A phase II study of methylphenidate for depression in advanced cancer

Methylphenidate for treating fatigue in palliative cancer care - effect and side effects in real-world data from a palliative care unit

BACKGROUND

Methylphenidate can be used for the treatment of cancer-related fatigue (CRF), although randomized controlled trials have shown conflicting results. The aim of this study was to use 'real-world' data to evaluate the effect and side effects of using methylphenidate in palliative cancer care with a focus on the late palliative phase and dose-response.

METHOD

A retrospective review of medical records from a palliative care unit in Sweden was performed to evaluate the effect and adverse events (AEs) of using methylphenidate to treat CRF. Univariable and multivariable regression was performed and odds ratio (OR) calculated. Adjustments were made for sex, age, cancer type, dose and starting treatment <4 weeks before death.

RESULTS

Of the 2,419 screened patients, 112 had been treated with methylphenidate for CRF. The treatment was assessed as being effective in 51 patients (46%). Twenty-six patients (23%) experienced AEs that were generally mild, including anxiety, palpitations, and insomnia. Patients starting the treatment <4 weeks before death (n = 54) were less likely to have an effect from treatment compared to those starting earlier; adjusted OR 0.24 (95% CI 0.10-0.55). Doses of 20 mg and above were well-tolerated and had a higher frequency of effect in the crude data but not after adjustment for confounding factors.

CONCLUSION

Methylphenidate is generally effective and well-tolerated for the treatment of CRF in palliative care. However, patients with a short life expectancy (<4 weeks) seem to benefit less from the treatment regardless of age, cancer type and dose.

Assessment of Stimulant Use and Cardiovascular Event Risks Among Older Adults

IMPORTANCE

Use of stimulants continues to increase among older adults for a variety of indications. An association between stimulant use and increased risk of cardiovascular (CV) events has been established among children and young adults, but few studies have explored the risk of CV events among older patients, a group with increased baseline risk.

OBJECTIVE

To evaluate the association between stimulant use and risk of CV events among older adults.

DESIGN, SETTING, AND PARTICIPANTS

This propensity score-matched cohort study, with 4 nonusers per 1 user, was conducted from July 1, 2017, to June 27, 2019, using data from population-based health care databases from Ontario, Canada, from January 1, 2002, to December 31, 2016. Included individuals were outpatients aged 66 years or older.

EXPOSURES

Initiation of a prescription stimulant.

MAIN OUTCOMES AND MEASURES

The primary outcome was a CV event, defined as a composite of emergency department visit or hospitalization for myocardial infarction, stroke or transient ischemic attack (TIA), or ventricular arrhythmia. Risk of CV event was assessed at 30 days, 180 days, and 365 days after initiation of stimulants from Cox proportional hazard models. A secondary analysis assessed each component of the primary outcome separately.

RESULTS

Among 6457 older adults who initiated a prescription stimulant (ie, the exposed group) and 24 853 older adults who did not initiate such treatment (ie, the unexposed group), the distribution of baseline patient characteristics was well balanced after matching (sex: 3173 [49.1%] men vs 12 112 [48.7%] men; standardized difference, 0.01; median [IQR] age: 74 [69-80] years vs 74 [69-80] years; standardized difference, 0.01). Within this cohort, there were 932 CV events during the 365-day follow-up (5.11 events per 100 person-years among individuals who initiated stimulants). In the primary analysis, stimulant initiation was associated with increased risk of CV events at 30 days (hazard ratio [HR], 1.4; 95% CI, 1.1-1.8) but not at 180 days (HR, 1.2; 95% CI, 0.9-1.6) or 365 days (HR, 1.0; 95% CI, 0.6 to 1.8). In the secondary analysis, stimulant initiation was associated with increased risk of ventricular arrhythmias (HR, 3.0; 95% CI, 1.1-8.7) and stroke or TIA (HR, 1.6; 95% CI, 1.1-2.1) at 30 days.

CONCLUSIONS AND RELEVANCE

This cohort study found that stimulant use was associated with an early increase in CV events among older adults with no association for long-term use.

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.

Sleep disturbance in patients with cancer: a feasibility study of multimodal therapy

BACKGROUND

Our aim was to determine feasibility and effect sizes of bright light therapy (BLT), melatonin (MLT), methylphenidate (MP) and eight combinations (BLT+MLT+MP, BLT+MLT, BLT+MP, BLT alone, MLT+MP, MLT alone, MP alone, placebo for BLT, MLT and MP) defined as multimodal therapy (MMT), to improve sleep quality (SQ) (Pittsburgh Sleep Quality Index (PSQI)) from baseline to day 15. We also examined the effects of MMT on insomnia, fatigue, depression, quality of life and actigraphy.

METHODS

Patients with advanced cancer with poor SQ (PSQI ≥5) were eligible. Using a double-blind randomised factorial study design, patients were randomised into 1 of the 8 arms for 2 weeks. Feasibility and effect sizes were assessed.

RESULTS

81% (54/67) of randomised patients completed the study. There were no differences in the demographics and SQ between groups. The adherence rates for BLT, MLT and MP were 93%, 100% and 100%, respectively. BLT+MLT+placebo of MP; BLT+placebo of MLT+placebo of MP; BLT+MLT+MP showed an effect size (Cohen's d) for change in PSQI scores of 0.64, 0.57 and 0.63, respectively. PSQI change using linear regression showed BLT (n=29) has effect size of 0.46, p=0.017; MLT (n=26), 0.24, p=0.20; MP (n=26), 0.06, p=0.46. No significant differences were observed in scores for insomnia, fatigue, depression, quality of life and actigraphy. There were no differences in adverse events by groups(p=0.80).

CONCLUSIONS

The use of MMT to treat SQ disturbance was feasible. BLT+MLT showed the most promising effect size in improvement in SQ, and additional larger studies are needed.

TRIAL REGISTRATION NUMBER

NCT01628029.

Fatigue in Cancer Patients in Palliative Care-A Review on Pharmacological Interventions

Simple Summary

Cancer related fatigue is a common and distressing symptom for patients with cancer during and after primary treatment, and also in the palliative phase of the disease trajectory. This review focuses on the pharmacological treatment of cancer related fatigue in patients with advanced or metastatic cancer. There are few high-quality studies performed in this setting, but both methylphenidate and corticosteroids might be used to relieve fatigue.

