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
SIO/ASCO
- 2023: Carlson et al. Integrative Oncology Care of Symptoms of Anxiety and Depression in Adults With Cancer: Society for Integrative Oncology-ASCO Guideline PubMed
Medications
| 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.