Nefazodone monoamine oxidase inhibitors

Maintenance/Continuation/Extended treatment There is no evidence to indicate how long the depressed patient should be treated with nefazodone. However, it is generally agreed that pharmacologic treatment for acute episodes of depression should continue for at least 6 months. Whether the dose of antidepressant needed to induce remission is identical to the dose needed to maintain euthymia is unknown. In clinical trials, more than 250 patients were treated for at least 1 year. Switching to or from a monoamine oxidase inhibitor (MAOi) At least 14 days should elapse between discontinuation of an MAOI and initiation of therapy with nefazodone. In addition, wait at least 7 days after stopping nefazodone before starting an MAOI. 

Most child and adolescent studies published thus far have focused on the effects of the tricyclic antidepressants (TCAs) and, more recently, the SSRIs. A few open studies have also shown that monoamine oxidase inhibitors (MAOIs) can be used safely with children and adolescents (Ryan et ah, 1988b), but noncompliance with dietary requirements may present a significant problem for minors. Other antidepressants, including the heterocyclics (HTC) (e.g., amoxapine, maprotiline), buproprion, venlafaxine, and nefazodone, have been found to be efficacious for the treatment of depressed adults (APA, 2000), but they have not been well studied for the treatment of MDD in children and adolescents. Therefore, this chapter mainly describes the use of SSRIs and TCAs for youth with MDD. 

FIGURE 9-6. Various treatments can be given in combination for panic disorder (i.e., panic combos). The basis of all many combination treatments is a serotonin selective reuptake inhibitor (SSRI). Other antidepressants such as venlafaxine, nefazodone, mirtazapine, tricyclic antidepressants, and monoamine oxidase inhibitors can all have antipanic actions, although they are second-line treatments, as are the benzodiazepines. On the other hand, benzodiazepines are often added to SSRIs, particularly at the initiation of an SSRI and intermittently when there is breakthrough panic. Cognitive and behavioral psychotherapies can also be added to any of these drug treatments. 

Although trazodone is related to nefazodone it probably potentiates 5-HT neurotransmission less. Trazodone is often added to monoamine oxidase inhibitors and serotonin re-uptake inhibitors at low doses (50-150 mg/day) as a hypnotic. In one case the combination of trazodone with nefazodone provoked the serotonin syndrome (37). 

In the 1980s an entirely new class of antidepressant arrived with the SSRIs, firstly fluvoxamine immediately followed by fluoxetine (Prozac). Within 10 years, the SSRI class accounted for half of antidepressant prescriptions in the United Kingdom. Further developments in the evolution of the antidepressants have been novel compounds such as venlafaxine, reboxetine, nefazodone and mirtazapine, and a reversible monoamine oxidase inhibitor, moclobemide. 

Drugs that inhibit cytochrome P450 3A4 (e.g., verapamil, dUtiazem, itraconazole, fluvoxamine, nefazodone, and erythromycin) can increase buspirone levels. Rifampin caused a 10-fold reduction in buspirone levels. Buspirone reportedly increases haloperidol levels and elevates blood pressure in patients taking a monoamine oxidase inhibitor (MAOI). 

Montgomery SA, Brown RE, Clark M Economic analysis of treating depression with nefazodone v. imipramine. Br J Psychiatry 168 768-771, 1996 Monti JM Effect of a reversible monoamine oxidase-A inhibitor (moclobemide) on sleep of depressed patients. Br J Psychiatry Suppl 155 61-65, 1989 Monti JM, Alterwain P, Monti D The effects of moclobemide on nocturnal sleep of depressed patients. J Affect Disord 20 201-208, 1990 Montkowski A, Holsboer F Absence of cognitive and memory deficits in transgenic mice with heterozygous disrupt of the brain-derived neurotrophic factor gene. J Psychiatr Res [in press)... 

Many noncyclic antidepressants are now available, including trazodone (Desyrel l), nefazodone (Serzone ), fluoxetine (Prozac ), sertraline (Zolotf ), citalopram (Celexa ), escitalopram (Lexapro ), paroxetine (Paxil ), tluvoxamine (Luvox ), venlafaxine (Effexor ), and bupropion (Wellbutrin ). Bupropion is also marketed under the brand name Zyban tor smoking cessation. Mirtazapine (Remeron ), a tetracyclic antidepressant, has recently become available. In general, these drugs are much less toxic than the tricyclic antidepressants (see p 90) and the monoamine oxidase (MAO) inhibitors (p 269), although serious effects such as seizures and hypotension occasionally occur. Noncyclic and tricyclic antidepressants are described in Table 11-7. 

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