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Second post on crazy boards. In short I have tried many different classes of Ad's with little help. I am copying my maoi proposal to my pdoc below. I apologize for length, this proposal should cover everything. 

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      I have been on Zoloft, Cymbalta, Strattera, Wellbutrin, remeron, fetzima, viibryd, deplin, Lamictal, Abilify, and Nuvigil with moderate to little help. Some boosts and stabilization here and there I will give credit for. Particularly Zoloft for anxiety, Cymbalta for uplifting feeling, Strattera short term for depression, Abilify possibly for irritation, and Nuvigil as a sort of stimulant with little to no crash.

      This being said my depression just feels very weighted, and dark. I can say for certain my depression has gotten much heavier and darker from 14 to 22. Both in a physical sense and in a mental sense. Suicidal ideations (not induced by medications.) have unfortunately become almost daily recently, now the act of suicide I would definitely be too scared to act out, but it's the thought process that scares me. Doing anything ranging from brushing my teeth to getting to work is more than just a chore, it's painful. My depression feels like a constant itch you cannot scratch, and over the years the itch has grown. My anxiety though not as severe as my Lethargy or depression is still very bad. My motivation is also very lacking in my life which is probably due to my depression.

    I find myself wanting to cry to get some relief but often cannot. I am getting increasingly tired of trying new meds without the benefit I need.

     I truly believe atleast 65% of my depression is biological and out of my control which is why I'm searching for a medicine that can allow me to more easily fulfill the other 35% or so treatable with cbt.

     Why I'm suggesting an irreversible maoi is for the following reasons.

  1. I believe have atypical depression

    1. sleepiness or excessive sleep, marked fatigue or weakness, moods that are strongly reactive to environmental circumstances, and feeling extremely sensitive to rejection.

  2. I have tried various classes of antidepressants and augmentations with little benefit

  3. My depression is extremely Lethargic/low energy.

  4. The maoi scare was overhyped

  5. I can follow dietary restrictions

  6. I could care less about sexual side effects or weight gain by this point in my life.

  7. Maoi’s are a powerful and underutilized tool in the psychiatric world.

  8. I understand the 2 week grace period that's required.

  9. Psychiatric times states that TCAs were found to be most effective in severe depression, especially with melancholic features. MAOIs, on the other hand, were more effective in less severe, chronic depression with prominent anxiety, without melancholic features, and often in the presence of reversed vegetative symptoms.35,36

*nardil had a change In formulation in 2003 so maybe parnate might be a better fit. User reports also show parnate might be more energizing than nardil.

*Emsam might be good as is a topical patch with less diet complications.

Would reboxetine be useful to take with an maoi?

Can I still take abilify with an maoi?

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I have ruled out thyroid issues and sleep apnea with my internal medicine doctor. I am seeing him again August 6 2018 to see if there are any other reasons besides a biochemical deficit that can be causing my extreme fatigue and oversleeping. 

My question to you guys is if you have had success with maoi's where as other antidepressants have failed? 

Thank you in advance for taking the time to read my post. 

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I took Parnate (simultaneous with Abilify) for quite a while - 2 or 3 years I think. It worked better for me than many other things, but for me, the effects didn't last. I eventually got ECT and came off Parnate. My pdoc wants to try another MAOI (Nardil) based on Parnate's efficacy but I'm on the fence. There's upsides and downsides to that class of medication. 

My pdoc used Abilify to help bridge the gap between coming off of the SSRI I'd been taking previously and starting the Parnate. Then I stayed on it for almost the whole time I was on Parnate.

I wish you luck in getting to try this med class. I think pdocs are too cautious about using these very effective meds.

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We have not discussed ect yet however I mentioned tms and rtms, and he said that is further down the line in the list of treatments. Not sure if maoi are the last stop but next time I see him I will show him my proposal and see what he has to say about it. 

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I would ask to start with Emsam as there are no diet restrictions until the highest dose. Abilify and MAOI may be contraindicated as Abilify effects serotonin and that **could** lead to serotonin syndrome. I don't think Abilify was out when Dr. Gilman wrote about MAOI's so he has not written about MAOI and Abilify interaction. He is the expert on MAOI's, peruse his web page, https://psychotropical.info/ for more info. Great webpage. There is no mention of MAOI's in the PI for Emsam. Checking the internet people are taking the 2 together but I could not find authoritative sources.

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  • 1 month later...

