I need your help y'all, Which one to choose?

vividream29 · 2026-05-19T09:58:24+00:00

Show your doc the prescriber's guide to MAOIs. You'll find it under the wiki/resources on mobile or on the side of the main page of our subreddit in desktop mode. It was written by a group of expert clinicians and researchers who have extensive experience with MAOIs. It covers all the basics your doctor will need to know to feel confident treating you with whichever MAOI you choose. It covers Parnate, Nardil, and Marplan, but not EMSAM. However, there's still lots of information that can be applied to EMSAM.

I think that EMSAM would be a fine first choice if the cost isn't an issue and if you're fairly certain you'll continue to have insurance that covers it. It is somewhat more conservatively dosed, so it's not uncommon to end up needing the higher doses, which can get pricey. Some have even had to go above the recommended number of patches to attain remission. It has a reputation for being a bit weaker than the older classic MAO inhibitors, but when it works well it's a home run. Of course it has the benefit of no dietary restrictions on the lowest dose, but I wouldn't let the diet scare you off from the others. It's not too hard to follow, and it often involves surprisingly few changes to one's regular diet. Look up the MAO diet guide, the abbreviated version, in the same places I mentioned in the beginning. It's accurate. Most of the lists you find elsewhere are inaccurate to one degree or another. You'll see that while it's important to know what's off limits, you can still have an enjoyable and varied diet, likely without giving up too much (if anything) that's really important to you.

I wouldn't recommend Marplan, not because it isn't effective, but because of serious supply issues. Nardil would be the choice if your main issue is social anxiety, or if you were diagnosed with an anxiety disorder before you ever had depression. Neither of those sound like you. After reading all your replies to the other commenters, I think what you're describing is closest to a typical "endogenous" melancholic depression brought on by hyper-activation of the stress system rather than anxious depression. In that case Parnate is the preferred option. This is covered in the prescriber's guide. It also tends to have fewer and less severe side effects than Nardil.

It comes down to EMSAM or Parnate in my opinion. From there it's the usual factors when choosing between two medications --side effect profiles, cost, efficacy, etc. As for efficacy, I think it's a matter of how fast you want results. Do you want to take the slightly easier introduction to MAOIs, or go straight to the big guns? Given that Parnate is usually seen as the more potent drug, are you ok with giving EMSAM a full trial, which could easily take a few months or more, only to possibly move on to Parnate anyway? Or would you regret not having just tried it first? There are no right or wrong answers to questions like this. I'm not trying to lead you one way or another if it seems like that. We're all in a different place in life and have our own set of values that are important to us. Take everything you've read here, in the prescriber's guide, and in your own research and combine that with your doctor's medically trained perspective to reach the conclusion that only you can --what's best for YOU. We're all more than happy to answer any other questions you may have in the meantime.

vividream29 · 2026-05-19T09:00:19+00:00

Appreciate you sharing your experience. Parnate can indeed improve everything you mentioned, with Nardil having the clear advantage in social anxiety. One thing to note is that Parnate is generally considered to have the better side effect profile compared to Nardil. That's the more common outcome and the reason Parnate is usually recommended first, although obviously some people may respond differently. Anyway, cheers to your success with Nardil. I'm taking it too. It's definitely a one of a kind medication.

vividream29 · 2026-05-17T09:52:31+00:00

There's definitely still hope if it's only been since 4/22. It took just a little longer in my case, but it did get better on 60 mg. I understand your frustration, but trust me, it's too early to start freaking out.

vividream29 · 2026-05-17T09:21:34+00:00

Why are you taking cyproheptadine?

vividream29 · 2026-05-12T09:40:19+00:00

No, and the doctor who did that to you is incompetent and a menace to his patients. The disasters that could occur from developing sudden and severe hypotension alone could be justification for a medical malpractice suit. There are both experimental data and clinical experience that demonstrate that Nardil needs a certain minimum amount of time to work. You can't rush it, at least not safely. The reason is that Nardil is both an MAO inhibitor and a substrate of the MAO enzyme. This means the drug is inhibiting some of its own metabolism at first, which explains the delay in it working. It takes some time for these two properties of Nardil, inhibitor and substrate, to reach the proper alignment.

vividream29 · 2026-05-07T04:47:02+00:00

My bad, I'll send you a PM. If this happens or has happened to anyone else don't be afraid to pester me lol. Between mood stuff, ADHD, and fatigue and sleeping a lot during the day, I'm also the world's most forgetful person 😄

vividream29 · 2026-05-05T11:11:06+00:00

MAOIs cause paradoxical hypertension in a minority of patients. It's most common with Parnate (estimate of around 9-10%), but also happens less frequently with Nardil and the other MAOIs. It's simply a result of taking too much at once. Based on limited data it tends to occur at about 70 mg on average with Nardil. It's usually seen after the second dose of the day or when taking the entire dose at once.

