Palliative Care Perspectives : Chapter 7: Psychosocial and Spiritual Aspects of Care : Pharmacologic Treatment of Depression

For several reasons, the pharmacologic treatment of depression in dying patients is particularly challenging:⁷

• Patients may be unable to swallow or retain medications due to dysphagia, nausea, and emesis.
  
  
• Patients may have less ability to cope with adverse side effects of medications due to their illness. Dry mouth, for example, is common in dying patients and is exacerbated by antidepressants with anticholinergic properties.
  
  
• Treatment of depression in dying patients is often a race against time. At the time of evaluation patients may have a life expectancy of days to weeks. The latency period of antidepressants, the time it takes for them to "kick in," may consume a significant portion of the patient's remaining life.

Depressed patients often need multimodal therapy that combines psychosocial interventions with pharmacotherapy.

Pharmacotherapy

Drug therapy should be tailored to the individual patient's situation. Relevant questions to ask in comparing medications include:^8,9

1. How long is the patient likely to live?
2. What side effects do you wish to avoid?
3. What side effects might enhance the patient's quality of life?

Psychostimulants

Psychostimulants such as methylphenidate and dextroamphetamine may be helpful when a rapid response (within 24 to 48 hours) is desired. They work best in patients with psychomotor retardation and should be avoided in agitated or confused patients. Positive side effects may include increased energy and appetite and counteraction of opioid-induced sedation. Psychostimulants may be continued indefinitely alone or with a selective serotonin reuptake inhibitor, and should be tapered off when they are being discontinued. Adverse effects include tremulousness, anxiety, and insomnia, although these are rarely seen with lower doses in most patients.¹⁰

Tricyclic antidepressants (TCAs).

TCAs can serve a dual purpose as antidepressants and as analgesics in the treatment of neuropathic pain. Because of their anticholinergic properties they must be used with caution in the elderly. TCAs have a delayed onset of action for depression (two to four weeks) and have extensive drug-drug interactions. Of the TCAs, nortriptyline and desipramine have fewer anticholinergic effects than does amitriptyline, and renal clearance is less variable with age.¹¹ Notably, the antidepressant and analgesic effects of TCAs are not related their anticholinergic side effects. Therefore, unless anticholinergic side effects are explicitly desired (which is rare), TCAs with fewer anticholinergic side effects are generally preferred.

Selective serotonin reuptake inhibitors (SSRIs).

The SSRIs have now become the first line of treatment for depression because of their safety profile, once-daily dosing schedule, and more rapid onset of action compared to TCAs (10 days to 2 weeks). In patients who are moderately to severely depressed, an SSRI may be given concomitantly with a psychostimulant, and the psychostimulant can be tapered off after one to two weeks if affect has improved.

Atypical antidepressants.

A variety of "atypical" antidepressants are on the market. Here I discuss just one, trazodone. Its sedative properties are advantageous in treating depressed patients with insomnia. It is commonly used as a sleeping pill by geriatricians and appears to be especially useful in confused or demented patients with a tendency toward nocturnal confusion (sundowning). This drug is well tolerated by the elderly. Priapism is very rarely a concern in these patients.

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Palliative Care Perspectives James L. Hallenbeck, M.D. Order hardback from Amazon.com Order paperback from Amazon.com Copyright © 2003 by Oxford University Press, Inc. The online version of this book is used with permission of the publisher and author on web sites affiliated with the Inter-Institutional Collaborating Network on End-of-life Care (IICN), sponsored by Growth House, Inc.