Use Of Anti-Depressants In Cancer Patients

Based on content from the NIH publication, “Treatment.”

Patients with cancer may be treated with a number of drugs throughout their care.

Some drugs do not mix safely with certain other drugs, foods, herbals and nutritional supplements.

Certain combinations may reduce or change how drugs work or cause life-threatening side effects.

It is important that the patient's health care providers be told about all the drugs, herbals and nutritional supplements the patient is taking, including drugs taken in patches on the skin. This can help prevent unwanted reactions.

Major depression may be treated with a combination of counseling and medications (drugs), like antidepressants. A primary care doctor may prescribe medications for depression and refer the patient to a psychiatrist or psychologist for the following reasons:

• A physician or oncologist is not comfortable treating the depression (for example, the patient has suicidal thoughts).
• The symptoms of depression do not improve after 2 to 4 weeks of treatment.
• The symptoms are getting worse.
• The side effects of the medication keep the patient from taking the dosage needed to control the depression.
• The symptoms are interfering with the patient's ability to continue medical treatment.

Antidepressants are usually effective in the treatment of depression and its symptoms. Unfortunately, antidepressants are not prescribed often for patients with cancer. About 25 percent of all patients are depressed, but only about 16 percent receive medication for the depression. The choice of antidepressant depends on the patient's symptoms, potential side effects of the antidepressant, and the person's individual medical problems and previous response to anti-depressant drugs.

The Food and Drug Administration has issued a warning that patients who are taking anti-depressants, like fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa), escitalopram (Lexapro), bupropion (Wellbutrin), venlafaxine (Effexor), nefazodone (Serzone), and mirtazapine (Remeron), should be closely monitored for signs of worsening depression and suicidal thoughts. A Patient Medication Guide (MedGuide) should also be given to patients receiving anti-depressants to warn them of the risk and suggest precautions that can be taken.

The FDA has also directed manufacturers of all antidepressant drugs to change the labeling for their products to include a boxed warning and more detailed warning statements about increased risk of suicidal thinking and behavior in children and adolescents being treated with anti-depressants. Some studies show that the benefits of proper anti-depressant use in children and adolescents, including careful monitoring for suicidal behavior, may outweigh the risks. However, for children younger than 12 years with major depression, only fluoxetine (Prozac) showed benefit compared to a placebo.

St. John's wort (Hypericum perforatum) is as an over-the-counter supplement that some compare with anti-depressants, placebo (inactive) drugs, or both, and has shown mixed results in treatment for depression. St. John's wort is not recommended as a treatment for depression due to its lack of strong effect, lack of standardization and possible interaction with other medications.

Most anti-depressants take three to six weeks to begin working. The side effects must be considered when deciding which anti-depressant to use. For example, a medication that causes sleepiness may be helpful in an anxious patient who is having problems sleeping, since the drug is both calming and sedating. Patients who cannot swallow pills may be able to take the medication as a liquid or as an injection. If the anti-depressant helps the symptoms, treatment should continue for at least six months. Electroconvulsive therapy (ECT) is a useful and safe therapy when other treatments have been unsuccessful in relieving major depression.

Treatment With Psychotherapy

Several psychiatric therapies have been found to be helpful in the treatment of depression related to cancer. Most therapy programs for depression are given in 4 to 30 hours and are offered in both individual and group settings. They may include sessions about cancer education or relaxation skills. These therapies are often used in combination and include crisis intervention, psychotherapy, and thought/behavior techniques. Patients explore methods of lowering distress, improving coping and problem-solving skills; enlisting support; reshaping negative and self-defeating thoughts; and developing a close personal bond with an understanding health care provider. Talking with a clergy member may also be helpful for some people.

Specific goals of these therapies include the following:

• Assist people who have a diagnosis of cancer and their families by answering questions about the illness and its treatment, explaining information, correcting misunderstandings, giving reassurance about the situation, and exploring with the patient how the diagnosis relates to previous experiences with cancer.
• Assist with problem solving, improve the patient's coping skills, and help the patient and family to develop additional coping skills. Explore other areas of stress, such as family role and lifestyle changes, and encourage family members to support and share concern with each other.
• Ensure that the patient and family understand that support will continue when the focus of treatment changes from trying to cure the cancer to relieving symptoms. The health care team will treat symptoms to help the patient control pain and remain comfortable, and will help the patient and his or her family members maintain dignity.

Cancer support groups may also be helpful in treating depression in patients with cancer, especially adolescents. Support groups have been shown to improve mood, encourage the development of coping skills, improve quality of life and improve immune response. Support groups can be found through the wellness community, the American Cancer Society, and many community resources, including the social work departments in medical centers and hospitals.

Recent studies of psychotherapy in patients with cancer, including training in problem solving, have shown that it helps decrease feelings of depression.

Current Clinical Trials

Check NCI’s list of cancer clinical trials for U.S. supportive and palliative care trials about depression that are now accepting participants. The list of trials can be further narrowed by location, drug, intervention, and other criteria.

By National Institutes of Health

The National Institutes of Health, a part of the U.S. Department of Health and Human Services, is the nation's medical research agency — making important discoveries that improve health and save lives. NIH is the largest single source of financing for medical research in the world, seeking new ways to cure disease, alleviate suffering and prevent illness. By providing the evidence base for health decisions by individuals and their clinicians, NIH is empowering Americans to embrace healthy living through informed decision-making. NIH is made up of 27 institutes and centers, each with a specific research agenda, focusing on stages of life, like aging or child health, or particular diseases or body systems.