Question

GB is a 55-year-old male patient with complaints of depression and anxiety. He was gainfully employed as a supervisor at his parent’s factory for 25 years until it closed three years ago. He has had other jobs in the past three years, but none that he has been able to sustain because of anxiety and fear of failing. He is married with three grown children. He denies use of drugs or alcohol. He does not have any acute or chronic medical history. His past psychotherapy history includes

• paroxetine 40mg daily (minimal clinical response after 6 months of use)
• Duloxetine titrated to 120mg per day with alprazolam 1mg three times daily (20% improvement in symptoms)
• Cognitive behavioral therapy--20 weeks (50% improvement)
• Addition of mirtazapine to BZD (alprazolam) and SNRI (venlafaxine) dose titrated to 45mg at bedtime—dose is not tolerated and reduced dose is not effective
• Duloxetine and mirtazapine are discontinued; bupropion XL is started and dose titrated to 450mg daily; alprazolam is unchanged (MDD episodes continue with insomnia and nightmares)

The physician you are with wants to start a MAO inhibitor.

1. What therapeutic options are there and what are advantages and disadvantages to each?
2. How will the conversion from bupropion XL to the MOA inhibitor be made?
3. What adjunctive therapy can help during the conversion?
4. What educational points would you need to share with the patient?

Answer 1

Monoamine Oxidase inhibitor is the antidepressant. It is a safer one and causes fewer side effects. this medication is a good option to relieve depression when another treatment has failed. It affects the neurotransmitter to communicate brain cells.
Advantages;
It is safe and has fewer effects.
It treats Parkinson's disease also
Disadvantages:
It needs diet restriction because it causes hypertension with some foods and medication
Conversion from the bupropion XL to the MAO inhibitor:
  Bupropion is a weak inhibitor of the neural activity in the norepinephrine and dopamine, but it does not inhibit MAO activity. Bupropion has an immediate release within 2 hours, 5hours extended release. MAO extended release 6 to 7 hours. MAOI antidepressant allows 14days to elapse between discontinuing bupropion and initiation of MAO intended to treat depression.
Adjunctive therapy:
During discontinuation of antidepressant therapy gradually taper the dose for 2 to 4 weeks to find out the withdrawal symptoms. Symptoms will be less because bupropion has minimal serotonergic activity.
Educational point:
- Advice the family and caregivers to observe the patient closely to avoid suicidal thoughts.
- Advice patients if they forget the dose they should not take it after a long period.
- Maintain the weight to avoid weight loss
- follow diet restriction like following a salt-restricted diet to avoid blood pressure
- Explain the patient about side effects that should be reported immediately.