Patient condition
Suggested antidepressant drug of choice
Depression with anxiety or agitation
Paroxetine (Paxil®)
Depression with lethargy and amotivation
Fluoxetine (Prozac®), buproprion (Wellbutrin®), or venlafaxine (Effexor®)
Preexisting cardiac disease
Congestive heart failure/coronary artery disease
SSRI, buproprion (Wellbutrin®)
Heart block
SSRI, buproprion (Wellbutrin®)
Hypertension
SSRI
Hypotension
Venlafaxine (Effexor®), desipramine (Norpramin®), nortriptyline (Pamelor®), SSRI, buproprion (Wellbutrin®)
Neurologic disease
Parkinsonism
Buproprion (Wellbutrin®)
Cerebrovascular accident (stroke)
SSRI
Migraine headaches
Desipramine (Norpramin®), nortriptyline (Pamelor®)
Miscellaneous
Prostatism
Buproprion (Wellbutrin®), SSRI (excluding paroxetine (Paxil®))
Irritable bowel syndrome
Desipramine (Norpramin®)
Diabetes
SSRI
HIV
Mirtazepine (Remeron®)
Thrombocytopenia or leukopenia
Citalopram (Celexa®), escitalopram (Lexapro®)
3.
A general treatment approach is to begin at a lower dose and to dose escalate every 3–7 days based upon the agent utilized.
a.
Geriatric patients and HSCT patients with complicated medical histories should begin at 50 % dose with slower increases.
b.
SSRIs should be initiated at therapeutic doses for most patients.
4.
It may take up to 3–4 weeks before symptoms begin to improve.
a.
Patients with psychomotor retardation and neurovegetative symptoms such as anorexia, profound fatigue, and excess sleep may respond earlier.
b.
Partial response may indicate a need for dose escalation while no response suggests the need to change medications.
c.
Efficacy can be equivalent across agents, but the need for multiple drug trials is justified as approximately 50 % of patients fail to respond to the first agent.
i.
When one chooses to exchange antidepressant agents , the washout period depends on the actual drug and its half-life as well as patient comorbidities.
ii.
1–2-week washout is recommended for most agents, particularly with monoamine oxidase (MAO) inhibitors and up to 5 weeks for fluoxetine.
iii.
This can be managed with a lower dose of the new agent as the prior agent is cleared from the patient if it is felt clinically necessary to treat a patient more aggressively.
5.
When responses are identified, drug administration should be maintained for a minimum of 6 months prior to initiating a slow taper.
a.
Most people require between 7 and 12 months of therapy for first depressive episode.
b.
For patients with recurrent or chronic depression, a minimum of a 12-month treatment course should be considered, as 50–80 % of patients will relapse without maintenance therapy .
6.
For most patients, tapering is needed if they have been on any drug for over 2 months.
a.
Nearly one third of patients will have withdrawal symptom with abrupt cessation of the agent, including somatic complaints of flu-like symptoms, gastrointestinal distress, arrhythmias, and sensory and sleep disturbances.
b.
Psychiatric manifestations include anxiety, agitation, mania, panic attacks, irritability, labile emotions with excess crying, and possibly delirium.
c.
Risk factors for the development of abstinence symptoms include
i.
SSRIs with short half-life (e.g., paroxetine, fluvoxamine)
ii.
Prolonged therapy
iii.
Presentation with anxiety
iv.
History of withdrawal.
d.
When seen, abstinence symptoms typically develop within 1–3 days after cessation with episodes lasting 7–14 days.
e.
If symptoms are significant, the agent can be reinstituted with a more gradual taper or changed to an agent with a longer half-life prior to tapering the antidepressant.
7.
Depression early in the post-HSCT period, which is often associated with hospitalization, may be hard to distinguish from the hypoactive/hypo-alert variant of delirium .
a.
Depression can be an acute situational response or can be chronic.
b.
SSRIs are often the first choice with the goal of utilizing a therapeutic dose from initiation of therapy (Table 29.2).
