Duloxetine for the treatment of mood disorder in cancer patients: a 12-week case-control clinical trial

Recent trends in the management of depression in persons with cancer

PURPOSE OF REVIEW

Depression is a prevalent comorbidity in cancer that significantly increases the risk for numerous negative health outcomes. This review updates the current evidence base for management of depression in cancer, highlighting new research directions based on the inflammatory hypothesis of depression.

RECENT FINDINGS

Research on pharmacotherapy and psychotherapy for depression in cancer has shown mixed efficacy partly because of methodological issues arising from the phenomenology of depression in cancer. After decades of stagnancy, more recent high-quality clinical trials are beginning to provide an evidence base to guide treatment. Inflammatory cytokine-associated depression is a subtype of depression that may have particular relevance in cancer, opening new avenues to explore therapeutic targets and biobehavioral impacts of interventions, which may improve cancer outcomes.

SUMMARY

The continuum of severity in cancer-related depression is important to consider in management approaches. Choice of treatment should be personalized to the patient and their symptom profile as there is currently insufficient evidence to recommend any particular medication or psychotherapy over another. Psychological interventions should be considered first line for mild-to-moderate depression, and pharmacological treatment added for more severe depression, which can be optimally delivered within a collaborative care model.

VIDEO ABSTRACT

http://links.lww.com/YCO/A62.

The Quality of Life of Patients with Suspected Lung Cancer before and after Bronchoscopy and the Effect of Mirtazapine on the Depressive Status

Objective Patients with suspected lung cancer often experience adverse side effects such as anxiety, depression, and a decreased appetite. These side effects influence the patients' quality of life and their ability to make decisions concerning appropriate treatment. This study examined the psychological status and quality of life of patients with suspected lung cancer before and after bronchoscopy treatment and evaluated the effect of mirtazapine prescribed to patients with depression. Methods To assess patient characteristics (e.g. age, gender, and medical history), a questionnaire including the Hospital Anxiety and Depression Scale - Japanese version and the Functional Assessment of Cancer Therapy-L was administered. Patients Forty-three patients admitted for bronchoscopy treatment between May 2017 and April 2018 were included. Results The results showed that patients with depression reported a worse quality of life than those without depression. Compared with no medication, the administration of mirtazapine alleviated depressive symptoms. Furthermore, the patients' depressive status was affected by their physical symptoms, including coughing, tightness of chest, and dyspnea. Conclusion Our results emphasize the importance of detecting depression in the early stages of a cancer diagnosis and have significant implications concerning pharmacological intervention in patients with cancer displaying signs of depression.

The effect of pregabalin and duloxetine treatment on quality of life of breast cancer patients with taxane-induced sensory neuropathy: A randomized clinical trial

Background:

The primary side effect of adjuvant chemotherapy with taxanes is the taxane-induced peripheral neuropathy (TIPN), which may have substantial negative impacts on patients’ quality of life (QOL). We investigated the effect of pregabalin and duloxetine on QOL of breast cancer patients who experienced TIPN.

Materials and Methods:

This was a randomized, double-blind clinical trial conducted at a chemotherapy center of Mazandaran University of Medical Sciences, Sari, Iran. Breast cancer patients 18 or more years old were included if they received paclitaxel or docetaxel and experienced neuropathy grade one or higher; and neuropathic pain score of four or more. Patients were treated with pregabalin or duloxetine until 6 weeks. Assessment of sensory neuropathy and QOL was performed at baseline, and 6 weeks after the initiation of the treatment.

Results:

At baseline, the mean score of global health status/QOL scale for pregabalin and duloxetine groups were 61 (standard deviation [SD]; 5.11) and 60.28 (SD; 5.44), respectively (P = 0.54). After 6 weeks, both interventions were associated with improvement of global QOL compared to baseline. The global health status/QOL score was not different between two groups after 6 weeks. While the emotional functioning was improved more favorably with duloxetine (P < 0.001); pregabalin was associated with more improvement in insomnia and pain scores (P = 0.05 and P < 0.001, respectively).

Conclusion:

Pregabalin as well as duloxetine improve the global QOL of breast cancer patients with TIPN. Different effects of treatments on subscale of QLQ-C30 could help clinicians to select the appropriate agent individually.

Comparison of the Anti-tumor Effects of Selective Serotonin Reuptake Inhibitors as Well as Serotonin and Norepinephrine Reuptake Inhibitors in Human Hepatocellular Carcinoma Cells

The anti-tumor effects of selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) on several types of cancer cells have been reported. However, comparison of the anti-tumor effects of these drugs on human hepatocellular carcinoma (HepG2) cells has not been studied. We compared the anti-tumor effects of four SSRIs and two SNRIs on HepG2 cells. SSRIs and duloxetine dose-dependently decreased cell viability. Milnacipran had no effect on cell viability. The half-maximal inhibitory concentration was lower in the order of: sertraline, paroxetine, duloxetine, fluvoxamine, escitalopram, and milnacipran. Exposure to sertraline (2 µM) significantly increased caspase-3/7 activity. These results suggest that, of the agents tested here, sertraline had the highest sensitivity to HepG2 cells, and activation of the caspase pathway is involved in the anti-tumor effects of sertraline in HepG2 cells.