Abstract

Fatigue is one of the most distressing symptoms experienced by cancer patients. The suggested biological mechanism for cancer related fatigue (CRF) includes immune activation triggered by tumor tissue or by anticancer treatment but other mechanisms have also been proposed. Previous large meta-analysis of interventions on fatigue focuses mostly on patients early in the disease trajectory, with only one tenth of included studies performed in palliative cohorts. The aim of this narrative review is therefore to present a background on CRF with focus on the palliative setting. A summary of recent randomized, controlled trials on pharmacological interventions on CRF in palliative care is presented, including studies on psychostimulants, corticosteroids, testosterone and melatonin. Interestingly, in several of these studies there was a positive and similar effect on fatigue in both the intervention and the placebo arm—indicating an important placebo effect for any pharmacological treatment. In addition, studies on dietary supplements and on pharmacological complementary medicines are discussed. To conclude, the evidence is still weak for using pharmacological treatments on CRF in palliative care patients—although methylphenidate and corticosteroids might be considered.

Brief and extended abstinence from chronic oral methylphenidate treatment produces reversible behavioral and physiological effects

Methylphenidate (MP) is a commonly prescribed psychostimulant to individuals with Attention Deficit Hyperactivity Disorder, and is often used illicitly among healthy individuals with intermittent breaks to coincide with breaks from school. This study examined how intermittent abstinence periods impact the physiological and behavioral effects of chronic oral MP self-administration in rats, and whether these effects persist following prolonged abstinence from the drug. Rats were treated orally with water, low-dose (LD), or high-dose (HD) MP, beginning at PND 28. This daily access continued for three consecutive weeks followed by a 1-week abstinence; after three repeats of this cycle, there was a 5-week abstinence period. Throughout the study, we examined body weight, food intake, locomotor activity, and anxiety- and depressive-like behaviors. During the treatment phase, HD MP decreased body weight, food intake, and depressive- and anxiety-like behaviors, while it increased locomotor activity. During intermittent abstinence, the effects of MP on locomotor activity were eliminated. During prolonged abstinence, most of the effects of HD MP were ameliorated to control levels, with the exception of weight loss and anxiolytic effects. These findings suggest that intermittent exposure to chronic MP causes physiological and behavioral effects that are mostly reversible following prolonged abstinence.

Palliative Care and the Management of Common Distressing Symptoms in Advanced Cancer: Pain, Breathlessness, Nausea and Vomiting, and Fatigue

Good symptom management in oncology is associated with improved patient and family quality of life, greater treatment compliance, and may even offer survival advantages. With population growth and aging, the proportion of patients with multiple symptoms—both related and unrelated to their cancer—is anticipated to increase, supporting calls for a more routine and integrated approach to symptom management. This article presents a summary of the literature for the use of symptom assessment tools and reviews the management of four common and distressing symptoms commonly experienced by people with advanced cancer: pain, breathlessness, nausea and vomiting, and fatigue. We also discuss the role of palliative care in supporting a holistic approach to symptom management throughout the cancer trajectory.

[Psychostimulants for late life depression]

OBJECTIVES

The use of psychostimulants in the treatment of depressive disorders is receiving renewed interest. Recent publications suggest a particular interest of psychostimulants in the treatment of depression in the elderly. The aim of this article is to review the literature on the role of psychostimulants in the treatment of depression in older adults.

METHODS

The literature review focused on efficacy and tolerability studies of psychostimulants in the treatment of depression for the elderly that were published between 1980 and 2016. The only inclusion criterion applied was an average age of the sample studied greater than or equal to 60 years.

RESULTS

Overall, 12 trials were selected: 3 controlled trials and 9 uncontrolled trials. Of the 3 controlled trials, one compared parallel groups and the other two were cross-tests. Among the psychostimulants, methylphenidate was the most studied molecule. The trials demonstrate an efficacy of this molecule in particular as an add-on therapy in old-age depression but for the most part with a level of proof that remains insufficient.

CONCLUSIONS

The small size of the samples and the methodological limitations of the studies obviate the possibility of extracting definitive conclusions concerning the place of psychostimulants in the treatment of depression in the elderly. Further studies are required in particular in the treatment of resistant depressive episodes.

Comorbid Depression in Adult Oncology

Depression is a common medical disorder that frequently occurs comorbidly with other medical disorders. Unfortunately, depression often goes unrecognized either due to somatic symptoms, which may be confused with the physical effects of cancer, chemotherapy, and radiation, or due to the belief that depression is a normal part of the cancer diagnosis. A combination of pharmacotherapy and psychotherapy is the most effective treatment for depression in cancer patients. Selective serotonin reuptake inhibitors are the most frequently used antidepressants. Selection of an antidepressant should be based on the patient's symptoms. Recognition and treatment of depressive symptoms in oncology patients is very important, and effective treatment may improve the oncology patients' quality of life and may also affect survival.

Effect of chronic social defeat stress on behaviors and dopamine receptor in adult mice

Victims of bullying often undergo depression, low self-esteem, high anxiety and post-traumatic stress disorder symptoms. The social defeat model has become widely accepted for studying experimental animal behavior changes associated with bullying; however, differences in the effects in susceptible and unsusceptible individuals have not been well studied. The present study investigated the effects of social defeat stress on behavior and the expression of dopamine receptors D1 and D2 in the brains of adult mice. Adult mice were divided into susceptible and unsusceptible groups after 10days of social defeat stress. Behavioral tests were conducted, and protein levels in the brains were assessed by Western blotting. The results indicate that all mice undergo decreased locomotion and increased anxiety behavior. However, decreased social interaction and impaired memory performance were only observed in susceptible mice. A significantly decreased expression of D1 was observed in the prefrontal cortex and amygdala of susceptible mice only. No significant differences in D2 expression were shown between control and defeated mice in any area studied. These data indicate that depression-like behavior and cognition impairment caused by social defeat stress in susceptible mice may be related to changes in the dopamine receptor D1.

