ANTI-DEPRESSANTS

The question is often: appropriate sadness or depression? Endogenous depression is surprisingly rare in terminal illness.

A truly depressed terminally ill patient can respond very dramatically within 7 to 10 days after starting a tricyclic anti-depressant in proper doses. Start with a low dose, then increase the dose as quickly as the patient will tolerate the side effects, particularly the dry mouth. (For example, start imipramine 10mg to 25mg, usually at bedtime, increasing the dose by steps to 75mg to 150mg per day.) (see Depression)

A useful guide to the speed of increase in daily doses of imipramine is:

Tricyclics can be categorized according to their sedative properties:

Agitated patients respond best to sedative tricyclics. Withdrawn patients benefit from less sedating or stimulant tricyclics. The newer tricyclics have fewer anti-cholinergic side effects, but some can cause bone marrow depression and monthly full blood counts are required.

Patients with chronic pain tend to get depressed. There is some evidence that long-term morphine causes depression. There is some evidence that imipramine has a morphine-potentiating effect. Therefore, in any patient who has suffered severe pains for more than a few months, consider a trial of imipramine.

Being anti-cholinergic, almost all anti-depressants can cause dry mouth, blurred vision and urinary retention, and can sometimes contribute to the patient’s confusion. (see Depression)

The author and publisher have taken precautions to ensure that the information in this book is error-free. However, readers must be guided by their own personal and professional standards of good practice in evaluating and applying recommendations made herein. The contents of this book represent the views and experience of the author, and not necessarily those of the publisher.