Monoamine oxidase inhibitors, commonly called MAOIs, are the other major antidepressant family. Phenelzine (Nardil) has been the MAOI most researched for the treatment of panic. Another MAOI that may be effective against panic attacks is tranylcypromine (Parnate).

Possible Benefits. Helpful in reducing panic attacks, elevating depressed mood, and increasing confidence. Can also help social phobias. Well studied. Tolerance does not develop. Non-addicting.

Possible Disadvantages. Dietary and medication restrictions are important and bothersome to some people. These include avoiding certain foods like aged cheese or meat and certain medications like cold remedies. Some agitation during first days. Delayed onset requires weeks to months for full therapeutic effects. Not as helpful for anticipatory anxiety. Dangerous in overdose.

Dietary Restrictions. Certain foods contain a substance called tyramine, which when combined with an MAO inhibitor can cause a "hypertensive crisis" that can produce dangerously high blood pressure, a severe headache, stiff neck, nausea, stroke or even death.

The patient using an MAO inhibitor must be quite responsible, since this medication requires significant dietary restrictions. No cheese (except cottage, farmer or cream cheese), sour cream, homemade yogurt, red wine, vermouth, liquors, beer, ale, sherry, cognac, Bovril or Marmite yeast extracts (baked goods prepared with yeast are OK), aged meats and fish, meat prepared with tenderizer, liver or liverwurst, overripe bananas, avocados, fava beans, Italian green beans, Chinese or English pea pods, or lima beans are to be eaten while on this medication.

Foods to eat in moderation include avocados, chocolate, figs, raisins and dates, soy sauce, caffeinated drinks, white wine and distilled alcoholic beverages (e.g., whiskey, gin, vodka)

Medication Restrictions. MAOIs have major interactions with many other drugs including anesthetics, analgesics, other antidepressants, and anxiolytics. The patient using an MAO inhibitor should always consult the prescribing physician before taking any additional medications. This especially includes over-the-counter cold medicines (including nose drops or sprays), amphetamines, diet pills, tricyclic antidepressants, and certain antihistamines.

Possible Side Effects. Difficulty sleeping; increased appetite; sexual side effects, especially difficulty achieving orgasms for men and women; weight gain; dry mouth; sedation (sleepiness); and low blood pressure symptoms, particularly on standing up rapidly, which can lead to postural hypotension.

As with any antidepressant, some patients will experience "hypomania", which causes them to feel unusually "high" and full of energy, talkative and very self-confident, with little need for sleep and a high sex drive. Patients don't always recognize this as a problem, but it can certainly be irritating to those around them.

Phenelzine (Nardil)

Possible Benefits. Useful for panic disorder as well as depression. In one study, using between 45 mg to 90 mg per day, phenelzine produced significant panic symptom reduction in more than 75% of patients. complete control of the panic attacks usually takes 4 to 6 weeks of treatment. Current research also suggests it can be beneficial for social phobia.

Possible Disadvantages. See disadvantages-Monoamine Oxidase Inhibitors, above. Use during pregnancy only with the approval of your physician. Avoid breast-feeding while on this drug.

Possible Side Effects. See side effects-Monoamine Oxidase Inhibitors, above. Weight gain, sometimes up to 20 pounds, and postural hypotension are common. Swelling around the ankles from fluid retention, headache, tremors, fatigue, constipation, dry mouth, loss of appetite, arrhythmias, difficulty having orgasm, insomnia or sleepiness. Decreased libido, inhibited orgasm and difficulty maintaining erection.

Dosages Recommended By Investigators. Each tablet of phenelzine is 15 mg. The initial dose is usually 15 mg or less and then gradually increased to 30 mg daily, in divided doses. Dosage is then three to six tablets per day, usually based on body weight. Most patients need a minimum of 45 mg daily. Maximum dose is usually 90 mg. You can take the entire dose at bedtime after one or two weeks unless you find this interferes with your sleep.

Tranylcypromine (Parnate)

Possible Benefits. Useful for panic attacks and depression. Very little anticholinergic or sedative effect. Little problem with weight gain.

Possible Disadvantages. See disadvantages-Monoamine Oxidase Inhibitors, above. Insomnia and postural hypotension can be persistent problems.

Possible Side Effects. Insomnia, postural hypotension, swelling around the ankles, some trouble having orgasm.

Dosages Recommended By Investigators. Starting dose is one to two 10 mg tablets. Increase the dose one tablet every three to four days. Maintenance dose is 30 to 60 mg in one or two doses in the morning or early afternoon.

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Reviewed: 02/2006