I concur with Dr. Feinberg’s much appreciated commentsReference Feinberg ¹ that cause me to wonder if I emphasized sufficiently the need to interpret the Editorial in the context of my monograph.Reference Gillman ² It is a viewpoint that only touches on selected aspects of this extensive subject. Although the monograph has not been published as a peer-reviewed article in a journal, it is a detailed, comprehensively referenced, recent analysis of dietary tyramine and drug interactions (bringing together other published work) and has been reviewed by several relevant experts (see the Acknowledgments), and is also linked as a seminal source by Dr. Stahl on the NEI Web site.

The monograph makes the points mentioned by Feinberg, especially that of the variation among subjects in sensitivity to the tyramine (Tyr) pressor response, which is just as variable as most biological processes. Perhaps it is in cases of greater Tyr sensitivity where the protective effect of NRIs may be especially useful? The pharmacology of that beneficial interaction is discussed in detail in the monograph. And I, likewise, emphasize the importance of “freshness” and checking domestic refrigerator temperatures. A further simple, but neglected, point is the routine measurement of sitting and standing BP at every consultation (the degree of postural hypotension is a guide to rapidity and extent of dose escalation): this is so helpful that I long ago prepared an explanatory PDF, including a BP graph, that can be downloaded from the MAOI section of my “Psychotropical” web site.Reference Gillman ²

These simple points are what clinicians are required to understand if they are to advise and guide patients: those who study the monograph will be empowered to do that.

I hope earnestly that Sue Trupin’s poignant personal experience, shared with us, will be a resonant remembrance that will inspire doctors to be less therapeutically timorous (after all, guidelines are not the last word in perspicacious pharmacology): I have often seen similar good responses from tranylcypromine (without the assistance of neuroleptics), after failure of ECT, in both “melancholic” and “psychotic” depression. And yet, how few would even consider that strategy? I have not met a patient who would choose ECT over tranylcypromine, but have met many, like Sue, who are angry that the option was not offered sooner (or at all). So, step up to the plate and hit a home run.