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Wednesday, September 30, 2009

MAOis For Dummies (And British Pundits)

Allegedly, British Prime Minister Gordon Brown takes a monoamine oxidase inhibitor (MAOi) antidepressant.

That's the rumor, based on the rumored fact that he is unable to eat certain things, notably cheese and Chianti wine. These are foods rich in tyramine, a chemical that's normally harmless, but can be toxic in people taking MAOis. So, if Brown is indeed on a Chianti-and-cheeseless regime, he almost certainly is taking one of the several MAOis on the market today.

The original source for this idea is this blogger, who claims to have heard it from an unnamed Brown aide. Is he to be believed? A glance over his website shows he is hardly an impartial commentator, and he goes on to demonstrate his psychological insight with statements like
"Obsessive Compulsive Disorder (OCD) is relatively common. Most of us display some obsessive features in everyday life, but under stress a minority of people become borderline or actual OCD in their behaviour, and need medication to control both this and the depression which almost always presents soon afterwards. ... Gordon Brown's symptoms are obvious when viewed in this light: the constant repetition of phrases, and an almost embarrassing (for his Party) need to spray every Parliamentary answer with statistics... they - and the constant speech repetition - represent Brown's unconscious means of controlling the severe anxiety that accompanies depression with OCD."
So one might think that his credibility is somewhat questionable. This hasn't stopped certain corners of the British blogosphere from getting very excited, however, and even respected political journalist Andrew Marr yesterday quizzed Brown about the issue.

Unfortunately, while many are eager to write about Brown and his possible pills, few of them seem to know anything about psychiatry or antidepressants, which has led to some embarrassing errors. So, for the benefit of British pundits, here are some helpful facts.

MAOis -
  • are not "powerful", "heavy duty" antidepressants. In terms of effectiveness, they are no better, on average, than Prozac. In fact, no antidepressant is much better than any other one. They differ in terms of side effects, but not "strength". For what it's worth, current opinion is that if there is a best antidepressant, it is escitalopram, a modern Prozac-like SSRI with very mild side effects, which is just about as unlike a MAOi as you can imagine.
  • do not "impair" or "affect judgment". Antidepressants don't. Except that they treat depression, and someone who's happy might make different judgments to someone who's depressed. But these drugs do not affect judgment in the way that intoxicants like alcohol or cocaine do. You don't get high on them. This is why they have no street value. Most drugs which impair judgment get used recreationally, because having your judgment impaired can be fun. Antidepressants aren't.
  • are not exclusively used in "severe depression". They are usually reserved for when a patient has not responded to other drugs. This is because of their troublesome side effects, including high blood pressure, and the fact that you can't eat cheese. But "treatment-resistant" depression is not the same as "severe" depression. In fact, the more severe the depression, the more likely it is to respond to treatment with conventional drugs. If Brown is on MAOis, he has probably tried at least two or three other drugs, but this is by no means uncommon because antidepressants just don't work especially well. According to the largest trial in a real-world setting, the STAR*D project, only 30% of people fully recover on their first antidepressant and only 30% of the rest respond to the second one.
  • are not especially effective in OCD, as the source of the rumor claimed - "this older class of drugs has one huge advantage: for severe depression and obsessive compulsive disorder it remains very effective", emphasis in the original. This is just flat-out wrong. Other antidepressants are more useful in OCD. Here's a recent review of drug therapy for OCD. MAOis get a mention... right at the end, after (deep breath) SSRIs, clomipramine, atypical antipsychotics, SNRIs, pregabalin, tricyclic antidepressants, and benzodiazepines. Here's the only published trial comparing a monoamine oxidase inhibitor to another drug, Prozac, for OCD. The MAOi didn't work, Prozac did.
  • were the first class of antidepressants to be discovered; the very first, iproniazid, was discovered in 1952. Others followed, such as tranylcypromine, phenelzine, and selegiline. Today, there are a handful of MAOis on the market. These include some newer drugs such as moclobemide (which has milder side effects) and the selegiline transdermal patch (which carries fewer dietary restrictions). MAOis are primarily used to treat depression, but are also used in Parkinson's disease.
So, even if Brown is taking MAOis, this has no implications regarding his mental state or competence to govern. What about the possibility that he is depressed? This could be relevant, but considering that the most popular British leader of all time famously suffered from severe depressive episodes throughout his life, including his time in office, the historical precedents are not unfavourable.

Realistically, none of this is going to change people's minds. No-one is really concerned about the possibility that Gordon Brown is using MAOis, or even the possibility that he's depressed. Rather, a lot of people just really don't like him, and this rumor is the latest stick with which to beat him. Blogger Guido Fawkes has been asking "Is Brown Bonkers?" for months. As one journalist put it, "Whether literally the case or not, however, this rumor carries the kind of psychological truth that tends to be more damaging than fact." Which didn't stop him from repeating the rumor uncritically.


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