The use of stimulant medications for non-core aspects of ADHD and in other disorders

Psychostimulants play a central role in the management of ADHD. Here we review the evidence pertaining to the use of methylphenidate, dexamphetamine and related amphetamine salts, the prodrug lisdexamfetamine and modafinil for the management of comorbid ADHD and non-ADHD indications. There is a growing consensus that stimulant medications are helpful at improving the emotional dysregulation and lability, and oppositional and conduct symptoms that are often associated with ADHD. There is some evidence that psychostimulants may improve outcomes in those with treatment resistant depression, reduce negative symptoms and improve cognitive performance in schizophrenia, and that methylphenidate may reduce binge eating in those with bulimia nervosa. In general medicine, whilst the evidence is at times contradictory, psychostimulants have been shown in some studies to be effective treatments for chronic fatigue and narcolepsy, and to improve outcomes post stroke, post head injury, in dementia and various cancers. It seems likely that these effects often result from a combination of, reduction in fatigue, improvements in concentration and cognitive functioning and a lifting of mood which may be a direct or indirect consequence of the medication. Further studies seem warranted and these should focus on efficacy, effectiveness and long term safety. This article is part of the Special Issue entitled 'CNS Stimulants'.

Ketamine for the treatment of depression in patients receiving hospice care: a retrospective medical record review of thirty-one cases

BACKGROUND

Depression is prevalent in patients receiving hospice care. Standard antidepressant medications do not work rapidly enough in this setting. Evidence suggests that ketamine rapidly treats treatment refractory depression in the general population. Ketamine׳s role for treating depression in the hospice population warrants further study.

METHODS

A retrospective medical record review of 31 inpatients receiving hospice care who received ketamine for depression on a clinical basis was conducted. The primary outcome measure was the Clinical Global Impression Scale, which was used retrospectively to rate subjects׳ therapeutic improvement, global improvement, and side effects from ketamine over 21 days. Additionally, time to onset of therapeutic effect was analyzed.

RESULTS

Using the Clinical Global Impression Scale, ketamine was found to be significantly therapeutically effective through the first week after ketamine dosing (p < 0.05), with 93% of patients showing positive results for days 0-3 and 80% for days 4-7 following ketamine dosing. Patients experienced global improvement during all 4 studied time periods following ketamine dosing (p < 0.05). Significantly more patients had either no side effects or side effects that did not significantly impair functioning at each of the 4 assessed time periods following ketamine dosing (p < 0.05). Additionally, significantly more patients experienced their first therapeutic response during days 0-1 following ketamine dosing (p < 0.001) than during any other time period.

CONCLUSIONS

These data suggest that ketamine may be a safe, effective, and rapid treatment for clinical depression in patients receiving hospice care. Blinded, randomized, and controlled trials are required to substantiate these findings and support further clinical use of this medication in hospice settings.

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.

Rapid response to methylphenidate as an add-on therapy to mirtazapine in the treatment of major depressive disorder in terminally ill cancer patients: a four-week, randomized, double-blinded, placebo-controlled study

This is a 4 week, randomized, double-blind, placebo-controlled study to examine the effects of methylphenidate as add-on therapy to mirtazapine compared to placebo for treatment of depression in terminally ill cancer patients. It involved 88 terminally ill cancer patients from University of Malaya Medical Centre, Kuala Lumpur, Malaysia. They were randomized and treated with either methylphenidate or placebo as add on to mirtazapine. The change in Montgomery-Åsberg Depression Rating Scale (MADRS) score from baseline to day 3 was analyzed by linear regression. Changes of MADRS and Clinical Global Impression-Severity Scale (CGI-S) over 28 days were analyzed using mixed model repeated measures (MMRM). Secondary analysis of MADRS response rates, defined as 50% or more reduction from baseline score. A significantly larger reduction of Montgomery-Åsberg Depression Rating Scale (MADRS) score in the methylphenidate group was observed from day 3 (B=4.14; 95% CI=1.83-6.45). Response rate (defined as 50% or more reduction from baseline MADRS score) in the methylphenidate treated group was superior from day 14. Improvement in Clinical Global Impression-Severity Scale (CGI-S) was greater in the methylphenidate treated group from day 3 until day 28. The drop-out rates were 52.3% in the methylphenidate group and 59.1% in the placebo group (relative risk=0.86, 95%CI=0.54-1.37) due to cancer progression. Nervous system adverse events were more common in methylphenidate treated subjects (20.5% vs 9.1%, p=0.13). In conclusions, methylphenidate as add on therapy to mirtazapine demonstrated an earlier antidepressant response in terminally ill cancer patients, although at an increased risk of the nervous system side effects.

A comprehensive review of palliative care in patients with cancer

One of the most challenging roles for the psychiatrist is to help guide terminally ill patients physically, psychologically and spiritually through the dying process. Patients with advanced cancer, and other life-threatening medical illnesses are at increased risk for developing major psychiatric complications and have an enormous burden of both physical as well as psychological symptoms. In fact, surveys suggest that psychological symptoms such as depression, anxiety, and hopelessness are as frequent, if not more so, than pain and other physical symptoms in palliative care settings. Psychiatrists have a unique role and opportunity to offer competent and compassionate palliative care to those with life-threatening illness. In this article we provide a comprehensive review of basic concepts and definitions of palliative care and the experience of dying, and the role of the psychiatrist in palliative care including assessment and management of common psychiatric disorders in the terminally ill, with an emphasis on suicide and desire for hastened death. Psychotherapies developed for use in palliative care settings, and management of grief and bereavement are also reviewed.

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.

Effects of methylphenidate on fatigue and depression: a randomized, double-blind, placebo-controlled trial

CONTEXT

Fatigue is highly prevalent in populations with advanced illness and is often associated with depressed mood. The role of psychostimulant therapy in the treatment of these conditions remains ill defined.

OBJECTIVES

To evaluate the response of fatigue and depression in patients with advanced illness to titrated doses of methylphenidate (MP) as compared with placebo.

