For several reasons, the pharmacologic treatment of depression in dying patients is particularly challenging:7
Depressed patients often need multimodal therapy that combines psychosocial interventions with pharmacotherapy.
Drug therapy should be tailored to the individual patient's situation. Relevant questions to ask in comparing medications include:8,9
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
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.
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.
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.
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.