Protocol for Management of Depressive Disorders in Cancer Patients
Protocol for Management of Depressive Disorders in Cancer Patients
Diagnostic interview & instruments to identify the disorder & to identify key symptoms; include interview with family/caregivers, careful sleep assessment
• Major depression
• Dysthymia
• Subsyndromal Depressive Disorder
• Bipolar Affective Disorder, Depressed Phase
• Presence of psychosis
• Presence of agitation
• Presence of initial or middle insomnia
• Presence of psychomotor retardation
• Presence of hypersomnia or staying in bed in the morning
• Presence of suicidality
• Presence of self-neglect
• Presence of homicidality
If the patient is suicidal, homicidal, severely agitated, psychotic, or neglecting self, then hospitalize; commitment if dangerous to self or others
Most depressed patients can be started on paroxetine, starting at 10 mg in the morning, taken with food. Increase to 20 mg per day after one week. If severe side effects at 10 mg, decrease to 5 mg, increase to 10 mg after one week.
Reassess paxil after 3 weeks: increase dose of paxil by 10 mg in the morning if poor response and side effects are low or tolerable.
Split dose (eg 30 mg am and 10 mg pm at supper) for daily doses above 30 mg.
After an adequate trial of paxil (typically 6 to 8 weeks at 40 or 50 mg daily), consider augmentation therapy such as adding desipramine 25 mg, lithium, triiodothyroxine, or pindolol. Alternatively, switch to another antidepressant.
For psychosis or agitation, add olanzapine starting at 2.5 mg qhs; increase to 5 mg qhs after 1 week (sooner for inpatients).
For initial or middle insomnia, trazodone 25 or 50 mg qhs.
For hypersomnia, staying in bed in the morning, complaints of fatigue or lack of energy, or psychomotor retardation, add methylphenidate starting at 5mg twice daily (at 6 am and at noon). Increase in increments of 5 mg per day at intervals of 1 week, depending on response.
For elderly or frail patients: use lower doses, possibly only half of usual adult dose.
For cancer patients experiencing nausea or anorexia from their illness or from chemotherapy, tricyclic antidepressants (eg desipramine) may be better tolerated than SSRIs which can cause nausea. A usual starting dose is 25 mg tid.
For bipolar patients, if there is a risk of an antidepressant-induced switch into mania, use low doses of antidepressants, monitor very closely for symptoms of mania, consider starting a mood stabilizer prior to or along with the antidepressant.
For all patients with insomnia: spend less time in bed (eg not more than 7 hours per day for adults, 6 hours for elderly); daytime naps not to exceed 15 minutes each.
For patients with hypersomnia or those who stay in bed (or go back to bed) after 7 am: instructions to get up out of bed by 6:30 am, whether they have slept or not.
For all patients: 30 minutes of cardiovascular exercise, 3 times per week (running or fast walking, swimming, cycling, cross-country skiing, aerobics, aerobic dance, aquafitness, rollerblading, etc.)
Henry Olders, MD, FRCPC
1 October, 1998