METHODS

In a randomized, double-blind, placebo-controlled trial, 30 hospice patients, both inpatients and outpatients, who had fatigue scores of at least four on a scale of zero to 10 (0=no fatigue and 10=worst fatigue), were randomly assigned to receive either 5mg of MP at 8 am and 1 pm or placebo. Doses of MP were titrated every three days according to response and adverse effects. Home care patients were monitored daily by telephone and visited by a research nurse on Study Days 0 (baseline), 3, 7, and 14. Fatigue was assessed using the Piper Fatigue Scale as the primary outcome measure and validated by the Visual Analogue Scale for Fatigue and the Edmonton Symptom Assessment Scale (ESAS) fatigue score. Subjects in inpatient facilities were interviewed or assessed by staff on an identical schedule. Depressive symptoms were assessed by the Beck Depression Inventory-II, Center for Epidemiologic Studies Depression Scale, and the ESAS depression score. Primary statistical analysis was conducted using repeated-measures multivariate analysis of the variance.

RESULTS

Both MP- and placebo-treated groups had similar measures of fatigue at baseline. Patients taking MP were found to have significantly lower fatigue scores (Piper Fatigue Scale, Visual Analogue Scale for Fatigue, and ESAS) at Day 14 compared with baseline. The improvement in fatigue with MP treatment was dose-dependent; the mean average effective dose was 10mg on Day 3 and 20mg on Day 14 (dose range of 10-40 mg). Placebo-treated individuals showed no significant improvement in fatigue. For patients with clinically significant depression on Day 0, treatment with MP was associated with a significant reduction in all test indices for depressed mood. For the placebo group, the changes in measures of depression were less than observed in the treatment group but were inconsistent between assessment tools. No significant toxicities were observed.

CONCLUSION

MP reduced symptoms of fatigue and depression when compared with placebo. The effect of MP on fatigue was dose-dependent and sustained over the duration of the study.

The prevalence and pharmacotherapy of depression in cancer patients

BACKGROUND

Depression is a frequent and serious comorbid condition in cancer patients that may require special attention. We investigate the prevalence of depression in cancer and review the current state of evidence regarding the effectiveness of drug treatment of depression in this group.

METHODS

We conducted a literature search for reports of prevalence rate of Major Depressive Disorder (MDD) in cancer patients based on Structured Clinical Interview based on DSM (SCID). We estimated the prevalence rate by combining the data of all reports. In addition we identified controlled trials studying the effect of psychotropic drugs in depressed cancer patients.

RESULTS

Based on the 31 reports, the estimated prevalence rate of depression in cancer patients is 10.8% (996/9248). There were 8 trials comparing antidepressant with other active treatment in cancer patients. Only mianserin and alprazolam demonstrated to improve the depressive symptoms.

LIMITATIONS

This literature review cannot resolve the challenge of diagnosing depression in severely ill and is subject to publication bias.

CONCLUSION

Despite the high prevalence of depression in cancer patients, studies on effective pharmacotherapy are relatively scarce. The evidence for the efficacy of conventional medication used for the treatment of depression such as tricyclics antidepressants and selective serotonin reuptake inhibitors is very limited. It is possible that they may be less suitable in this setting because of their relatively late onset of action. The use of psychostimulants which have a rapid onset of action therefore deserves more attention.

Depression and end-of-life care for patients with cancer

Patients with cancer and depression experience more physical symptoms, have poorer quality of life, and are more likely to have suicidal thoughts or a desire for hastened death than are cancer patients who are not depressed. Despite the ubiquity of depressive symptoms in cancer patients at the end of life, critical questions remain unanswered with respect to etiopathogenesis, diagnosis, and treatment of depression in these vulnerable patients. The pharmacotherapy of depression in patients with advanced cancer should be guided by a palliative care approach focused on symptom reduction, irrespective of whether the patient meets diagnostic criteria for major depression. Earlier and more intensive supportive care for patients with cancer reduces symptom burden and may prolong life for patients with advanced disease. Symptom-oriented clinical trials are needed to improve end-of-life cancer care.

Factors associated with response to methylphenidate in advanced cancer patients

BACKGROUND

There has been increasing interest in the use of methylphenidate for cancer-related fatigue (CRF) in patients with advanced cancer. However, there is limited literature on the specific patient characteristics associated with response to methylphenidate. Our objective of this study was to identify the specific patient characteristics associated with response to methylphenidate and to compare day 1 response with day 8 response.

METHODS

We retrospectively reviewed the records of patients in two prospective controlled clinical trials that we had conducted who had received methylphenidate for cancer-related fatigue. Baseline patient characteristics, symptoms (as assessed by the Edmonton Symptom Assessment System [ESAS] and Functional Assessment of Chronic Illness Therapy-Fatigue [FACIT-F]), and response (change in fatigue) at the end of day 1 treatment were analyzed to determine their association with response to methylphenidate on day 8.

RESULTS

A total of 82 patients with advanced cancer who received methylphenidate for CRF were included in our review. The median age was 55 years, 66% were female, 74% were white, and the most common cancer type was breast (37%). Fifty out of 82 patients (61%) responded to methylphenidate (≥ 7 points in FACIT-F). The intensity of baseline fatigue positively correlated with the response to methylphenidate (p < .001). Change in fatigue in response to methylphenidate was not associated with intensity of baseline depression, anxiety, drowsiness, or daily opioid dose. Better improvement of fatigue after treatment on day 1 was associated with more improvement with fatigue on day 8 as assessed by FACIT-F (p = .0004) and ESAS (p = .0001). Day 1 response as a predictor of day 8 response had a sensitivity of 0.84, a positive predictive value of 0.67, and specificity of 0.6.

CONCLUSIONS

Response to methylphenidate is associated with higher baseline fatigue but not with higher baseline depression or sedation. Additionally, day 1 improvement is highly sensitive as a predictor of long-term improvement.

The use of referenced-EEG (rEEG) in assisting medication selection for the treatment of depression

OBJECTIVE

To evaluate the efficacy of rEEG(®)-guided pharmacotherapy for the treatment of depression in those circumstances where rEEG and STAR*D provided different recommendations.

