MAOIs: Introductory Comments

"Knowledge is of two kinds. We know a subject ourselves, or we know where we can find information upon it." Samuel Johnson

"Beware of false knowledge; it is more dangerous than ignorance." George Bernard Shaw

MAOI antidepressant drugs are safe and effective, with generally low levels of side-effects, and with an appropriate knowledge base, quite easy to use.

Seeing patients we have treated achieved complete remission after years of illness is one of the most rewarding feelings and achievements that we get as doctors and specialists. You will experience that feeling more frequently once you have learned to treat people with MAOIs.

Many specialists are missing out on the opportunity to effectively treat large numbers of patients by not knowing about these drugs and how to use them. As doctors we are but a child of our time and we are molded by the social and commercial milieu that forms our training experience. Unfortunately this has been an MAOI deficient environment for quite some time. Even more unfortunately, the quantity of Shaw's "false knowledge" is also extensive, even classic text books and reviews frequently have seriously mis-informed fact and comment: it was I who discovered that MB was an MAOI, so read as an example of this, my analysis of the methylene blue fiasco and learn how the FDA and the UK MHRA made extensive errors and gave ill-informed advice to doctors.

The three decades of the Prozac era may now be receding, but I am old enough to recall the previous chapters in the story and see the perspective. That causes me to comment that some of the Prozac-era drugs have caused more difficulties and problems than the MAOIs ever did. When reviewing the Prozac era I am struck by the fact that such a large number of patients were treated so extensively with a group of drugs of such marginal efficacy: indeed one is tempted to call it the “anodyne era” (do no harm, but not much good either).

It is difficult to summarise the history of MAOI use in psychiatry without being critical of the level of knowledge in the profession. One strong  influence which compounds the misinformation/misperception problem about drugs in general, and out-of-patent drugs in particular, is the strong bias concerning promotion, advertising and teaching produced by the financial muscle of pharmaceutical companies. Their objective is to sell new generation expensive in-patent drugs, irrespective of whether they can actually fudge the evidence to make them look better or not.

I am an internationally acknowledged expert on serotonin toxicity and have published extensively about drug toxicity and interactions involving most psychotropic drugs (1-9).

There are many other sections on this website related to safe and effective use of drugs and my special expertise in serotonin toxicity enables me to talk particularly authoritatively concerning that aspect of MAOI interactions.

I have reviewed elsewhere the evidence relating to the declining use of MAOIs by doctors over the last three or four decades. Although there is little or no data relating to the younger generation of doctors it is reasonable to assume that an even smaller proportion of the latest generation have adequate experience, or knowledge, of these drugs.

Those who wish to learn more about MAOIs will require a little intellectual courage and tenacity because what is written about these drugs is a good example of how easy it is for dogma to become established as scientific fact even when it is based on poor evidence and minimal experience. Sadly, much of what has been written about MAOIs is simply second or third rate scholarship, much of which is factually incorrect. I do not want to dwell on that aspect here, but it is important to be confident of the accuracy and objectivity of that statement. The brief example I will use is that of the generally accepted proscription that one cannot combine TCAs and MAOIs. This is reproduced in almost all standard texts. How and why that is incorrect is dealt with in great detail in several of my papers about serotonin toxicity. Perhaps the best general overview of that question is in my 'Biological Psychiatry' review (5) and the MB review (8).

So, if you are going to use MAOIs you need to acquire the knowledge and have the intellectual fortitude to challenge misconceptions and dogmas. Those who are unable to marshal those qualities will have greater difficulty challenging commonly accepted views and the various misleading clinical guidelines on treatment. Guidelines are admirable things for general purposes and for less experienced practioners, but it is important to remember that all good guidelines are preceded by specifically stated caveats relating to the importance of individual cases and the use of clinical judgement by the treating doctor. They are only guides, not ex cathedra dictates.

Those who opine that treatments should not be given because they are not in the guidelines do not understand the responsibilities of the clinician and the priorities of good clinical medicine. That idea conceptually meshes with the George Bernard Shaw quote:

"When a stupid man is doing something he is ashamed of, he always declares that it is his duty."

Or in our field of endeavour the individual would protest that they had “followed the guidelines”.