Mood Disorders in Cancer

1. See Also
   1. Delirium in Cancer
   2. Preparatory Grief
   3. End-Of-Life Care
   4. Discussing Terminal Illness
   5. Cancer Symptom
   6. Breaking Bad News
   7. Preparatory Grief
   8. Grief
2. Epidemiology
   1. Incidence at end of life: 25-77%
3. Risk Factors
   1. Cancer Pain or other unrelieved Cancer Symptoms
   2. Progressive physical Impairment
   3. Advanced disease
   4. Medications
      1. Corticosteroids
      2. Benzodiazepines
   5. Previous psychiatric illness
      1. Major Depression
      2. Substance Abuse
   6. Specific conditions
      1. Pancreatic Cancer
      2. Cerebrovascular Accident
4. Evaluation
   1. See Major Depression
   2. Evaluate for Suicidal Ideation
   3. Depression is not inevitable at the end of life
      1. Patients should be able to enjoy their remaining days
5. Differential Diagnosis
   1. Preparatory Grief
6. Management: General Measures
   1. See Major Depression
   2. See Anxiety
   3. Psychotherapy: "Be there, be sensitive, be silent"
   4. Employ adjunctive and alternative measures
      1. Massage
      2. Music
      3. Relaxation Techniques
   5. Cancer Pain components
      1. Biological
      2. Psychological
      3. Social
      4. Spiritual
   6. Address cancer specific fears
      1. Fear of abandonment by "over-burdened" caretakers
      2. Anticipation of painful death
      3. Fear for family well-being after they die
      4. Fear of spiritual afterlife
7. Management: Stimulants
   1. Indications
      1. Preferred agents in patients with short remaining anticipated Life Expectancy (less than weeks)
   2. General
      1. Advantages
         1. Onset of Antidepressant effect in days
         2. Decreases Opioid related Sedation
         3. Improves appetite and energy
      2. Contraindications
         1. Agitation
         2. Delirium
         3. Confusion
      3. Precautions: May worsen certain conditions
         1. Anxiety
         2. Dyspnea
         3. Tremulousness
         4. Insomnia
   3. Agents
      1. Dexedrine (Dextroamphetamine)
      2. Methylphenidate (Ritalin)
         1. Start: 5 mg PO qAM and qNoon
         2. Increase: Every 3 days up to usual total dose of 10-20 mg/day (maximum: 30 mg PO bid)
8. Management: Antidepressants
   1. Consider starting concurrently with stimulant (see above)
   2. Selective Serotonin Reuptake Inhibitor (SSRI)
      1. Sertraline (Zoloft)
      2. Citalopram (Celexa)
         1. Risk of QT Prolongation at higher doses (20 mg is max recommended dose in elderly)
      3. Escitalopram (Lexapro)
      4. Fluoxetine (Prozac)
         1. Drug Interactions: CYP2D6 Inhibitor
      5. Paroxetine (Paxil)
         1. Drug Interactions: CYP2D6 Inhibitor
   3. Tricyclic Antidepressants and SNRI (Second line due to Anticholinergic effects; consider in painful Neuropathy)
      1. Amitriptyline
         1. Other Tricyclics and SNRIs are associated with less Anticholinergic effects
      2. Nortriptyline (Pamelor)
      3. Desipramine (Norpramin)
      4. Duloxetine (Cymbalta)
   4. Other Antidepressants
      1. Mirtazapine (Remeron)
         1. May assist sleep due to Sedation
         2. May increase appetite and reduce Nausea
      2. Bupropion (Wellbutrin)
         1. Lowers Seizure threshold
         2. Risk of Insomnia
9. References
   1. (2001) JAMA 285(22):2898 [PubMed]
   2. Periyakoil (2002) Am Fam Physician 65(5):883-98 [PubMed]
   3. Widera (2012) Am Fam Physician 86(3): 259-64 [PubMed]