MATERIALS AND METHODS

This was a randomized, single-blind, parallel group, 12 center, US study of rEEG-guided pharmacotherapy vs. the most effective treatment regimens reported in the NIH sponsored STAR*D study. Relatively treatment-resistant subjects ≥18 years who failed one or more antidepressants were required to have a QIDS-16-SR score ≥13 and a MADRS score ≥26 at baseline. All subjects underwent a washout of all current medications (with some protocol-specified exceptions) for at least five half-lives before receiving a QEEG and rEEG report. Subjects randomized to rEEG were assigned a regimen based on the rEEG report. Control subjects who had failed only SSRI's in their current episode were randomized to receive venlafaxine XR. Control subjects who had failed antidepressants from ≥2 classes of antidepressants were randomized to receive a regimen from Steps 2-4 of the STAR*D study. Treatment lasted 12 weeks. The primary outcome measures were change from baseline for self-rated QIDS-SR16 and Q-LES-Q-SF.

RESULTS

A total of 114 subjects were randomized and 89 subjects were evaluable. rEEG-guided pharmacotherapy exhibited significantly greater improvement for both primary endpoints, QIDS-SR16 (-6.8 vs. -4.5, p<0.0002) and Q-LES-Q-SF (18.0 vs. 8.9, p<0.0002) compared to control, respectively, as well as statistical superiority in 9 out of 12 secondary endpoints.

CONCLUSIONS

These results warrant additional studies to determine the role of rEEG-guided psychopharmacology in the treatment of depression. If these results were confirmed, rEEG-guided pharmacotherapy would represent an easy, relatively inexpensive, predictive, objective office procedure that builds upon clinical judgment to guide antidepressant medication choice.

Phase III, randomized, double-blind, placebo-controlled study of long-acting methylphenidate for cancer-related fatigue: North Central Cancer Treatment Group NCCTG-N05C7 trial

PURPOSE

Fatigue is one of the most common symptoms experienced by patients with cancer. This trial was developed to evaluate the efficacy of long-acting methylphenidate for improving cancer-related fatigue and to assess its toxicities.

PATIENTS AND METHODS

Adults with cancer were randomly assigned in a double-blinded manner to receive methylphenidate (target dose, 54 mg/d) or placebo for 4 weeks. The Brief Fatigue Inventory was the primary outcome measure, while secondary outcome measures included a Symptom Experience Diary (SED), the Short Form-36 (SF-36) Vitality Subscale, a linear analog self-assessment, the Pittsburgh Sleep Quality Index, and the Subject Global Impression of Change.

RESULTS

In total, 148 patients were enrolled. Using an area under the serum concentration-time curve analysis, there was no evidence that methylphenidate, as compared with placebo, improved the primary end point of cancer-related fatigue in this patient population (P = .35). Comparisons of secondary end points, including clinically significant changes in quality-of-life variables and cancer-related fatigue change from baseline, were similarly negative. However, a subset analysis suggested that patients with more severe fatigue and/or with more advanced disease did have some fatigue improvement with methylphenidate (eg, in patients with stage III or IV disease, the mean improvement in usual fatigue was 19.7 with methylphenidate v 2.1 with placebo; P = .02). There was a significant difference in self-reported toxicities (SED), with increased levels of nervousness and appetite loss in the methylphenidate arm.

CONCLUSION

This clinical trial was unable to support the primary prestudy hypothesis that the chosen long-acting methylphenidate product would decrease cancer-related fatigue.

[Using psychostimulants in end-of-life patients with hypoactive delirium and cognitive disorders: A literature review]

OBJECTIVE

To review the research about psychostimulant effects on cognitive functions in end-of-life patients diagnosed with hypoactive delirium or cognitive disorders.

METHOD

The MEDLINE (1966-March 2008), Embase (1974-March 2008), PsycINFO (1806-March 2008), IPA (1970-March 2008), CINAHL (1982-March 2008), ISI Web of Science (1945-March 2008), Current Contents (March 2007-March 2008), Access Medicine (2001-March 2008), and ProQuest Dissertations & Theses (1980-March 2008) databases were searched with keywords related to delirium, cognition, psychostimulants, and palliative care for French or English articles in a dementia-free and hyperactive delirium-free end-of-life population. Cognitive functions had to be assessed before and after initiation of the psychostimulant treatment. Moreover, treatment had to be initiated after the onset of cognitive impairments.

RESULTS

A total of 173 studies were screened. Five studies on methylphenidate and 1 study on caffeine met inclusion criteria and were included in this review. Two studies were case reports, 2 were open-label trials, and 2 were double-blind, crossover randomized placebo-controlled trials. Three studies were conducted with hypoactive delirium patients and all studies were conducted in an advanced cancer patient population.

CONCLUSIONS

The reviewed studies support the use of methylphenidate to improve end-of-life patient cognitive functions, particularly in the case of hypoactive delirium. Caffeine seems to have beneficial effects on psychomotor activity. Further well-designed studies are needed to consolidate these findings.

Depression assessment and classification in palliative cancer patients: a systematic literature review

The objective of this study was to review the literature on depression in palliative cancer care in order to identify which assessment methods and classification systems have been used in studies of depression. Extensive electronic database searches in PubMed, CancerLit, CINAHL, PsychINFO, EMBASE and AgeLine as well as hand search were carried out. In the 202 included papers, 106 different assessment methods were used. Sixty-five of these were only used once. All together, the Hospital Anxiety and Depression Scale (HADS) was the most commonly used assessment method. However, there were regional differences and while the HADS dominated in Europe it was quite seldom used in Canada or in the USA. Few prevalence and intervention studies used assessment methods with an explicit reference to a diagnostic system. There were in total few case definitions of depression. Among these, the classifications were in general based on cut-off scores (77%) and not according to diagnostic systems. The full range of the DSM-IV diagnostic criteria was seldom assessed, i.e. less than one-third of the assessments in the review took into account the duration of symptoms and 18% assessed consequences and impact upon patient functioning. A diversity of assessment methods had been used. Few studies classified depression by referring to a diagnostic system or by using cut-off scores. Evidently, there is a need for a consensus on how to assess and conceptualize depression and related conditions in palliative care.