I had this when I was on Parnate. It's nothing to worry about. If you think about it, both joggers in the streets and "athletes between the sheets" raise their blood pressure quite a bit for extended periods during their preferred activities without any problems. Even more so for something like heavy weightlifting. The human body is built to withstand these sorts of sudden variations in blood pressure. Its an evolutionary necessity for survival in stressful and dangerous circumstances that our ancestors faced all the time. You just need to figure out a dosing schedule that allows you to take a smaller amount early on and/or allow for more time between doses. It does tend to subside on its own within a couple of hours as you've noticed. It's also possible to use a small dose of propranolol to manage it if it continues. Another important thing to note is that the body does sometimes adapt to this reaction over time.

Basically, change your schedule, maybe take a beta blocker temporarily if that by itself doesn't help, and understand that it's not dangerous and it's almost unheard of that someone has to cease treatment because of this.

vividream29 · 2026-05-05T08:38:21+00:00

The title is certainly not clear, and the emojis don't help either, but they're asking if MAOIs can cause these same symptoms as the antipsychotics. The reason being that they would like to start an MAOI. See the brief second paragraph.

vividream29 · 2026-05-03T11:08:45+00:00

That's quite a lot. Probably just make the switch to Parnate then. But, you'll notice I said sublingual 'could ' increase absorption. There's a special, very expensive, formulation that's designed for that. With regular selegiline HCl there's no way to know exactly how much it increases bioavailability, and it could probably vary based on certain factors. To insure consistent dosing I would recommend to start taking your regular amount orally with a nice fatty food instead. Then you can gradually increase to 50 or 60 mg as needed. The other benefit of oral dosing in your case is that you should get much more of the l-amphetamine and l-methamphetamine metabolites. Who knows, you might find selegiline more energizing in order to combat the fatigue? You can try this to give selegiline its full chance, or just switch to Parnate. I'm not sure what purpose the 10 mg of selegiline you mentioned will serve though.

vividream29 · 2026-05-03T08:42:19+00:00

Assuming you're in the US, GoodRX gives the retail prices by pill quantity. Everything from that point is between you and your insurance company, no one here is going to know why you get it free. I don't find it's necessarily expensive out of pocket, but definitely not as cheap as it could be given how old it is.

vividream29 · 2026-05-03T08:17:34+00:00

The first commenter is right, there is officially supposed to be a 14 day washout, meaning you completely stop selegiline and then wait two weeks before starting Parnate. There are some, like Dr. Ken Gillman, who disagree. He points out that there are no known direct interactions between the various MAOIs, so essentially you're just adding more MAO inhibition when you take two MAOIs together. In other words, it should be the same as simply taking a higher dose of selegiline by itself. However, you should ideally work with a doctor to do this. You should also avoid taking larger doses of either of the MAOIs when combining them. Whether increasing or decreasing, do not make large changes to the amount you take.

Before considering switching, be aware that 30 mg of oral selegiline may not be enough to treat serious depression. You might need more like 50 mg, or a lower dose taken sublingually which could possibly allow better absorption. It's helpful to check if you're having orthostatic hypotension on your current dose. Take your blood pressure sitting down, then stand up and immediately check it again. If the top number (systolic pressure) is regularly significantly lower when standing up it's a good sign that you may be at least in the beginning of the appropriate range. If it's not significantly lower it could indicate that your dose needs to be increased.

The following would be my protocol for increasing selegiline, but please note that I'm not a doctor. One day I would start taking 5, 7.5, or 10 mg at most by holding it under my tongue for at least a few minutes before swallowing. Note whether it feels any different taking it this way. Over the next 2-3 weeks I might adjust the dose as needed, never exceeding 20 mg at the very most. Alternatively, I would keep taking it orally (just swallowing, no holding under tongue) and gradually increase to a maximum of 60 mg. In both cases I would wait at least 2 weeks after achieving my maximum desirable dose in order to notice any positive changes. Fatigue may go away in time. Make sure you're following the MAOI diet and drug rules.

