Blogs to Boards: Question 14

The patient agrees to pharmacologic therapy for his depression, and declines offers of counseling/therapy.   Your best estimate is that he has 4-8 weeks to live based on performance status and tempo of decline.

Which of the following are appropriate drug approaches for his depression?

  1. Methylphenidate
  2. Ketamine
  3. Dronabinol
  4. Sertraline

Discussion: Correct answers are (a) and (b)

  1. Is correct: Methylphenidate and other psychostimulants are rapidly-acting, with onset of mood elevation occurring ~immediately (if they are going to be effective at all).
  2. Is correct: Ketamine has been described as a depression therapy for decades, albeit one on the margins of accepted medical practice; there is a recent resurgence in interest for its use at life’s end, because its effects are immediate. Patients usually receive a single infusion, which stabilizes mood for weeks at a time.  Can be used orally too.
  3. Dronabinol has no defined role as an antidepressant.
  4. Most SSRIs take at least 4 weeks to become effective, which is 50-100% of the patient’s anticipated survival. While SSRIs are first-line antidepressants in the general population as well as for patients with advanced illness, this is not as true as prognosis shortens.

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