increments of 10 mg per day every 1-3 weeks to a maximum of 60 mg per day 6
• Consider more gradual dosage increases in patients at risk for hypotension 6
• Transdermal selegiline formulation limits the need for dietary restrictions and has fewer side effects than many other antidepressants 1, 2

Major Safety Concerns with MAOIs

• Risk of hypertensive crisis when combined with tyramine-rich foods or certain medications 6
• Risk of serotonin syndrome when combined with other serotonergic drugs, which can be life-threatening 6
• Contraindicated with other MAOIs, SSRIs, SNRIs, tricyclic antidepressants, sympathomimetic drugs, and numerous other medications 6
• Activation of mania/hypomania in patients with bipolar disorder 6
• Hypotension (including postural hypotension and syncope), particularly at doses above 30 mg daily 6

Medication Washout Periods

• When switching to or from MAOIs, adequate washout periods are essential (typically 2 weeks, 5 weeks for fluoxetine) 7
• Gradual tapering is recommended when discontinuing MAOIs to avoid withdrawal effects 7, 6
• Consider discontinuing tranylcypromine gradually because of the risk for withdrawal effects 6

Patient Education and Monitoring

• Patients must be educated about avoiding tyramine-rich foods and beverages while taking MAOIs and for 2 weeks after stopping 6
• Monitor blood pressure closely in all patients taking MAOIs 6
• Patients should avoid over-the-counter medications without consulting a healthcare provider 7
• Patients should be taught to recognize signs of serotonin syndrome and hypertensive crisis 7
• Patients should inform all healthcare providers about MAOI use 7

Common Pitfalls to Avoid

• Insufficient treatment duration (less than four weeks) or inadequate dosing can lead to poor results with MAOIs 3
• Failure to maintain adequate washout periods when switching between MAOIs and other antidepressants can lead to serotonin syndrome 7
• Overlooking over-the-counter medications and supplements as potential contributors to serotonin syndrome or hypertensive crisis 7, 8
• Combining MAOIs with cold medicines containing sympathomimetics (pseudoephedrine, phenylephrine) or dextromethorphan 7

Duration of Treatment

• Antidepressant treatment should not be stopped before 9-12 months after recovery 5
• Treatment with MAOIs often has to be long-term, and some degree of pharmacological dependence may develop 3