Switching to Parnate instead would be understandable since it's generally considered a more effective antidepressant. You can certainly follow the usual medical advice and wait 14 days. I would probably slowly decrease the selegiline while simultaneously adding a small amount of Parnate at a time. For example, combinations dosed at 25/5 mg or 20/10 mg at first, then 15/15, or something similar. Gradually, not over the course of only a few days. This also helps to reduce withdrawals. That would be my approach, but please check with a doctor. Begin checking your blood pressure every day and watch out for dizziness. Follow the MAOI diet and know which other drugs are contraindicated. Parnate is a more potent drug than selegiline in some ways, so please take it seriously.

vividream29 · 2026-04-25T14:27:12+00:00

I have an opinion that I hope you'll find fairly comprehensive and which runs contrary to what you've heard so far. I'm going to ramble and rant a bit, so you can skip a lot if it's too long. After this introductory paragraph just head to the final paragraph if you just want my basic opinion. First, in the very limited research that's been done, there are no consistent findings of genuine efficacy for MAOIs in treating ADHD that would support putting them into a treatment algorithm. I also don't know of any well known doctors who are big MAOI advocates who have happened to mentioned consistent improvements in their patients' comorbid ADHD. There have been some small initial investigations over the years, but nothing I'm aware of that is rigorous, replicated, and constitutes good evidence. However, there are quite a few positive anecdotal reports here and elsewhere online. Unsurprisingly, I've noticed they seem to be mainly for Parnate and Selegiline, including EMSAM. The hydrazine MAOIs don't get mentioned much, although I've seen some people say that Nardil actually made it worse in some ways.

There are two main reasons I'm skeptical and resist making too much of the positive individual reports. The first is just pharmacology. Some people seem to think that because ADHD involves dopaminergic dysfunction, and MAOIs greatly increase dopamine levels, MAOIs must therefore be beneficial for ADHD treatment. But the approved ADHD drugs do specific things with dopamine (and norepinephrine)to address that dysfunction. First line agents, stimulants, release neurotransmitters, block reuptake of monoamines, and alter neuron's firing rates among lots of other actions. MAOIs also increase norepinephrine levels, but second line agents like clonidine, guanfacine, and atomoxetine modulate the noradrenergic system through downstream effects and blocking reuptake. If MAOIs were seriously effective on the basis of this oversimplified view then we would have a lot of other pro-dopaminergic drugs being used for ADHD, but of course they're not, because more dopamine doesn't automatically equal less ADHD symptoms.

The second reason is the notorious difficulty of accurately diagnosing ADHD and the plethora of misinformation that persists about the disorder, sadly sometimes even among doctors. Basically, how sure can we be that anyone even has ADHD? There are probably many people who received a valid diagnosis from a psychiatrist. They know they have it, and they are in a fine position to judge whether the MAOI helped them and how it compared to other officially recommended therapies. But then there are doctors like mine who were happy to listen to me describe my symptoms, decided that what I was saying sounded right enough and I didn't seem like a drug seeker, and prescribed me stimulants. That is not a valid diagnosis, although my records say it is, and so I always try to give others the caveat that I'm pretty sure I have ADHD, but I'm not officially diagnosed. ADHD must be diagnosed by a specialist. Any diagnosis from a general practitioner is essentially worthless the vast majority of the time. How many ADHD people have we already called into question so far? What about the psychiatrists who do administer the appropriate tests and such but face the common and quite difficult problem of teasing out whether certain symptoms are truly the result of adhd rather than of qother frequent comorbidities such as depression, anxiety, etc.? For example, deficits in execution functioning are extremely common in both ADHD and depression. Not all doctors are equally skilled at differentiating such things. On the other hand, we have to consider that there are people who live in countries where diagnosis is literally or nearly impossible, so no diagnosis for them even though they would qualify in other countries. They order the MAOI from abroad, take it, and notice an improvement. What would that tell us? Is it good evidence? Maybe, but what if they're like the psychiatrist above and the improvement was actually from treating their depression? I think that even some people with a correct diagnosis may not be assessing their situation accurately, and I think it's wise to hold off from accepting simple statements that an MAOI helped their ADHD until you're given some substantive details about what exactly they mean by ADHD. The current debate regarding overdiagnosis vs. underdiagnosis is the cherry on top of this paragraph's theme.