Table 29.2
Selected antidepressants and dosing (suggested starting at 50 % dose if elderly or debilitated)
Drug | Starting dose (daily) (mg) | Dosing range (daily) (mg) | Comments |
|---|---|---|---|
Selective serotonin reuptake inhibitors (SSRI) | |||
Citalopram (Celexa®) | 10–20 | 20–60 | QTc prolongation increased with doses > 40 mg/day with minimal increase in benefit |
Escitalopram (Lexapro®) | 10 | 10–20 | Doses above 20 mg may confer little additional benefit |
Fluoxetine (Prozac®) | 20 | 10–80 | More activating than other SSRI |
Paroxetine (Paxil®) | 20 | 20–50 | More anxiolytic than other SSRI but more delirium |
Sertraline (Zoloft®) | 50 | 50–200 | – |
Serotonin norepeinephrine reuptake inhibitors (SNRI) | |||
Duloxetine (Cymbalta®) | 40 | 60–120 | Dosed twice daily, best evidence for diminishing neuropathic pain as collateral benefit |
Venlafaxine (Effexor®) | 50–75 | 150–375 | May cause hypertension over 300 mg daily, many dosing forms |
Miscellaneous agents | |||
Buproprion (Wellbutrin®) | 100–200 | 300–450 | Many dosage forms, helps with tobacco addiction |
Desipramine (Norpramin®) | 50–75 | 150–300 | No longer agent of first use in any patient group |
Mirtazapine (Remeron®) | 15 | 15–45 | May diminish nausea and increase appetite |
Nortriptyline (Pamelor®) | 50–75 | 75–150 | No longer agent of first use in any patient group |
i.
If side effects are encountered, they are most often gastrointestinal or central nervous system and occur within the first 2 weeks.
The gastrointestinal side effects may be diminished by twice daily dosing within the first month.
ii.
Syndrome of inappropriate antidiuretic hormone (SIADH) has been seen but usually occurs late.
iii.
For patients with hepatic dysfunction or for the elderly, initiating therapy at the lowest dose available with slow titration upward is recommended.
8.
Psychomotor retardation or impairment involves a general slowdown of thought processes, emotional reactions, and physical movements .
a.
Manifests with speech abnormalities including changes in volume and intonation, fixed eye gaze or lack of eye contact, psychomotor slowing, slumped posture, and increased self-touching, particularly of the face.
b.
Considered to be a key aspect of major depressive disorder or the depressed phase of bipolar disorder.
c.
Can be associated with certain medications including benzodiazepines, cannabis, and antipsychotics , as well as calcineurin inhibitors, particularly in elderly patients.
d.
Initially thought to be strictly a psychiatric illness, it may be associated with physical conditions such as Parkinson’s disease.
e.
Recommendations for the treatment vary with inconsistent reports of efficacy in the literature for SSRIs , tricyclics, and monoamine oxidase inhibitors.
29.4 Sleep Disorders
Insomnia , or trouble sleeping, is a common problem for patients with cancer. Several recent studies have reported an incidence of 30–50 % in cancer patients compared to 15 % in the general population. In addition, symptoms of insomnia were found in 23–44 % of patients 2–5 years after treatment for cancer. Despite this prevalence, one study found that only 16 % of patients with insomnia informed their health care provider about the problem, and many practitioners failed to ask about sleep. This likely occurs for one of the several reasons: insomnia may be viewed as a normal response to the cancer diagnosis and treatment; insomnia may be viewed as a lesser priority than the cancer treatment; and practitioners may lack the knowledge to diagnose and treat this problem.
1.
Insomnia may present as difficulty falling asleep, multiple awakenings during the night, or early morning awakenings with the inability to get back to sleep. All of these can be heightened during the acute inpatient hospital stay and can contribute to development of delirium.
2.
Criteria for insomnia syndrome, as defined by the international classification of sleep disorders.
a.
Difficulty sleeping characterized by 30 min or more to fall asleep and/or more than 30 min of nighttime awakenings, with a ratio of total sleep time to time spent in bed of less than 85 %.
b.
The sleep disturbance must occur at least three nights per week and cause significant impairment of daytime functioning or marked distress .
3.
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Many patients may not fit these specific criteria but suffer from the symptoms of insomnia nonetheless .
a.
Insomnia can lead to fatigue, memory and concentration problems, mood disturbances, and psychiatric disorders.
b.
Studies have suggested that insomnia may play a role in physical symptoms, shorter lifespan, and immunosuppression.
c.
For these reasons, and to improve quality of life, patients should seek and be offered treatment for insomnia.
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