Modafinil for attentional and psychomotor dysfunction in advanced cancer: a double-blind, randomised, cross-over trial

Cognitive impairment seems to be highly prevalent in patients with advanced cancer. Modafinil, a novel vigilance and wake-promoting agent, may be an alternative treatment. We wanted to investigate this treatment on attentional and psychomotor dysfunction in cancer patients. 28 cancer patients with a tiredness score of 50 mm or more on a scale of 0 to 10 (0=no tiredness, 10=worst possible tiredness) and Karnofsky Performance Status 40-70 were included. All medications were kept stable during the trial despite short acting opioids for breakthrough pain. On day 1 the patients were randomly assigned to receive 200 mg Modafinil orally or placebo and on day 4 they crossed-over to the alternative treatment. Finger Tapping Test (FTT), Trail Making Test (TMT) and Edmonton Symptom Assessment System (ESAS) were evaluated before tablet intake and again 4, 5 hours after. FTT for the dominant hand as well as TMT were statistically significantly improved on modafinil (p-values=0.006 and 0.042, respectively). On ESAS, depression and drowsiness also improved statistically significantly (p-values=<0.001 and 0.038, respectively). Modafinil in a single dose regimen was significantly superior to placebo regarding two cognitive tests of psychomotor speed and attention. Furthermore subjective scores of depression and drowsiness were significantly improved by modafinil.

Cancer-related fatigue: central or peripheral?

To evaluate cancer-related fatigue (CRF) by objective measurements to determine if CRF is a more centrally or peripherally mediated disorder, cancer patients and matched noncancer controls completed a Brief Fatigue Inventory (BFI) and underwent neuromuscular testing. Cancer patients had fatigue measured by the BFI, were off chemotherapy and radiation (for more than four weeks), had a hemoglobin level higher than 10 g/dL, and were neither receiving antidepressants nor were depressed on a screening question. The controls were screened for depression and matched by age, gender, and body mass index. Neuromuscular testing involved a sustained submaximal elbow flexion contraction (SC) at 30% maximal level (30% maximum elbow flexion force). Endurance time (ET) was measured from the beginning of the SC to the time when participants could not maintain the SC. Evoked twitch force (TF), a measure of muscle fatigue, and compound action potential (M-wave), an assessment of neuromuscular-junction transmission were performed during the SC. Compared with controls, the CRF group had a higher BFI score (P<0.001), a shorter ET (P<0.001), and a greater TF with the SC (CRF>controls, P<0.05). This indicated less muscle fatigue. There was a greater TF (P<0.05) at the end of the SC, indicating greater central fatigue, in the CRF group, which failed to recruit muscle (to continue the SC), as well as the controls. M-Wave amplitude was lower in the CRF group than in the controls (P<0.01), indicating impaired neuromuscular junction conduction with CRF unrelated to central fatigue (M-wave amplitude did not change with SC). These data demonstrate that CRF patients exhibited greater central fatigue, indicated by shorter ET and less voluntary muscle recruitment during an SC relative to controls.

Prioritising drugs for single patient (n-of-1) trials in palliative care

Many of the drugs prescribed commonly to palliative care patients have potentially significant side-effects and are of unproven benefit. The acquisition of evidence to support the prescribing of these drugs has been very slow. Single patient trials (SPTs) (also known as n-of-1 trials) offer a potential means of obtaining the evidence necessary to support or refute the use of several of the drugs and interventions whose use is currently based on physician experience or anecdote alone. A list of SPTs considered "most urgent", for commonly employed treatments and for the most common and most troublesome symptoms in palliative care is presented. These are drugs for which the gap between evidence and practice is greatest, where the evidence of efficacy is most lacking, where significant side effects potentially lead to the greatest morbidity, or where cost is a major patient burden. Although not all the drugs used in palliative care are suitable, SPTs provide a potential alternative method of gathering evidence in palliative care.

Cancer-related fatigue

CRF is indisputably a significant problem with important public health and medical economic implications. As the prevalence of cancer survivorship grows, the impact of CRF will increase. Physiatrists have not historically played an active role in caring for affected patients. In the author's opinion, this is unfortunate, since the holistic, integrated, and cross-disciplinary approach that characterizes physiatry seems ideally suited to offer patients meaningful benefit. Physiatrists with a clinical interest are likely to be robustly rewarded with interest from the oncological community, as CRF is a frustrating and devastating problem for patients and clinicians alike.

Methylphenidate side effects in advanced cancer: a retrospective analysis

INTRODUCTION

Methylphenidate (MP) is often recommended for symptom control in advanced cancer. Little is known about its side effects in frail adults.

OBJECTIVES

To evaluate MP-associated symptoms or side effects (S/E).

METHODS

Data was collected from 2 published prospective cohort series and a phase 2 study of MP for symptom control in advanced cancer. All 3 reports had identical dosing schedules and symptom assessments. Initial MP doses were 10 mg/d (5 mg at 8 AM and at 12 noon) titrated up to a maximum of 30 mg/d. Depression, fatigue, and symptoms identified as possible MP S/E were evaluated for presence (prevalence) and for severity (using categorical scales) before MP (day 0) and on days 3, 5, and 7 thereafter. The categorical scale used was none, mild, moderate, and severe.

RESULTS

62 patients were enrolled. Fifty completed 7 days of MP with a median age of 69 (range 30-90) years. Thirty-five received MP 10 mg/day. Most (96%) had improvement in depression and/or fatigue. Among the 62 patients, new symptom prevalence throughout the study was agitation (16%), insomnia (16%), dry mouth (15%), nausea (10%), tremors (6%), anorexia (5%), headache (3%), palpitations (2%), and vomiting (2%). Patients could have more than 1 symptom simultaneously. Seven (11%) withdrew due to MP S/E. Some symptoms present before MP showed significant improvement during MP therapy.

CONCLUSIONS

(1) Treatment with MP (10-20 mg/d) in advanced cancer is well tolerated. (2) S/E symptoms with MP appeared to improve spontaneously despite continued MP therapy. (3) Depression and fatigue improved at doses lower than those recommended in other clinical conditions. (4) MP improved depression and fatigue, and some secondary symptoms associated with them. Methylphenidate (MP) appears safe when used in the treatment of depression and fatigue in advanced cancer.