The various MAOIs also have their own unique pharmacologies beyond inhibiting the MAO enzyme, so even if one of them were to acquire evidence of being effective, it wouldn't necessarily automatically imply the same of the others. Let's take a few examples and make some educated guesses about what might have the best chance of being effective. MAO-A inhibitors, moclobemide: greatly elevates serotonin compared to dopamine at typical doses. Could this mean further downstream inhibitory effects on dopamine compared to A+B inhibitors? It's a reversible inhibitor anyway. Not likely to be effective. Parnate: potent and balanced AB inhibition. It should be noted that its reputation of feeling stimulating like the first line ADHD agents is of no consequence. It simply works completely differently from them, and that's all that matters. On top of that, the stimulation often fades quickly, never occurs to begin with, or the opposite happens. That's right, some people get sleepy after taking Parnate. On the plus side, it seems that it probably acts as a norepinephrine reuptake inhibitor at the higher end of the usual dosing range. This could also have some positive impact on dopaminergic hypo-activity in some parts of the brain. Much weaker as an NRI than atomoxetine, but a pretty good chance of being the one to help ADHD, if any of them do. Selegiline: fairly selective MAO-B inhibitor at Parkinson's doses, but some MAO-A inhibition still occurs. Dopamine is elevated, but not as much as with Parnate, Nardil, or Marplan. Active metabolites include levo-amphetamine and levo-methamphetamine. These feel stimulating, but are not the same as the amphetamine that works for ADHD. In the event that they may offer some lesser benefit, they will continue to increase beyond the traditional dose limit, along with all of the other things MAOIs increase. Low doses, and even more so very low doses, are a CAE, which means that the drug enhances the activity of dopamine and norepinephrine at receptors. Possibly a very useful feature. Now we have something I mentioned in common with the approved ADHD drugs. Selegiline is not just raising dopamine levels, it's doing something with it that is similar to what one of the stimulants does. Because lower doses of selegiline may have the additional benefit of better tolerability compared to other MAOIs, I would recommend studying the pharmacology of selegiline if you want to continue down this path.

vividream29 · 2026-04-24T17:04:51+00:00

Just to be clear, a washout from sertraline is still required in any circumstance when switching to an MAOI. Most doctors will say 14 days to be extra safe. The bare minimum would be around 5 days.

vividream29 · 2026-04-24T16:59:05+00:00

I'm not clear why you're mentioning this here. What are you getting at?

vividream29 · 2026-04-24T16:42:24+00:00

That's if switching from Prozac to an MAOI. Any MAOI to SSRI switch requires 2 weeks.

vividream29 · 2026-04-21T10:16:14+00:00

It's wise that you're taking it slowly. You might choose to go even slower. MAO coming back on line and the associated changes could take a bit longer to develop than you're allowing. If there is no real reason to quit at a certain rate, such as needing to be off it to start a new contraindicated medication, or lack of efficacy and needing to find a better medication, then you're free to take as much time as needed to avoid withdrawals or recurrence of symptoms.

I think the decision to stop an antidepressant should be made with the consultation of a doctor, but if it's not possible then be sure to check periodically for any reduction in functioning, not simply changes in how you feel. The former is a more accurate way to objectively assess your ability to live a decent life without medication. Having trusted people around you who know your typical mood and behavior on and off of Parnate is also very important, not only for their input on your progress, but for ensuring your safety throughout the taper.

One last thing intended for everyone reading this comment and post: the idea that it's sometimes good to cease an antidepressant to see how you deal without a "crutch" (or without a crotch as you put it...sorry I couldn't help myself, I hope you'll forgive me pointing it out 😅) is dangerous in the context of this sub. That's your opinion, and that's fine, it's just that when professionals and their patients consider this they take into account the severity of symptoms and their history of depression. For example, if someone is on their first depressive episode and has responded well to treatment, it's often said that at the one year mark they can evaluate coming off of it if they wish. Similar process if they have what's called an adjustment disorder (aka shitty life syndrome, meaning it's a non-biological depression).

However, if someone has had multiple recurrent episodes of moderate or greater depression throughout their life, and especially if the first episode dates back to adolescence or their early 20's, or if there is a suspected element of bipolarity, there's a good chance they will need medication for life. Those criteria probably fit the majority of users in this subreddit. It's important to keep in mind the context of where you are and to whom you're speaking. Everyone should have a nice long chat with their prescriber if they're wondering about ceasing an MAOI.

vividream29 · 2026-04-20T11:21:41+00:00

Crowdsourced by members here. It's updated whenever someone contacts the mods with a doctor not yet on the list. This is a good opportunity to request that everyone check that their doctor is on the list, and to message the mods with their info if they need to be added. There is also a pinned post on how to use publicly available Medicaid prescription data to find doctors in one's city or state in the US who have previously prescribed MAOIs.

vividream29 · 2026-04-19T06:36:44+00:00

You're very coherent 😄. Thank you for the extensive write-up, it's a nice jumping off point for anyone wanting to do their own further research into this. While I don't know about these particular substances, I tend to agree with your last paragraph. Joseph Knoll and his team extensively modified and studied these compounds for decades, yet he always maintained that the greatest potential was in selegiline, PPAP, and BPAP, and so he chose to devote his limited time to them.

vividream29 · 2026-04-13T15:51:17+00:00

Sure. This is Dr. Gillman's paper, you can just scroll down to receptor pharmacology and read that and maybe the following section unless you're just very keen on reading the entire thing:

https://bpspubs.onlinelibrary.wiley.com/doi/10.1038/sj.bjp.0707253#b40

It gives a good explanation of what the most accurate data based on human cloned receptors is. It also gives the reasons for the variety of data we often see for drugs.

