Treat depression at the end of life with methylphenidate.
Methylphenidate is a rapid-acting psychostimulant that is well tolerated and effective in the treatment of depression at the end of life; results can be seen as quickly as 24 to 48 hours after initiation.
The most appropriate treatment for this patient's depression is methylphenidate. Patients with a serious, life-threatening illness and untreated depression have poorer quality of life, which can lead to increased caregiver stress and burden. Diagnosing depression in terminally ill patients, however, is challenging. Although anticipatory grief is common in patients at the end of life and is considered a normal part of most end-of-life experiences, it can be distinguished from clinical depression by the patient's ability to find enjoyment and a fluctuating mood. Patients with depression at the end of life have symptoms that include hopelessness, pervasive guilt, and worthlessness. Depression in terminally ill patients responds well to both pharmacologic and nonpharmacologic treatments. Tricyclic antidepressants, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and mirtazapine are all effective agents. Prognosis should be taken into account because these medications take weeks to reach peak effect. This patient has symptoms consistent with clinical depression as well as a limited life expectancy. Methylphenidate is a rapid-acting psychostimulant that is well tolerated and may be effective in the treatment of depression; once initiated, results can be seen within 24 to 48 hours. Methylphenidate may also have the benefit of improving cancer-associated fatigue.
Selective serotonin reuptake inhibitors, such as citalopram and sertraline, are effective in the treatment of depression; however, they can take many weeks and dose titration to reach effectiveness. Given this patient's limited life expectancy, a more rapid-acting agent is needed.
Cognitive behavioral therapy, when available, is an effective therapy for patients with depression and a serious medical illness. However, most trials showing benefit are centered on multiweek, if not several-months-long, interventions and are of limited availability for patients on home hospice.