Just saw my pdoc. Will be titrating off viibryd and abilify for parnate. We both agreed the pros might out weight the cons of maoi's. From what he states emsam is not much more beneficial than your standard snri, so he thinks it's better to get a clear view on the potential of a full mao a and b inhibitor. 

I'm really hoping parnate eases my depression and Lethargy because I cannot handle feeling like this 24/7. My depression is chronic. Doesn't come or go in waves. It just is. And it sucks... One thing I'm afraid of is obviously the interactions but also not sleeping well. As if I get no sleep It makes everything worse. 

Edited by aspillane
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Just wanted to say I know how you feel.

My depression is more of the agitated kind, which is pretty bad too.  I sometimes get so restless I can't sleep or sit still....

Good luck, please keep us updated on Parnate and what you try, as I am going to be looking for new ADs.

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On 8/31/2018 at 4:17 AM, aspillane said:

Will be titrating off viibryd and abilify for parnate.

That's strange that your pdoc wants you to titrate off the Abilify too, because antipsychotics are common bridging medicines for use during the washout period to keep the depression at bay. There isn't really any real danger of taking Abilify with an MAOI concomitantly, according to my pdoc. She has had me on various AAPs with Emsam, Parnate, and Marplan before. But each pdoc has their own medical opinion.

On 8/31/2018 at 4:17 AM, aspillane said:

From what he states emsam is not much more beneficial than your standard snri, so he thinks it's better to get a clear view on the potential of a full mao a and b inhibitor.

This is also a strange opinion, because, while selegiline, the active component of Emsam, is a selective MAO-B inhibitor in the low doses taken orally for Parkinson's disease, in higher oral doses and in the transdermal patch form, it loses its selectivity and inhibits both MAO-A and MAO-B. Some argue that the 6 mg/24 hr dose doesn't quite have the potency necessary to inhibit MAO-A sufficiently for depression, and at least 9 mg/24 hr or 12 mg/24 hr is necessary, but I'm no expert on this matter. But again, to each pdoc their own medical opinion. Personally, I didn't have success with Emsam until I personally experimented with it and put a 6 mg + 9 mg patch on for 15 mg, but my pdoc refused to go above 9 mg, so I ditched it for Parnate, which was vastly more successful, but only when I took it with Adderall, which is classically contraindicated, but can be done with supervision of a very well-trained pdoc. TCAs may also be taken with a MAOI to enhance their efficacy in this same manner, but only the secondary amine TCAs that have minimal SERT occupancy and subsequently have minimal serotonin reuptake inhibition, like nortriptyline or desipramine.

On 8/31/2018 at 4:17 AM, aspillane said:

I'm really hoping parnate eases my depression and Lethargy because I cannot handle feeling like this 24/7. My depression is chronic. Doesn't come or go in waves. It just is. And it sucks...

I hope it works for you too. I empathize with you on your depression. While I'm bipolar type 2, my depressive episodes are very long-lasting and very deep. They very seldom relent into euthymia or hypomania, although lately I seem to have been doing somewhat decently, thankfully. I sincerely hope you get the relief you so deserve. I hope that if Parnate doesn't work well enough, that your pdoc is open to augmentation with at least an AAP, maybe even a small stimulant or TCA dose, as the latter two are extremely effective in treatment-resistant depression.

On 8/31/2018 at 4:17 AM, aspillane said:

One thing I'm afraid of is obviously the interactions but also not sleeping well. As if I get no sleep It makes everything worse.

Parnate, unfortunately, is actually the MAOI most frequently associated with hypertensive crisis, because not only is it an MAOI, but it is also a norepinephrine-dopamine reupake inhibitor and releasing agent not unlike amphetamine (it is actually a substituted amphetamine). Ironically, you will experience postural hypotension in the beginning which is a risk for syncope (which will eventually go away), as well as a drop in blood pressure throughout therapy with Parnate. But one thing that's neat about taking a TCA with high affinity for the NET (a potent norepinephrine reuptake inhibitor), such as nortriptyline or especially desipramine, is that it will actually inhibit the "cheese effect" (the pressor response) caused by dietary tyramine or anything else that would cause a reaction with MAOIs to raise blood pressure, such as a norepinephrine releasing agent (e.g., amphetamine). Too bad many pdocs consider TCAs to be unconditionally contraindicated.

