Q:  MAOIs & Amphetamine Abuse

I am Bipolar II with a past history of amphetamine abuse.  Would the prior abuse make the older MAOIs and Selegiline poor choices for a persistant moderate depression. Mood seems stable, Depakote 1000mg serum level 75, other ADs have been tried. I am aware of the amphetamine/methamphetamine metabolites associated with MAOIs and have no desire to revisit the horrors of abuse.

Thank you
 

Dear Mr. R'
I am not aware of any reason to use such caution.  I have never heard of any misuse of MAOI's to "get high", for example, nor of people feeling "hooked" on an MAOI because of some sensation they got similar to a street amphetamine, nor of "withdrawal" effects coming off MAOI's that were similar in some way to coming off regular use of stimulants (there are reported withdrawal syndromes with antidepressants, but to my knowledge the MAOI's were not clearly associated with one, although usually we taper folks off this kind of thing anyway and so might have missed seeing such a syndrome -- as opposed to seeing it commonly when people taking the routine dose of Paxil, for example, stop from the usual starting dose of 20 mg). 

However, I came along after the era of substantial use of MAOI's.  I've used them, but not often enough to know from direct experience of the concerns you have raised.  It might be tough to find a psychiatrist nowadays who's actually used them a lot; you'd need to look for somebody who's been at the business more than 15 years, I think.  (Prozac came out in 1987 and really shifted things away from MAOI's starting about then).  

I just came from a conference in which the speaker reminded us that Parnate, an MAOI, has the best data suggesting it does not promote cycling like other antidepressants, so an MAOI may well be the safest medication to consider in your circumstance, in that respect at least.  Check out this article on the diet recommendations, it's the best I've ever seen on the subject (you'll have to get a librarian to help you access the whole article).  However, there's a more recent article that actually tested pizza, pepperoni no less, and found that commercial versions did not contain worrisome levels of tyramine!  That's quite a change from the standard recommendations, so should be discussed, like all of this reply, with your doctor...

Dr. Phelps