Update on research-based interventions for anxiety in patients with cancer

Anxiety may begin at the moment a person is diagnosed with cancer and may fluctuate throughout the cancer trajectory as physical illness improves or declines. The purpose of this article is to present current evidence for nurses to implement interventions to reduce anxiety in patients who have cancer. The PubMed and CINAHL® databases were searched to identify relevant citations addressing interventions that treat or prevent anxiety symptoms in patients with cancer. Based on available evidence, the interventions addressed herein are categorized according to the Putting Evidence Into Practice (PEP®) rating schema. Interventions include pharmacologic and nonpharmacologic approaches to care, and meet criteria for three PEP categories: likely to be effective, effectiveness not established (the largest category of results), or effectiveness unlikely.

Putting evidence into practice: evidence-based interventions for depression

Depression is a distressing emotion that occurs during various times of the cancer trajectory. Depression often goes unrecognized and untreated, which can significantly affect cost, quality of life, and treatment adherence. The Oncology Nursing Society's Putting Evidence Into Practice depression project team reviewed current literature to identify evidence-based interventions to reduce depression in people with cancer. Pharmacologic and nonpharmacologic interventions were evaluated, and opportunities for nurses to integrate recommendations into practice are offered in this article.

Mental adjustment to cancer: the role of anxious and depressive symptoms under treatment

OBJECTIVE

Depression is a risk factor for poor quality of life and mental adjustment to cancer. This research aims to evaluate the course of mental adjustment to illness of cancer patients with anxious-depressive symptoms who receive antidepressant therapy (ADT).

METHOD

Eighty oncological patients with and without depressive symptoms were divided into three groups. Group 1: 30 depressed cancer patients who underwent ADT with SSRI; Group 2: 30 depressed cancer patients who refused ADT; Group 3: 20 non-depressed cancer patients. Patients were evaluated at tO and 4 (tl) and 12 (t2) weeks later through: Hamilton Depression Rating Scale (HDRS), Hamilton Anxiety Rating Scale (HARS), Hospital Anxiety Depression Scale (HADS), and MINI-MAC.

RESULTS

HDRS and HARS mean scores were stable and under threshold across the study only in Group 3; at t2 they improved in Group 1 and worsened in Group 2. The improvements in anxiety and depression scores were associated with ADT and related to the changes in Mini-MAC helpless-hopeless, anxious preoccupations, cognitive avoidance and fighting spirit dimensions.

CONCLUSION

The improvement of mental adjustment to illness is directly related to the decrease of anxious-depressive symptoms among depressed cancer patients under antidepressant therapy.

Treatment of depressive symptoms in patients with cancer

Depression is the most common psychological condition in patients with cancer. These patients often have worse outcomes, such as decreased adherence to treatment and increased suicide rates. Since depression is common and often under recognized in this patient population, guidelines recommend screening every patient with cancer for depression. Both psychotherapy and pharmacotherapy are shown to be effective to treat depression in patients with cancer. Psychotherapy, specifically cognitive behavioral therapy, is preferred in patients with more mild depressive symptoms, while pharmacotherapy is used for more severe depression. Dignity therapy and supportive-expressive therapy are also recommended for patients near the end of life. Pharmacotherapeutic options for treatment include antidepressants and psychostimulants. Guidelines recommend SSRIs, SNRIs, or mirtazapine as first line treatment, with TCAs often avoided due to side effects. Psychostimulants, such as modafinil and methylphenidate, can be used as well, and are especially effective for patients near the end of life. SSRIs may also be useful to prevent the development of depression in patients taking drugs known to cause depression, such as interferon alfa. Treatment of depression in patients with cancer should be based on patient specific symptoms and situation. This article will review both non-pharmacologic and pharmacologic treatment options in patients with cancer and comorbid depression.

Efficacy and safety of pharmacotherapy in cancer-related psychiatric disorders across the trajectory of cancer care: a review

At least 25-30% of patients with cancer and an even higher percentage of patients in an advanced phase of illness meet the criteria for a psychiatric diagnosis, including depression, anxiety, stress-related syndromes, adjustment disorders, sleep disorders and delirium. A number of studies have accumulated over the last 35 years on the use of psychotropic drugs as a pillar in the treatment of psychiatric disorders. Major advances in psycho-oncology research have also shown the efficacy of psychotropic drugs as adjuvant treatment of cancer-related symptoms, such as pain, hot flushes, pruritus, nausea and vomiting, fatigue, and cognitive impairment. The knowledge about pharmacokinetics and pharmacodynamics, clinical use, safety, side effects and efficacy of psychotropic drugs in cancer care is essential for an integrated and multidimensional approach to patients treated in different settings, including community-based centres, oncology, and palliative care. A search of the major databases (MEDLINE, Embase, PsycLIT, PsycINFO, the Cochrane Library) was conducted in order to summarize relevant data concerning the efficacy and safety of pharmacotherapy for cancer-related psychiatric disorders in cancer patients across the trajectory of the disease.