Methylphenidate for the treatment of depressive symptoms, including fatigue and apathy, in medically ill older adults and terminally ill adults

BACKGROUND

Depressive symptoms, fatigue, and apathy are common symptoms among medically ill older adults and patients with advanced disease, and have been associated with morbidity and mortality. Methylphenidate has been used to treat these symptoms because of its rapid effect. Despite the long history of methylphenidate use for the treatment of depressive symptoms, fatigue, and apathy, there is little definitive evidence to support its use.

OBJECTIVE

The aim of this paper was to review the efficacy and tolerability of methylphenidate in the treatment of depressive symptoms, fatigue, and apathy in medically ill older adults and adults receiving palliative care.

METHODS

English-language articles presenting systematic reviews, clinical trials, or case series describing the use of methylphenidate for the treatment of depressive symptoms, fatigue, or apathy in medically ill older adults or adults receiving palliative care were identified. The key words methylphenidate and either depressive, depression, fatigue, or apathy were used to search the Cochrane Database, MEDLINE, PsycINFO, and International Pharmaceutical Abstracts. Included articles addressed depressive symptoms, fatigue, or apathy in (1) older adults (generally, age > or =65 years), particularly those with comorbid medical illness; (2) adults receiving palliative care; and (3) adults with other chronic illnesses. I excluded articles regarding treatment of depression in healthy young adults; bipolar disorder and attention-deficit/hyperactivity disorder; and narcolepsy, chronic fatigue syndrome, and related disorders.

RESULTS

A total of 19 controlled trials of methylphenidate in medically ill older adults or patients in palliative care were identified. Unfortunately, their conflicting results, small sample sizes, and poor methodologic quality limited the ability to draw inferences regarding the efficacy of methylphenidate, although evidence of tolerability was stronger. The available evidence suggests possible effectiveness of methylphenidate for depressive symptoms, fatigue, and apathy in various medically ill populations.

CONCLUSION

In the absence of definitive evidence of effectiveness, trials of low-dose methylphenidate in medically ill adults with depression, fatigue, or apathy, with monitoring for response and adverse effects, are appropriate.

A randomized, double-blind, placebo-controlled trial assessing the impact of dexamphetamine on fatigue in patients with advanced cancer

Fatigue is very common in patients with cancer. Current guidelines suggest that psychostimulants are "reasonable to consider for severe fatigue." This randomized, double-blind, placebo-controlled trial investigated the hypothesis that dexamphetamine in fatigued patients with advanced cancer would produce a clinically significant improvement with minimal side effects. Fifty patients with advanced cancer, who were receiving palliative care, were randomized to dexamphetamine 10mg twice daily or placebo for eight days. Effectiveness was assessed using the Brief Fatigue Inventory and the McGill Quality-of-Life Questionnaire. The side effects were recorded. The results were analyzed on an intention-to-treat basis. The baseline demographics, fatigue levels, and quality-of-life scores were similar between the two arms. Patients were elderly, had impaired performance status (Eastern Cooperative Oncology Group score=3), and were taking a range of neurologically active medications. Thirty-nine patients completed the trial. There was a transient improvement in the fatigue levels on day 2, but no significant difference in fatigue (P=0.267) or quality of life (P=0.579) by the end of the study. Statistical modeling did not reveal any significant predictors of response to dexamphetamine. These results suggest that dexamphetamine 20mg daily, although well tolerated, does not significantly improve fatigue or quality of life in patients with advanced cancer, as measured by the selected instruments.

The opportunity for psychiatry in palliative care

The need for psychiatrists to work with patients and families living with chronic life-threatening illnesses has never been greater. Further, psychiatrists may find exciting work within the relatively new field of palliative care, which is devoted to the prevention and relief of all suffering. Increasingly, individuals are living longer with multiple issues that cause suffering, interfere with their lives, and often lead to psychosocial sequelae. To ensure state-of-the-art care for patients and families throughout an illness and any ensuing bereavement period, many experienced psychiatrists are needed as consultants to, and as members of, interdisciplinary palliative care teams. This need presents limitless opportunities for psychiatrists to care for patients, provide education, and engage in research. The potential to make a difference is great.

Evidence-Based Recommendations for Cancer Fatigue, Anorexia, Depression, and Dyspnea

Purpose

The experience of patients with cancer often involves symptoms of fatigue, anorexia, depression, and dyspnea.

Methods

We developed a set of standards through an iterative process of structured literature review and development and refinement of topic areas and standards and subjected recommendations to rating by a multidisciplinary expert panel.

Results

For fatigue, providers should screen patients at the initial visit, for newly identified advanced cancer, and at chemotherapy visits; assess for depression and insomnia in newly identified fatigue; and follow up after treatment for fatigue or a secondary cause. For anorexia, providers should screen at the initial visit for cancer affecting the oropharynx or gastrointestinal tract or advanced cancer, evaluate for associated symptoms, treat underlying causes, provide nutritional counseling for patients undergoing treatment that may affect nutritional intake, and follow up patients given appetite stimulants. For depression, providers should screen newly diagnosed patients, those started on chemotherapy or radiotherapy, those with newly identified advanced disease, and those expressing a desire for hastened death; document a treatment plan in diagnosed patients; and follow up response after treatment. For general dyspnea, providers should evaluate for causes of new or worsening dyspnea, treat or symptomatically manage underlying causes, follow up to evaluate treatment effectiveness, and offer opioids in advanced cancer when other treatments are unsuccessful. For dyspnea and malignant pleural effusions, providers should offer thoracentesis, follow up after thoracentesis, and offer pleurodesis or a drainage procedure for patients with reaccumulation and dyspnea.

Conclusion

These standards provide a framework for evidence-based screening, assessment, treatment, and follow-up for cancer-associated symptoms.

