Intervention
continued...
Table 5 and Table 6 highlight tips that may be useful in determining what medication is best to use for a particular patient. The tables focus on the effects these medications may have beyond their antidepressant effects that may decrease or increase patient distress, such as fatigue, insomnia, and nausea and vomiting.
Table 5. Physical Symptom- and Distress-Driven Approach to Choosing an Antidepressanta in Adult Cancer Patients
SSRI = selective serotonin reuptake inhibitor; TCA = tricyclic antidepressant; + = use of this medication could relieve the symptom; - = use of this medication could worsen the symptom.
a In general, doses should start low and increase slowly. This list does not indicate absolute indications or contraindications for particular medications. A current Physicians' Desk Reference or another reliable drug information resource and experience should guide clinical decision making.
b Although all SSRIs have the potential paradoxical side effect of hypersomnia, fluoxetine is particularly activating. Bupropion is also somewhat activating.
c Sedating antidepressants are useful for insomnia, either alone or in addition to another antidepressant. Trazodone and mirtazapine are often used as sleep aids in combination with another antidepressant.
d Some antidepressants are useful in treating neuropathic pain. The most studied of these are the TCAs, particularly amitriptyline.
e Sedating antidepressants are most useful for anxious/agitated patients. These include the TCAs, trazodone, mirtazapine, and nefazodone.
| Distressing Symptom |
SSRI |
TCA |
Psychostimulants |
Other |
| Fatigue |
+b |
� |
+ |
+b |
| Insomniac |
� |
+ |
� |
+c |
| Neuropathic paind |
+ |
+ |
� |
� |
| Opioid side effects |
+ |
� |
+ |
� |
| Constipation |
+ |
� |
+ |
� |
| Loss of appetite (weight loss) |
� |
+ |
+ |
� |
| Anxiety |
+ |
+ |
� |
+e |
| Dry mouth/stomatitis |
+ |
- |
+ |
� |
Table 6. Factors to Consider in Choosing an Antidepressant For Adult Cancer Patients
SSRI = selective serotonin reuptake inhibitor; TCA = tricyclic antidepressant; + = use of this medication could relieve the symptom; - = use of this medication may be a less appropriate choice.
a In general, TCAs and psychostimulants can cause and exacerbate cardiac arrhythmia. SSRIs, bupropion, venlafaxine, and nefazodone are generally less likely to cause cardiac problems. EKGs should be obtained before starting TCA medication, and a cardiologist should be consulted if there is concern for cardiac compromise.
b The shorter-acting SSRIs (sertraline and paroxetine) are less problematic than fluoxetine in patients with hepatic dysfunction. There is less potential for adverse drug interactions and fewer problems related to drug accumulation due to a shorter half-life. Sertraline and nefazodone reportedly have less effect on hepatic P450 enzyme activity.
c Clinicians should consider whether antidepressant doses and administration schedules require modification for their patients with renal or hepatic insufficiency.
d The TCAs are contraindicated in closed-angle glaucoma.
| Comorbid Medical Conditions |
SSRI |
TCA |
Psychostimulants |
Other |
| Cardiac history |
+ |
- |
� |
+a |
| Hepatic dysfunction |
+b |
+ |
- |
� |
| Renal dysfunctionc |
� |
� |
� |
� |
| Glaucoma |
+ |
-d |
� |
� |
| Neuropathic pain |
+ |
+ |
� |
� |
It should be noted that electroconvulsive therapy (ECT) is a useful and safe therapy when other interventions have not succeeded in relieving the depressive syndrome that may represent a life-threatening complication of treatable cancer.[60,61] Experience is limited, however, in using ECT in patients receiving mirtazapine and trazodone, and there are no clinical studies establishing the use of ECT in patients receiving SSRIs. Prolonged seizures have occurred rarely in patients receiving fluoxetine.