Tolerability aspects in duloxetine-treated patients with depression: Should one use a lower starting dose in clinical practice?

OBJECTIVE

This study questions whether a lower starting dose of duloxetine (DLX) could be beneficial for patients with depression, in terms of tolerability and safety in routine clinical care.

RESEARCH DESIGN AND METHODS

Post-hoc analyses of a multicenter, prospective, non-interventional, 6-month study in adult outpatients with a depressive episode was undertaken.

MAIN OUTCOME MEASURES

Treatment-emergent adverse events (TEAEs), serious adverse events (SAEs), discontinuations due to TEAEs and hospitalizations due to depression, were all documented at 2 weeks, 4 weeks, 3 months and 6 months after treatment initiation/switch to DLX.

RESULTS

Of 4517 patients enrolled, 4313 were included for TEAE evaluation. TEAEs occurred in 17.2% of patients, and SAEs occurred in 0.79% of patients, including one case of suicidal ideation. 1404 patients discontinued within 6 months (TEAEs: n = 119). Starting treatment with 30 mg/day DLX (72.7%) was favored in females, or after inadequate efficacy of previous antidepressant treatment; 60 mg/day DLX was favored in more severe depression and patients receiving concomitant pain medication.

CONCLUSION

Initiating treatment with 60 mg/day DLX was not associated with poorer tolerability in this study. Physicians may be guided by their clinical experience to carefully consider the individual benefit/risk ratio and TEAE susceptibility when deciding to start treatment with a higher or a lower dose of DLX.

Evidence-Based Treatment of Depression in Patients With Cancer

Purpose

Depression is a common condition in patients with cancer, although there has been a relative paucity of research on the effectiveness of treatment in this population. This review summarizes the psychosocial and pharmacologic treatment of depression in patients with cancer based on a consideration of evidence regarding etiologic factors and treatment outcomes.

Methods

A review of the evidence base for psychosocial and pharmacologic interventions for depression in patients with cancer was performed, including original studies, systematic reviews, and meta-analytic studies in the literature.

Results

Recent evidence from randomized controlled trials has demonstrated the efficacy of psychosocial and pharmacologic treatments to alleviate depression in patients with cancer. Further research is needed to establish their relative and combined efficacy and their role in the treatment of depression that is less severe and occurs in association with more advanced disease. First-line recommendations for the treatment of depression in patients with cancer are difficult to derive based on current evidence, because comparative studies have not been conducted to support the superiority of one treatment modality over another in this population.

Conclusion

Both psychosocial and pharmacologic interventions have been shown to be efficacious in treating depression in cancer, but further research is needed to establish their relative and combined benefit. Future research directions include the development and evaluation of novel interventions targeted to specific biologic and psychosocial risk factors.

Tratamiento farmacológico de la depresión en cáncer

Objetivo: La depresión mayor es uno de los trastornos psiquiátricos más ampliamente reconocidos en los enfermos de cáncer. En España alrededor de un 16,49% de los pacientes oncológicos desarrollan un Trastorno Depresivo Mayor. Cuando la sintomatología depresiva interfiere en el adecuado funcionamiento del paciente oncológico, los antidepresivos son el tratamiento de primera línea. El objetivo de este estudio es analizar la eficacia de las distintas opciones farmacológicas utilizadas para la depresión en pacientes oncológicos.Método: Se realiza una búsqueda bibliográfica en la base de datos PubMed mediante los términos:cancer AND depression treatment AND antidepressant . Se analizaron un total de 36 artículos con un diseño tipo ensayo clínico. Resultados: Se ha encontrado que los fármacos inhibidores de la recaptación de serotonina (ISRS) son eficaces para el tratamiento de la depresión en pacientes con cáncer. La paroxetina es una de las más eficaces. Los antidepresivos de perfil dual también han demostrado eficacia por su rapidez de acción y su utilidad en síntomas colaterales como los síntomas vasomotores y los dolores. La mirtazapina es de gran utilidad en síntomas como el dolor, náuseas, insomnio y ansiedad.Conclusiones: La elección de la medicación debe estar basada en el perfil de síntomas del paciente, el potencial beneficio, la tolerabilidad y el riesgo/beneficio con el propósito de diseñar una estrategia para cada paciente. Los fármacos que han demostrado mayor eficacia y tolerabilidad en nuestro estudio han sido los ISRS, la mirtazapina y los antidepresivos de acción dual.