Coadministration of phenelzine and methylphenidate for treatment-resistant depression

Abstract

TO THE EDITOR: Several strategies have been used in attempts to manage treatment-resistant depression. Some strategies include lithium augmentation, liothyronine, and lamotrigine. A combination that has shown efficacy is a monoamine oxidase inhibitor (MAOI) with a psychostimulant. When combined with an MAOI, which inhibits neuroamine catabolism, psychostimulants have been associated with severe toxicity including hypertensive crisis and intracranial hemorrhage, severe hyperthermia, seizures, other central effects, and death.We report a case where combination therapy with phenelzine and methylphenidate were used effectively and safely.Case Report. A 31-year-old white woman was admitted to an inpatient mental health unit secondary to suicidal ideations. Her depression symptoms upon admission included hopelessness, insomnia, reduced appetite, reduced concentration and energy, psychomotor slowing, and frequent crying spells. Her recurrent depression had not substantially responded to >50 electroconvulsive therapy treatments (initially with good success in 1996) or methylphenidate augmentation of a novel antidepressant. However, the methylphenidate had aided her concentration at that time. The depression also had not responded to monotherapy trials of paroxetine, sertraline, fluoxetine, venlafaxine, bupropion, and mirtazapine. Axis I diagnoses were major depression, recurrent, severe, as well as attention deficit disorder.On hospital day 1, the patient started phenelzine 15 mg/day (Table 1). On day 4, the phenelzine dose was increased to 15 mg twice daily. On days 5 through 8, methylphenidate 10 mg/day was initiated and increased by adding 2.5 mg at noon daily. On day 6, since the blood pressure (measured 4 times daily) remained within normal limits, phenelzine was increased to 15 mg 3 times daily. The patient's blood pressure remained normal throughout hospitalization. She reported an episode of dizziness that was transient and did not return. On day 9, the patient reported improvement in mood and was discharged on day 10 due to her financial concerns. Her discharge medications were phenelzine 15 mg 3 times daily and methylphenidate 10 mg in the morning and 7.5 mg at noon. Several months after she was discharged, her outpatient therapist reported that the woman was doing well on this combination and had finished her college degree.We dedicate this report to the late Dr. Pio Albert Pol, the treating psychiatrist in this case. His sincere kindness and unwavering commitment to his patients go unparalleled.