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    Depression (PDQ®): Supportive care - Health Professional Information [NCI] - Intervention

    Table 2. Antidepressant Medications for Ambulatory Adult Patients continued...

    Benzodiazepines

    Benzodiazepines can be used to effectively treat the anxiety that may be associated with depression. In patients receiving antidepressant medications and benzodiazepines concomitantly, the latter drugs may be discontinued after patients' depressive symptoms begin to abate; however, both agents can be continued safely if needed. Benzodiazepines should never be stopped abruptly because withdrawal symptoms with possible seizures may occur. The dose of benzodiazepines should be tapered slowly at a rate of approximately 25% every 3 to 4 days.

    Psychostimulants

    Clinical experience (see Table 3) suggests that analeptic agents (e.g., methylphenidate and dextroamphetamine) are useful at low doses for patients whose symptoms include depressed mood, apathy, decreased energy, poor concentration, and weakness.[36][Level of evidence: II] They are particularly useful for patients with advanced cancer who have a limited life expectancy (weeks to a few months). Compared with traditional antidepressants such as the TCAs and SSRIs that take 3 to 4 weeks to take effect, the psychostimulants often demonstrate antidepressant effects within a few days of starting treatment. They promote a sense of well-being, decreased fatigue, and increased appetite. Analeptic agents can be helpful in countering the sedating effects of opioids, and in comparison with antidepressants, they are rapidly effective. Adverse effects associated with analeptic agents include insomnia, euphoria, and mood lability. High doses and long-term use may produce anorexia, nightmares, insomnia, euphoria, or paranoia.

    Methylphenidate and dextroamphetamine are administered in divided doses early in a patient's waking cycle to avoid sleep disturbances (e.g., insomnia and nighttime arousal). Like benzodiazepines, these medications are adjuncts to antidepressant medications; they may be started concomitant with an antidepressant and discontinued when depressive symptoms abate.[37,38]

    Table 3. Clinical Trials of Psychostimulants in Cancer Patients

    Study Comments Drug(s) Outcome
    Meyers et al. 1998[39] Brain tumor; N = 30 methylphenidate (Ritalin) ↑ mood, ↑ cognition, ↑ function
    Olin and Masand 1996[40] Mixed cancer; N = 59; chart review dextroamphetamine (Dexedrine); methylphenidate (Ritalin) ↓ depression, ↑ appetite
    Bruera et al. 1992[41] Cancer pain vs. opioid infusion; N = 20 methylphenidate (Ritalin); placebo ↑ cognition, ↓ sedation
    Fernandez et al. 1987[38] Mixed cancer; rapid onset; N = 30 methylphenidate (Ritalin; up to 80 mg) ↓ depression
    Bruera et al. 1986[42] Pain; double-blind cross-over study; N = 24 mazindol (Mazanor) ↓ pain, ↓ appetite, no effect on mood
    Joshi et al. 1982[43] Terminally ill amphetamine ↑ comfort
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