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Mood Disorders in Cancer
Aka: Mood Disorders in Cancer, Depression in Cancer, Anxiety in Cancer, Mood Disorders in Terminally Ill Patients, Cancer Related Mood Disorders, End-of-Life Depression
- See Also
- Delirium in Cancer
- Preparatory Grief
- End-Of-Life Care
- Discussing Terminal Illness
- Cancer Symptom
- Breaking Bad News
- Preparatory Grief
- Grief
- Epidemiology
- Incidence at end of life: 25-77%
- Risk Factors
- Cancer Pain or other unrelieved Cancer Symptoms
- Progressive physical Impairment
- Advanced disease
- Medications
- Corticosteroids
- Benzodiazepines
- Previous psychiatric illness
- Major Depression
- Substance Abuse
- Specific conditions
- Pancreatic Cancer
- Cerebrovascular Accident
- Evaluation
- See Major Depression
- Evaluate for Suicidal Ideation
- Depression is not inevitable at the end of life
- Patients should be able to enjoy their remaining days
- Differential Diagnosis
- Preparatory Grief
- Management: General Measures
- See Major Depression
- See Anxiety
- Psychotherapy: "Be there, be sensitive, be silent"
- Employ adjunctive and alternative measures
- Massage
- Music
- Relaxation Techniques
- Cancer Pain components
- Biological
- Psychological
- Social
- Spiritual
- Address cancer specific fears
- Fear of abandonment by "over-burdened" caretakers
- Anticipation of painful death
- Fear for family well-being after they die
- Fear of spiritual afterlife
- Management: Stimulants
- Indications
- Preferred agents in patients with short remaining anticipated Life Expectancy (less than weeks)
- General
- Advantages
- Onset of Antidepressant effect in days
- Decreases Opioid related sedation
- Improves appetite and energy
- Contraindications
- Agitation
- Delirium
- Confusion
- Precautions: May worsen certain conditions
- Anxiety
- Dyspnea
- Tremulousness
- Insomnia
- Agents
- Dexedrine (Dextroamphetamine)
- Methylphenidate (Ritalin)
- Start: 5 mg PO qAM and qNoon
- Increase: Every 3 days up to usual total dose of 10-20 mg/day (maximum: 30 mg PO bid)
- Management: Antidepressants
- Consider starting concurrently with stimulant (see above)
- Selective Serotonin Reuptake Inhibitor (SSRI)
- Sertraline (Zoloft)
- Citalopram (Celexa)
- Risk of QT Prolongation at higher doses (20 mg is max recommended dose in elderly)
- Escitalopram (Lexapro)
- Fluoxetine (Prozac)
- Drug Interactions: CYP2D6 Inhibitor
- Paroxetine (Paxil)
- Drug Interactions: CYP2D6 Inhibitor
- Tricyclic Antidepressants and SNRI (Second line due to Anticholinergic effects; consider in painful Neuropathy)
- Amitriptyline
- Other Tricyclics and SNRIs are associated with less Anticholinergic effects
- Nortriptyline (Pamelor)
- Desipramine (Norpramin)
- Duloxetine (Cymbalta)
- Other Antidepressants
- Mirtazapine (Remeron)
- May assist sleep due to sedation
- May increase appetite and reduce Nausea
- Bupropion (Wellbutrin)
- Lowers Seizure threshold
- Risk of Insomnia
- References
- (2001) JAMA 285(22):2898 [PubMed]
- Periyakoil (2002) Am Fam Physician 65(5):883-98 [PubMed]
- Widera (2012) Am Fam Physician 86(3): 259-64 [PubMed]