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 EuroPMC
**2014: Andersen et al. Screening, assessment, and care of anxiety and depressive symptoms in adults with cancer: an American Society of Clinical Oncology guideline adaptation EuroPMC
==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 EuroPMC
=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.
Category:Supportive oncology