Antidepressants and other psychiatric medications in cancer care

Guidelines

Given the rapid change in evidence in many areas of hematology/oncology, readers are encouraged to consider any guideline published 5+ years ago to be for historical purposes, only.

ASCO

• 2023: Andersen et al. Management of Anxiety and Depression in Adult Survivors of Cancer: ASCO Guideline Update PubMed

Medication	Class	Indication	Starting dose	Target dose	Half-life	Interactions	Side effects
Citalopram (Celexa)	SSRI	Anxiety Depression	10 mg	20-40 mg	35 hours	Mild 2D6 inhibition Platelet dysfunction QTc prolongation	Nausea fatigue
Escitalopram (Lexapro)	SSRI	Anxiety Depression	5 mg	10-20 mg	27-32 hours; 50% greater in elderly patients	Mild 2D6 inhibition Platelet dysfunction	Nausea fatigue
Fluoxetine (Prozac)	SSRI	Anxiety Depression	10 mg	20-60 mg	4-6 days (fluoxetine); 9.3 days (norfluoxetine)	CYP450 2D6 inhibition Very long half-life and multiple drug interactions	Nausea Sedation
Sertraline (Zoloft)	SSRI	Anxiety Depression	50 mg	150-200 mg	26 hours	Weak 2D6 inhibition Inhibits platelet function	Nausea
Venlafaxine (Effexor XR)	SNRI	Anxiety Depression	37.5 mg	150 mg	5 hours (parent drug); 11 hours (active metabolite)	2D6 inhibition Reduces platelet function	Hypertension Nausea Flu-like withdrawal
Bupropion (Wellbutrin)	Other antidepressant	Activating Depression	SR: 50-75 mg XR: 150 mg	150-300 mg	21 hours	Strong 2D6 inhibition	Seizure risk (Black box) Anxiety
Mirtazapine (Remeron)	Other antidepressant	Anxiety Depression Insomnia	7.5 mg	30-40 mg	20-40 hours	Neutropenia reported 2D6 substrate	Weight gain Sedation
Trazodone (Desyrel)	Other antidepressant	Anxiety Insomnia	25-50 mg	50-100 mg	3-6 hours (first phase); 5-9 hours (second phase)	3A4 substrate	Sedation Nausea
Desipramine (Norpramin)	Tricyclic	Anxiety Depression Insomnia Boost pain control	10-25 mg	Check blood levels and EKG	12-27 hours	Strong 2D6 inhibition Rare agranulocytosis	Anticholinergic symptoms
Imipramine (Tofranil)	Tricyclic	Anxiety Depression Insomnia Boost pain control	10-25 mg	Check blood levels and EKG	11-25 hours	Strong 2D6 inhibition Rare agranulocytosis	Anticholinergic symptoms
Nortriptyline (Pamelor)	Tricyclic	Anxiety Depression Insomnia Boost pain control	10-25 mg	Check blood levels and EKG	18-44 hours	Strong 2D6 inhibition Rare agranulocytosis	Anticholinergic symptoms
Gabepentin (Neurontin)	Anti-seizure	Anxiety Insomnia Pain control	100 mg	Large range from 300-3600 mg	5-7 hours	Renal excreted (i.e. not metabolized)	Sedation
Lamotrigine (Lamictal)	Anti-seizure	Elevates mood	25 mg	200 mg (for psych)	14 hours with enzyme-inducing anticonvulsants (EIA); 59 hours with valproic acid (VPA); 28 hours with EIA & VPA	No weight gain Other anti-seizure medications can double blood levels of lamotrigine	Stevens-Johnson with any change in dose (Black box)
Aripiprazole (Abilify)	Antipsychotic	Agitation Anxiety	5 mg	15-20 mg	75 hours (CYP2D6 extensive metabolizers); 146 hours CYP2D6 poor metabolizers)	QTc prolongation may be less than other atypicals No CYP450 inhibition Rare agranulocytosis	Less weight gain Extrapyramidal symptoms including akathisia and risk of tardive dyskinesia when mixed with prochlorperazine (Compazine) or metoclopramide (Reglan)
Olanzapine (Zyprexa)	Antipsychotic	Agitation Anxiety Insomnia	2.5-5 mg	10 mg	21-54 hours	QTc prolongation	Sedation Weight gain
Quetiapine (Seroquel)	Antipsychotic	Agitation Anxiety Insomnia Nausea	25-50 mg	100-300 mg	6-7 hours	3A4 substrate, limited drug/drug interactions QTc prolongation	Sedation Weight gain
Zolpidem (Ambien)	Insomnia	Insomnia	5 mg	5-10 mg	2.5-3.1 hours	Alcohol interaction Hepatic metabolism	Sedation Dizziness Parasomnias

Information adapted from a table created by Christine Wittmann, MD and Laurie Rosenblatt, MD. Used with permission.