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Depression in Patients with Pain
The somatic symptoms of depression (e.g., anorexia, insomnia, fatigue, and weight loss) are less reliable and lack specificity in the patient with cancer.134 Of greater diagnostic value are the psychological symptoms of depression: dysphoric mood, hopelessness, worthlessness, guilt, and suicidal ideation.298 A history of familial depression or of previous depressive episodes makes this diagnosis more probable.
An evaluation of cancer treatment-related organic factors that can present as depression should accompany treatment. Such factors include corticosteroids,440 chemotherapeutic agents,8 whole-brain radiation,114 CNS metabolic-endocrine complications,60 and paraneoplastic syndromes.363
Depressed patients with cancer are usually treated with supportive psychotherapy, cognitive-behavioral techniques, and antidepressant medications.298 The efficacy of tricyclic and other antidepres-sants in cancer patients is well established.372 Psychostimulants are most helpful in the treatment of depression in patients with advanced disease and in those for whom dysphoric mood is associated with severe psychomotor slowing and even mild cognitive impairment. Clinicians are referred to the AHCPR Guideline on treatment of depression for further information on this subject.117
A patient's use of meperidine while on an MAOI is absolutely contraindicated because it can lead to hyperpyrexia and cardiovascular collapse. One should be extremely cautious when using any opioid analgesics in patients on Monamine oxidise inhibitors (MAOIs), because myoclonus and delirium have been reported.63 Sympathomimetic drugs and other less obvious MAOIs, such as the chemotherapeutic agent procarbazine, can cause a hypertensive crisis in patients taking an MAOI. If a patient has responded well to an MAOI for depression in the past, its continued use is warranted, but with caution.
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