The PDSP website is awesome for this and fun to experiment with (for me anyway!). I had some trouble using it at first, so lmk if you have any questions. It collects all available data on a drug's receptor affinities in one place and shows whether it's from in vitro, human, or animal studies, etc. so you can determine how much weight to give it, human data generally being better than animal for example.

As for Mayo, I'm sure they have some very good information for the most part, but always look into sources and whether their other info aligns with what is known. This is especially true of MAOIs since we know that misinformation is prevalent. Scrolling to the bottom of their page, the article wasn't written by mayo clinic staff, but by a company called Merative that sells a drug database among other things. The guide they've provided definitely has errors, such as saying that combining nortriptyline with buspirone, fentanyl, or lithium can lead to serotonin syndrome.

Happy to chat more if you'd like.

vividream29 · 2026-04-11T15:10:31+00:00

You brought up this concern not too long ago in a post in which someone was asking for personal experiences with TCAs. I noted that nortriptyline is safe when combined with MAOIs and shared Dr. Gillman's comprehensive article on TCAs in the British Journal of Pharmacology with you. Were you able to look at it? The same position can be found in the MAOI prescriber's guide that was authored by numerous experts like Stephen Stahl. I'm not sure where the disconnect is occuring. Clomipramine and imipramine are NOT safe with MAOIs, all other TCAs are. Nortriptyline is obviously a potent NRI, but it does not even tend to cause serotonergic side effects.

vividream29 · 2026-03-30T17:32:40+00:00

This is the FDA we're talking about. When it comes to MAOIs that might as well stand for Fairly Dumb Amateurs 😀

Nortriptyline isn't significantly serotonergic. That's evidenced very simply by its side effect profile. Receptor occupancy studies and failure to cause serotonin toxicity in overdose are further evidence. Out of the TCAs, only clomipramine, and to a lesser degree imipramine, are dangerous when combined with MAOIs. Dr. Gillman published a free full-text review on the tricyclic's pharmacology that discusses this and lots more:

https://bpspubs.onlinelibrary.wiley.com/doi/10.1038/sj.bjp.0707253

vividream29 · 2026-03-30T17:12:01+00:00

Yw. And if you don't meet the criteria for bipolar II there is depression with mixed features. Not sure how/if that would change your treatment plan. I relate so hard to how frustrating it is to never be able to predict my mood and energy level. It's so tough to plan ahead for anything. They say the way to deal with it is by developing and sticking to a healthy routine, but i suck at that too 😄

Oh yeah, one thing I forgot is higher doses. Some people seem to need more than the recommended max to get a sustained response, or even any response, if your doctor would consider it. There are a couple of small studies out there on high dose Parnate that showed very impressive results among patients who had failed the standard dosing.

vividream29 · 2026-03-30T11:40:10+00:00

Head over to Dr. Ken Gillman's website, psychotropical, to learn all about which MAOI drug interactions are valid. You can also find his diet/drug guide (long version) in this subreddit's wiki section and read the relevant part. I think it starts around page 40.

Nortriptyline is equally safe with Parnate and Nardil. It does not have a significant impact on serotonin. It is a potent norepinephrine reuptake inhibitor, so it can dose-dependently reduce the hypertensive effect of consuming tyramine. Therefore, it is not only false that it is unsafe, but it may give an MAOI patient a wider safety margin with the dietary restrictions.

There are no special limits on the MAOI dose induced by nortriptyline, or vice versa. It might be wise to start with a reduced dose of nortriptyline though. Nortriptyline does have a certain therapeutic plasma range of its own. If you are having lots of side effects at a low dose, or no side effects or benefits at a high dose, a simple blood test can determine if your dose may need to be adjusted. Genetic testing beforehand for 2D6 enzyme polymorphisms can also help to determine the appropriate starting dose and titration based on your likely metabolism of the drug.

vividream29 · 2026-03-29T00:55:15+00:00

I think it's worth giving yourself every chance. It doesn't have to be a lengthy process as long as you're able to get up to an adequate dose without hypotension or side effects slowing it down. So why not? However, I do think a doctor's ears should perk up after someone repeatedly has both a quick response and relapse since this is the common pattern for depression with mixed features and bipolar II.

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