II. Epidemiology

  1. Incidence at end of life: 25-77%

III. 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

IV. 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

V. Differential Diagnosis

VI. 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

VII. 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)

VIII. 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

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