Taking Emsam: A Different Kind of Antidepressant

Since I’ve written several posts on my growing worries about antidepressants, I thought I’d tell you about the one I’m taking now.

Emsam has worked for me longer than any other, and the dietary restrictions it requires have been a small price to pay.

Among antidepressants, the MAOI class has been relegated to 3rd or 4th tier treatment after other medications have failed. That’s how I started taking Emsam. After a dozen years spent trying 20 meds without success, I was a good candidate for a drug of last resort.

Recently, I’ve gotten curious about how these antidepressants work and why you have to leave certain foods out of your diet when taking them. I’m no expert in neurobiology, but I think I get the gist of what MAOIs do and the problems they cause. I’m adding references at the end of the post so you can get the full story, told in vivid technical color.

What’s an MAOI?

MAOI stands for monoamine oxidase inhibitor. MAOIs do what almost all the other antidepressants on the market do. They increase the level of one or more of the three neurotransmitters thought to be related to depression: serotonin, norepinephrine and dopamine.

Unlike the more recent antidepressants, the MAOIs act on all three, especially dopamine.

Antidepressants increase the available amounts of these monoamines by interfering with the breaking down of neurotransmitters after they’ve served their purpose. That purpose is to carry messages from one neuron to another across a gap called the synapse.

The antidepressants increase the amount of the neurotransmitters available in that gap outside the neuron cell.

After they’ve done their work, they are brought back inside the neuron they came from and are broken down for reuse. There are several steps in that breakdown process, and antidepressants of different types specialize in slowing down one or another of those steps.

The most widely prescribed drugs are reuptake inhibitors. (For example, Prozac is a selective serotonin reuptake inhibitor – SSRI) They interfere with the transporter proteins that take the neurotransmitters back to be reprocessed.

MAOIs target the enzyme (monoamine oxidase) that triggers the actual breakdown of the neurotransmitters into other chemical substances.

The basics are summarized in the name, MAOI.

1. Monoamine (MA) is the general name for a large group of neurotransmitters.

2. Monoamine oxidase (MAO) is an enzyme serving as the catalyst needed for the neurotransmitter breakdown process. (A molecule is pictured above in the squiggly ribbon diagram.)

3. An MAO inhibitor (MAOI) interferes with the action of monoamine oxidase in that process.

The Danger of Stroke.

But there’s a catch to messing around with monoamine oxidase.

The action of the MAOIs also interferes with the processing of a particular monoamine compound called tyramine that is found naturally in the small intestine. Certain foods are especially rich in this same tyramine. When the tyramine in these foods is added to what’s already in your gut, then you’re in trouble.

Though it’s not known exactly how this happens, too much tyramine triggers a huge spike in blood pressure, and that can cause a deadly stroke. Even if you don’t get the stroke, you have to get to a hospital for emergency treatment.

Given this danger, why would you want to take one?

How Effective are MAOIs?

The upside is that they’re much better than other antidepressants.

How good are they? Studies of MAOIs have shown them to be the most effective of all the antidepressants now in use. They’re especially good for treatment resistant cases like mine. Only electroconvulsive therapy has a higher rate of remission.

According to the STAR-D study, 30% of patients had remission of most or all symptoms when treated with a single selective serotonin reuptake inhibitor or SSRI (citalopram). In MAOI studies, the remission rate goes as high as 50%.

But there is the potential problem of that deadly stroke.

Naturally, psychiatrists have to be careful in prescribing any MAOI. Dietary restrictions have to be followed to avoid the tyramine-rich foods. That sort of regimen is hard for a lot of people to follow so many stop taking the antidepressant.

An even greater concern is that suicidal patients might stay on the drug but ignore the food restrictions.

That’s where Emsam comes in. It reduces the risk of the hypertension crisis.

Emsam and Selegiline

Emsam is different from the other MAOIs. First Emsam is not the name of the antidepressant itself but rather the name of the transdermal delivery system (that is, a very high tech patch) that contains an MAOI called selegiline.

The patch provides one improvement, and selegiline gives another.

The older MAOI’s, such as Parnate and Nardil, are taken orally like every other antidepressant. When they hit the small intestine, they stop the breakdown of tyramine and set the stage for the dangerous interaction with the wrong kind of foods.

The patch, however, avoids the gastrointestinal tract and delivers the medication directly to the bloodstream and from there to the central nervous system.

Selegiline is one of a new generation of MAOIs. These newer drugs act more selectively than the old ones. At least at low doses, they do not affect the form of monoamine oxidase that works in the small intestine.

You don’t have to restrict your diet on the low dose. However, at the higher doses, selegiline is not so selective, and the food restrictions kick in.

I take the highest dose.

Foods to Avoid.

Which foods do I have to avoid? Unfortunately, it’s hard to find any two lists that agree completely, but the best science indicates a relatively small number of problem foods.

The hypertensive crisis came to be called the “cheese reaction” because the first cases involved eating nicely aged cheese. Aged is the key word. In addition to cheese, there are many types of aged meat – dried, smoked, cured – as well as sausages like salami that can cause the same reaction. Fresh meat, fish and cheese are OK.

I never was a fan of beef jerky, hard sausage or cured meat (well, I did like bacon). Now that I’m a vegetarian, it doesn’t matter anyway.

I do miss the great aged cheeses of the world,, though I ate them pretty sparingly.

Among other problem foods are fava beans, soy bean curd in many forms (tofu, protein concentrates, miso), sauerkraut, and tap beer. Marmite and other yeast concentrates, are not allowed, but Brewer’s yeast and the yeast used in baking are fine.

Here’s the downside of being a vegetarian and soy fan. Tofu is pretty basic, and it would be nice to have that. At least soy milk is OK.

That’s it. These are the food restrictions backed by scientific evidence.

You may see all sorts of other foods, like raisins, bananas, coffee, chocolate – lots more – that were initially on the list in the 1960s. Those claims were based on isolated cases and haven’t made it through more recent tests.

These limitations have changed my diet, and I’ve been living with them for years. As a trade-off for severe symptoms, dropping a few foods has not been a problem.

I’m still taking Emsam, in combination with lamotrigine (a mood stabilizer), and still doing well. However, I’ve had enough ups and downs in the last year to wonder if it’s the medications that are helping or if it’s everything else I do to stay healthy.

I’ve decided to phase them out because of my concerns about long-term use of any antidepressants. But that’s a story for another post.

Have you ever tried an MAOI? Did it work? Were the food restrictions a problem?

Here are a couple of references with full text available online.

Transdermal Selegiline: The New Generation of Monoamine Oxidase Inhibitors

Monoamine Oxidase Inhibitors: A Modern Guide to an Unrequited Class of Antidepressants