The Use of Antidepressants in Oncology

A Review and Practical Tips for Oncologists

L. Grassi; M. G. Nanni; G. Rodin; M. Li; R. Caruso

Disclosures

Ann Oncol. 2018;29(1):101-111. 

In This Article

Abstract and Introduction

Abstract

Background The use of psychotropic drugs, namely those with an antidepressant profile (ADs), is a mandatory part of an integrated treatment of psychiatric disorders among cancer patients. We aimed to synthetize the most relevant data emerging from published studies to provide tips about the use of ADs in oncology.

Design A search was made of the major databases over the last 30 years (Embase/Medline, PsycLIT, PsycINFO, the Cochrane Library), including narrative reviews, systematic reviews and meta-analyses summarizing the results from observational studies and randomized clinical trials assessing effectiveness, safety profile, interactions, contraindications and use of ADs in oncology with regard to both psychiatric (depressive spectrum, stress-related, anxiety disorders) and cancer-related symptoms (e.g. pain, hot flashes and fatigue).

Results The weight of evidence supports the efficacy of ADs for more severe major depression in individuals with cancer and as an adjuvant treatment in cancer-related symptoms, although the methodological limitations of reported randomized controlled trials do not permit definite conclusions. Data also indicate that there should be caution in the use of ADs in cancer patients in terms of their safety profile and potential clinically significant interactions with other prescribed medications. Practical recommendations that have been made for the use of ADs in cancer patients, in the context of a multimodal approach to depression treatment, have been summarized here.

Conclusions ADs are a relatively safe and effective treatment for more severe major depression in cancer patients. However, more research is urgently needed regarding the efficacy of ADs in different cancer types and cancer settings, their interactions with anticancer agents and their additive benefit when integrated with psychosocial interventions.

Introduction

Although emotional distress needing clinical attention can affect 40%–60% of cancer patients,[1] a formal diagnosis of a psychiatric disorder according to the usual nosology psychiatric systems, such as the International Classification of Disease of the World Health Organization or the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, can be made in about 25%–30%.[2,3] Among these, adjustment and stress-related disorders and major depression have been most studied in terms of prevalence, consequences and treatment in oncology.[4–8]

Accumulated research over the last 35 years has examined the role of antidepressants (ADs) in the reduction of depressive symptoms and improvement of quality of life among cancer patients.[9–11] Two important qualifications should be noted in the research findings on AD treatment in cancer. The first is that ADs have been shown to be effective in the treatment of other psychiatric disorders, mainly stress-related disorders and anxiety disorders.[12,13] The second is that ADs have also been used as adjuvant treatment of non-psychiatric cancer-linked symptoms, such as hot flashes, neuropathic pain, nausea and vomiting, fatigue and pruritus.[14] For these reasons, it has been suggested that these medications should be referred to in terms of their pharmacodynamic profile, which may then be linked to the underlying neurobiological characteristics of the symptoms, the neurotransmitter or molecular system being modified and the mechanism of the action, described as the Neuroscience-Based Nomenclature.[15] This can help clinicians to appreciate the pharmacologic profile of these drugs, the different therapeutic mechanisms and the effects at different doses[16] in the context of an integrated pharmacological and psychological ('PsychopharmOncology') treatment model in oncology.[17]

The aims of this narrative review are (i) to summarize the characteristics, the precautions and safety profile of ADs in the treatment of depression, other psychiatric disorders and cancer-related symptoms in cancer patients; and (ii) to suggest guidelines for an appropriate and evidence-based use of ADs in oncology.

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