As for sleep, get ready to have about a month's worth or more of insomnia on Parnate! Seriously, I could not sleep on Parnate for a long time. It's very common to experience insomnia on Parnate, too. Very low doses of trazodone are very commonly used with Parnate, but I'm sure you've used that before.  Depending on how well that worked (or not), that might be an option for you. Also, a good thing about trazodone is that it's a 5-HT2A antagonist (which is part of how it helps you sleep), and that (I believe) will help protect you should you succumb to serotonin syndrome for any reason.

Best of luck to you! I hope you get relief!

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I got the test done using my DNA & Dr. sending it to GeneSite to see which antidepressants would work after 25 years of trying, you can get this test of you've tried many medications and been unsuccessful at finding relief for depression or for bipolarism. Almost all antipsychotics and antidepressants are contrary to my genetics, and serum levels build up to a high degree. If you are getting all the nasty side effects, this could be the problem. I must stay on a low dose of all but 13 of antidepressants, and of those 13 I've already been on over seven 7. Try getting this test done.

Edited by coralreef77
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@mikl_pls

Thank you for your thourough, and thoughtful reply. You covered a lot of territory so I will respond as best as possible. 

In short my pdoc is a very good pdoc. He is in the top 15% in terms of his knowledge on pharmacology in his own words. He is a therapist as well.  He states that he has on occasion prescribed an maoi for patients who are very med compliant and have tried various other antidepressants. He fully admits he is not an expert in the field of maoi's so what he wants me to do is try parnate 10mg, going up to 20mg if necessary. And if after doing this, If I don't get the benefit I need, then he will direct me to another psychiatrist who strictly deals with pharmacology only, and would be in the top 5% in terms of med knowledge. A second opinion essentially.

Based on what my doc said, and being that many pdocs are completely uninformed or even misinformed on maoi's, it seems like it takes a serious expert, top 5% of Pdocs, who are properly informed in the field of maoi's.  

I'm am in my washout phase right now. Which utterly sucks BTW, not because of withdrawls, just because my depression sucks that bad. I am still taking abilify, as i have done my own research on maoi's, and just like you stated,  can ease the washout period. 

My biggest fear is the insomnia associate with parnate, as I already suffer from insomnia. It sucks because once I do fall asleep, I can easily sleep for 16 hours. I forgot to ask my pdoc if I can take something for sleep, so once he prescribes parnate, I will ask. Hopefully he knows trazadone, and even remeron are safe with parnate.

He preferred parnate over the other 2 as I suffer from adhd, oversleepping, and very low energy during the daytime. 

According to https://www.mdedge.com/psychiatry/article/66132/depression/mao-inhibitors-option-worth-trying-treatment-resistant-cases/page/0/1

^Emsam is better for people who are bipolar, as you are. And parnate for endogenous depressions. Lack of energy and motivation, which I am. 

Thanks again for your reply! 

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@coralreef77

I have gotten the genetic test done and am compliant with most meds, including maoi's

@BiranOCD

I will 100% keep yall updated on my run with parnate. I get agitated very quickly as well. I recommend you ask your doc to try and augment abilify with your current AD as not only can It potentiate your AD, it can also help with Agitation. Unfortunately it didn't help me much. Agitation it actually did help with. But everyone is different. 

What meds, augmentations have you tried Brian? 

 

Edited by aspillane
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19 hours ago, aspillane said:

In short my pdoc is a very good pdoc. He is in the top 15% in terms of his knowledge on pharmacology in his own words. He is a therapist as well.  He states that he has on occasion prescribed an maoi for patients who are very med compliant and have tried various other antidepressants. He fully admits he is not an expert in the field of maoi's so what he wants me to do is try parnate 10mg, going up to 20mg if necessary. And if after doing this, If I don't get the benefit I need, then he will direct me to another psychiatrist who strictly deals with pharmacology only, and would be in the top 5% in terms of med knowledge. A second opinion essentially.

I really feel uncomfortable with your pdoc "handing your brain off" to another pdoc. But if he thinks that's what's best, then I think he is the professional! I just know that I personally wouldn't be comfortable with that decision lol.

19 hours ago, aspillane said:

Based on what my doc said, and being that many pdocs are completely uninformed or even misinformed on maoi's, it seems like it takes a serious expert, top 5% of Pdocs, who are properly informed in the field of maoi's.

I must be spoiled by my pdoc! Wow...