Fatigue in palliative care patients -- an EAPC approach

Fatigue is one of the most frequent symptoms in palliative care patients, reported in .80% of cancer patients and in up to 99% of patients following radio- or chemotherapy. Fatigue also plays a major role in palliative care for noncancer patients, with large percentages of patients with HIV, multiple sclerosis, chronic obstructive pulmonary disease or heart failure reporting fatigue. This paper presents the position of an expert working group of the European Association for Palliative Care (EAPC), evaluating the available evidence on diagnosis and treatment of fatigue in palliative care patients and providing the basis for future discussions. As the expert group feels that culture and language influence the approach to fatigue in different European countries, a focus was on cultural issues in the assessment and treatment of fatigue in palliative care. As a working definition, fatigue was defined as a subjective feeling of tiredness, weakness or lack of energy. Qualitative differences between fatigue in cancer patients and in healthy controls have been proposed, but these differences seem to be only an expression of the overwhelming intensity of cancer-related fatigue. The pathophysiology of fatigue in palliative care patients is not fully understood. For a systematic approach, primary fatigue, most probably related to high load of proinflammatory cytokines and secondary fatigue from concurrent syndromes and comorbidities may be differentiated. Fatigue is generally recognized as a multidimensional construct, with a physical and cognitive dimension acknowledged by all authors. As fatigue is an inherent word only in the English and French language, but not in other European languages, screening for fatigue should include questions on weakness as a paraphrase for the physical dimension and on tiredness as a paraphrase for the cognitive dimension. Treatment of fatigue should include causal interventions for secondary fatigue and symptomatic treatment with pharmacological and nonpharmacological interventions. Strong evidence has been accumulated that aerobic exercise will reduce fatigue levels in cancer survivors and patients receiving cancer treatment. In the final stage of life, fatigue may provide protection and shielding from suffering for the patient and thus treatment may be detrimental. Identification of the time point, where treatment of fatigue is no longer indicated is important to alleviate distress at the end of life.

The elusive concept of the symptom cluster

PURPOSE/OBJECTIVES

To provide an integration and synthesis of literature on the definition and importance of the symptom cluster, theoretical frameworks to explain it, analysis strategies to identify it, interventions to alleviate it, and suggestions for future research.

DATA SOURCES

A literature review from 1995-2007 was conducted using MEDLINE. Clinical guidelines, descriptive research, intervention studies of multiple symptoms, and theoretical and conceptual articles were examined. Articles were reviewed if at least two of the four symptoms of interest were examined in relation to one or more other symptoms. Conceptual models were included if they explained or allowed for the notion of a symptom cluster.

DATA SYNTHESIS

Four symptoms were examined as a candidate symptom cluster for this analysis: fatigue, insomnia, pain, and depression. Symptom clusters were identified by expert opinion, group comparisons, shared variance among symptoms (including factor analysis and mediation analysis), identification of subgroups, influence of symptoms on patient outcomes, or the identification of a common underlying mechanism. Regardless of the method chosen for identifying a symptom cluster, the substantial evidence showed that various combinations of the target symptoms formed a symptom cluster.

CONCLUSIONS

Although the findings suggest that fatigue, insomnia, pain, and depression constitute a viable cluster for further study, more research is needed to define the cluster and describe its underlying mechanisms. Addressing multiple symptoms is beneficial in reducing negative patient outcomes; however, more work needs to be done to understand the efficacy of intervention for symptom clusters.

IMPLICATIONS FOR NURSING

When conducting symptom assessment, healthcare providers should address the four symptoms (fatigue, insomnia, pain, and depression) targeted in this review because evidence of clustering exists. Guidelines provided by the National Comprehensive Cancer Network for fatigue and distress provide algorithms and decision trees for assessment and management.

Fatigue: implications for the elderly

Sporadic and chronic fatigue are common, but an underlying etiology is identified in only up to 10% of cases. Under-reporting makes fatigue's prevalence unknown. Some estimate up to 50% of elders suffer from mild fatigue. Causes vary, but prevailing theory links most fatigue as a secondary consequence to illness and medication. Fatigue is prominently linked to sleep disorders, depression, heart disease, Parkinson's disease, anemia, and cancer. Fatigue and its consequences should be assessed routinely. Empiric treatment is the norm, focusing on managing fatigue, and, when possible, selecting agents with fewer side effects. Exercise, diet, and promoting good sleep hygiene have beneficial effects in symptom management.

Pharmacologic treatment of cancer-related fatigue

Fatigue is the most commonly reported symptom in patients with cancer, with a prevalence of over 60% reported in the majority of studies. This paper systematically reviews pharmacologic agents in the treatment of cancer-related fatigue (CRF). We conducted a literature review of clinical trials that assessed pharmacologic agents for the treatment of CRF. These agents include hematopoietics (for anemia), corticosteroids, and psychostimulants. Other therapeutic agents that are less well studied for CRF but are currently the focus of clinical trials include l-carnitine, modafinil, bupropion, and selective serotonin reuptake inhibitors such as paroxetine. Disclosure of potential conflicts of interest is found at the end of this article.

Fatigue, depression, and insomnia: evidence for a symptom cluster in cancer

OBJECTIVES

To review the evidence for considering fatigue, depression, and insomnia as a symptom cluster in cancer.

DATA SOURCES

Empirical studies, clinical articles, and review articles.

CONCLUSION

The single- and multi-symptom measurement approaches are of limited usefulness in distinguishing fatigue, depression, and insomnia. Studies in which these symptoms have been measured concurrently in patients with cancer yield consistent evidence of high positive correlations. Results do not appear to be solely a function of overlap in measurement approaches.

IMPLICATIONS FOR NURSING PRACTICE

Successful management of fatigue, depression, and insomnia in cancer patients are likely to combine pharmacologic and nonpharmacologic therapies.

Psychostimulants in the treatment of depression : a review of the evidence

Psychostimulants have euphoric and alerting properties that suggest their usefulness in treating depressive disorders; however, problems with tolerance and dependence with some drugs militate against their widespread therapeutic use where more acceptable licensed alternatives are available. The introduction of modafinil, a stimulant not associated with tolerance and dependence, has re-awakened interest in psychostimulants as antidepressants. The available literature, while containing somewhat inconsistent data of rather poor quality, does suggest that psychostimulants have useful antidepressant properties and are usually well tolerated. They may be useful as adjuncts to standard antidepressants in refractory depression, but have particular utility in conditions where a prompt therapeutic effect is desired and where tolerance and dependence are less of a concern. Such conditions include the treatment of depression in terminal illness and in extreme old age.Psychostimulants, although now largely discarded as treatment options for depression, deserve careful consideration as potential therapeutic agents in specific patient subgroups.