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Antidepressants


- by Dr. James Meschino, DC, MS, ROHP

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Introduction

In the United States, a 2005 independent report stated that 11% of women and 5% of men in the non-institutionalized population take antidepressants

The Three Most Common Types Of Anti-Depressants Include: 

  1. MAOIs (monoamine oxidase inhibitors)
  2. Tricyclics
  3. SSRIs

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Antidepressants

Dr. James Meschino, 

DC, MS, ROHP

1. MAOIs (Monoamine oxidase inhibitors)

MAOIs work by blocking the enzyme monoamine oxidase which breaks down the neurotransmitters dopamine, serotonin, and norepinephrine (noradrenaline). MAOIs can be as effective as tricyclic antidepressants.

Because there are potentially fatal interactions between this class of medication and certain foods (particularly those containing Tyramine), red wine, as well as certain drugs, classic MAOIs are rarely prescribed anymore.

Why Are MAOI Dangerous?

When ingested orally, MAOIs inhibit the catabolism of dietary amines. Sufficient intestinal MAO-A inhibition can lead to hypertensive crisis, when foods containing tyramine are consumed (so-called "cheese syndrome”), or hyperserotonemia if foods containing tryptophan are consumed. The amount required to cause a reaction exhibits great individual variation. Thus, foods containing tyramine can be a problem for people on MAOI.

As well, the amino acid tyrosine, found in many foods, is the precursor to catecholamines, not tyramine. Tyramine is a breakdown product of tyrosine. In the gut and during fermentation tyrosine is decarboxylated to tyramine.

Ordinarily, tyramine is deaminated in the liver to an inactive metabolite, but when the hepatic MAO (primarily MAO-A) is inhibited by MAOI drugs, the "first-pass" clearance of tyramine is blocked and circulating tyramine levels can climb.

In turn, elevated tyramine competes with tyrosine for transport across the blood-brain barrier (via aromatic amino acid transport) where it can then enter adrenergic nerve terminals.

Once in the cytoplasmic space, tyramine will be transported into synaptic vesicles thereby displacing norepinephrine. The mass transfer of norepinephrine from its vesicular storage space into the extracellular space via mass action can precipitate the hypertensive crisis. Hypertensive crises can sometimes result in stroke or cardiac arrhythmia if not treated

In foods, tyramine is often produced by the decarboxylation of tyrosine during fermentation or decay: 

  • Foods containing considerable amounts of tyramine include meats that are potentially spoiled or pickled, aged, smoked, fermented, or marinated (some fish, poultry, and beef); most pork (except cured ham); processed meat, chocolate; alcoholic beverages (RED WINE).
  • Fermented foods - most cheeses (except ricotta, cottage cheese, cream cheese), sour cream, yogurt, shrimp paste, sauerkraut.
  • Fermented Soy Products - soy sauce, soy bean condiments, teriyaki sauce, tofu, tempeh, miso soup.
  • Some Beans And Nuts - broad (fava) beans, green bean pods, Italian flat (Romano) beans, Chinese (snow) pea pods, peanuts, Brazil nuts, coconuts.
  • Some Fruits and Vegetables - avocados, bananas, pineapple, eggplants, figs red plums, raspberries, yeast, and an array of cacti.

2. Tricyclic Antidepressants

Tricyclic antidepressants are the oldest class of antidepressant drugs and include such medications as amitriptyline and desipramine. Tricyclics block the reuptake of certain neurotransmitters such as norepinephrine (noradrenaline) and serotonin. They are used less commonly now due to the development of Selective Serotonin Reuptake Inhibitors, which are safer and have fewer and/or less pronounced side effects.

Side effects include increased heart rate, drowsiness, dry mouth, constipation, urinary retention, blurred vision, dizziness, confusion, and sexual dysfunction. However, tricyclic antidepressants are still used because of their effectiveness, especially in severe cases of major depression.

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Antidepressants

Dr. James Meschino, 

DC, MS, ROHP

3. Selective Serotonin Reuptake Inhibitors (SSRIs)

Selective serotonin reuptake inhibitors family of drugs includes fluoxetine (Prozac), paroxetine (Paxil, Seroxat), escitalopram (Lexapro, Esipram), citalopram (Celexa), sertraline (Zoloft), and fluvoxamine (Luvox). These antidepressants typically have fewer adverse events and side effects than the tricyclics or the MAOIs, although such effects as drowsiness, dry mouth, nervousness, anxiety, insomnia, decreased appetite, and decreased ability to function sexually may occur.

St John’s Wort

Evidence suggests that it acts to decrease breakdown of serotonin, dopamine, epinephrine, and clinical studies support its use for mild to moderate depression. The most commonly prescribed antidepressant in Germany is reported to be (concentrated extracts of) hypericum perforatum (St John's Wort).

Note: You can not recommend St John’s Wort or 5-hydroxy tryptophan to patients taking prescription antidepressant drugs, or they may develop life-threatening serotonin syndrome

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