19 hours ago, aspillane said:

I'm am in my washout phase right now. Which utterly sucks BTW, not because of withdrawls, just because my depression sucks that bad. I am still taking abilify, as i have done my own research on maoi's, and just like you stated,  can ease the washout period.

Oh yeah, it does utterly suck. It is the absolute worst... I don't blame you for taking it in your own hands to take the Abilify anyway. I would do it myself. But my pdoc did keep me on Abilify. I also kept myself on nortriptyline during the washout phase both to and from MAOIs. Secondary amine TCAs are safe to administer with MAOIs, but I am not advising you to take anything not prescribed by your pdoc! This website is a good wealth of information about MAOIs. https://psychotropical.info/

19 hours ago, aspillane said:

My biggest fear is the insomnia associate with parnate, as I already suffer from insomnia. It sucks because once I do fall asleep, I can easily sleep for 16 hours. I forgot to ask my pdoc if I can take something for sleep, so once he prescribes parnate, I will ask. Hopefully he knows trazadone, and even remeron are safe with parnate.

I would bring your research material with you. Hopefully you can convince him, if he doesn't know, that it is safe to take with Parnate. If not, there's always the Z-drugs like Ambien, Sonata, and Lunesta, and the benzos like Restoril, etc.

19 hours ago, aspillane said:

He preferred parnate over the other 2 as I suffer from adhd, oversleepping, and very low energy during the daytime.

I could see why he preferred Parnate. Parnate can help all that.

19 hours ago, aspillane said:

^Emsam is better for people who are bipolar, as you are. And parnate for endogenous depressions. Lack of energy and motivation, which I am.

Really strange, because I got nothing out of Emsam, and I responded well to Parnate (so long as I had Adderall with it. When my pdoc took the Parnate away and increased the dose of Parnate, I crashed...).

19 hours ago, aspillane said:

Thanks again for your reply! 

You're more than welcome!

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Well I clicked on this because I thought it said Maori proposal. You've proposed to a Maori? Congratulations! But it's about a type of medication that I know nothing about. So erm... If you were ever to get married to a maori then you could do the haka dance like this

Which would be much more interesting than most weddings. I really love that video - not typically romantic but so nice. It has absolutely no relevance to your question but... erm... I'm not at all sure to finish that sentence. Hopefully you'll like the video. Erm... bye.

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  • 2 weeks later...

Long story short I tried parnate for 2 days. And just couldn't. Insomnia was insane! Depression became way worse. I was a shell of a human being and only pacing around helped mildly.  

Back on fetzima 20mg, Abilify 4mg, and lamictal I am building up the dose on. 

I can once say I am feeling good about things. Having that washout period and seeing how bad my depression got really gave me an outlook on things. 

We figured out I'm more efficient on low dose snri as higher doses caused major fatigue. 

Well maoi I get I won't be seeing you anytime soon. I will not miss you. Hopefully I will never need you. 

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8 hours ago, aspillane said:

Long story short I tried parnate for 2 days. And just couldn't. Insomnia was insane! Depression became way worse. I was a shell of a human being and only pacing around helped mildly.  

Back on fetzima 20mg, Abilify 4mg, and lamictal I am building up the dose on. 

I can once say I am feeling good about things. Having that washout period and seeing how bad my depression got really gave me an outlook on things. 

We figured out I'm more efficient on low dose snri as higher doses caused major fatigue. 

Well maoi I get I won't be seeing you anytime soon. I will not miss you. Hopefully I will never need you. 

The thing about Fetzima is that in low doses it affects norepinephrine more than serotonin unlike other SNRIs where the opposite is true. It could be that you need a norepinephrine boost more than serotonin. 

Sorry the Parnate didn't work out for you. :( But glad that you are starting to feel better.

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Thnx! The big downside to any ssri snri is that they make me oversleep and more fatigued during the day. But I can sleep and depression are much better. 

Seeing a second opinion doc within a couple months. He's the best of the best but hard to get in to see. Nuvigil helps a bit but I don't think that's the best option long term. 

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35 minutes ago, aspillane said:

Thnx! The big downside to any ssri snri is that they make me oversleep and more fatigued during the day. But I can sleep and depression are much better. 

Seeing a second opinion doc within a couple months. He's the best of the best but hard to get in to see. Nuvigil helps a bit but I don't think that's the best option long term. 

Interesting, I'm often stimulated by SNRIs. Everyone's different, though!

I think out of all stimulant options, Nuvigil would be the most preferable to most prescribers.

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