Combining a classic monoamine oxidase inhibitor with a tricyclic antidepressant in therapy-resistant depression: a case report and literature review

Combining a monoamine oxidase inhibitor (MAOI) with a tricyclic antidepressant (TCA) is considered to be contra-indicated because there is a risk that the recipient develops a serotonin syndrome. An accidental clinical observation motivated us to search and study publications relating to the risk and effectivity of combining these two types of antidepressants. AIM: To search and study articles on the risks and effectivity of combining the use of MAOIs and TCAs in the treatment of therapy-resistant depression. METHOD: We searched in PubMed and also studied relevant articles that papers referred to in the database. RESULTS: Because many case-reports have been misinterpreted, the patients' risk of developing a serotonin syndrome and other complications as a result of the combined use of MAOIs and TCAs is overestimated. The literature provides some evidence that the combination therapy may be effective for some patients who have not responded to TCA or MAO-I monotherapy. Combination therapy seems to be safe if monitored carefully and if TCAs with marked serotonergic affinity are avoided. To enhance safety, the MAOI should be added to a TCA or both the TCA and MAOI should be started simultaneously and titrated slowly. CONCLUSION: The combination of a MAOI and a TCA can be a possible treatment for patients with treatment resistant depression when monotherapy with either a TCA or a MAOI has failed.