The purpose of this study is to determine whether methylphenidate is an effective treatment
for depression and to document the safety and tolerability of methylphenidate in combination
with an Selective Serotonin Reuptake Inhibitor (SSRI) in SSRI treated, terminally ill,
hospice and palliative care cancer patients. The investigators hypothesize that depressed
hospice and palliative care patients will be more likely to have a 50% reduction in scores
on a clinical measure of depression after treatment with Methylphenidate plus an SSRI
compared to those patients who are taking a placebo plus an SSRI.
Background: Major depressive disorder can be diagnosed in between 5% and 26% of terminally
ill patients. This disorder causes suffering, and is associated with suicidality, increased
pain, and increased caregiver burden and caregiver depression. Treatment of depression in
cancer patients in hospice and palliative care is complicated by shortened life expectancy.
Currently-approved antidepressants take several weeks to be effective. Methylphenidate has
been reported in case series and very small randomized trials in patients without cancer as
a rapidly effective treatment for depression in medically ill patients. There are no
randomized controlled trials to test this agent in terminally ill cancer patients.
Objectives: (1) To determine the effectiveness and safety of methylphenidate for depression
treatment in cancer patients receiving hospice and palliative care, (2) to explore whether
successful treatment of depression is associated with improved quality of life, and (3) to
explore whether effective treatment of depression influences caregiver depression and
Methods: We will conduct an 18-day randomized, double-blind, fixed-dose (10 mg bid),
placebo-controlled clinical trial of methylphenidate for depression in eligible veteran and
non-veteran cancer patients with advanced cancer in the following settings: inpatient and
outpatient hospice, inpatient and outpatient palliative care, and inpatient and outpatient
cancer clinics. We will determine whether improvement in depression is mediated by decreased
pain and document the safety and tolerability of methylphenidate in these patients. We will
explore whether improvement in depression results in improved quality of life for these
patients, and decreases caregiver depression and burden.
Eligible patients who answer yes to the question "are you sad or depressed" will be invited
to participate. They will complete measures of depression [Structured Clinical Interview for
Diagnosis (SCID), Montgomery-Asberg Depression Rating Scale (MADRS) as primary outcome,
Hospital Anxiety and Depression Scale (HADS) as secondary outcome], quality of life, pain,
and cognition at baseline. MADRS scores must be greater than 19 and SCID positive for
depression at study entry. Subjects will be randomized to either methylphenidate plus an
SSRI, or placebo plus an SSRI. Subjects may continue any previously prescribed SSRI, or will
be prescribed citalopram if untreated. Participants will be evaluated with the same measures
as baseline on days 3, 6, 12 and 18 of the study. In an open label portion of the study,
methylphenidate-treated patients whose depression has improved will be followed up to 2
months. Cox proportional hazard analysis will be used to analyze the primary outcome. An
estimated 104 subjects will be entered over five years. Caregivers will complete measures of
depression and caregiver burden at days 0 and 18.
Findings: Forty-six subjects were enrolled. Because enrollment was lower than anticipated,
we added all cancer clinics at OHSU to increase subject enrollment. Seventy-eight percent of
subjects were men, and their mean age was 64 years.
The mean time to remission of depression was 10.3 days (SE = 1.77) in the methylphenidate
group and 8.1 (SE = 1.31) for the placebo group (p = 0.38, log rank test). The response to
placebo was high, suggesting that even with a larger number of patients our original
analytic approach would not have been able to show a difference. For example, by day six of
the study 69% of placebo patients and 54% of the methylphenidate subjects no longer met
depression criteria. However, after first remission, 5 placebo patients relapsed, where as
only 1 methylphenidate patient relapsed to depression. By day 18, 84.6% of methylphenidate
patients were in remission, compared to 60% of placebo patients (p = NS). On the HADS the
mean score for each group was 10.4 on screening, but had declined to 6.8 on day 18 in the
methylphenidate group and 8.1 on day 18 in the placebo group (p = NS).
Because of the correlated nature of the data, we tested for linear trend in the MADRAS
scores over time using Generalized Estimation Equation modeling. The overall test for linear
trend in both the placebo and methylphenidate groups revealed a significant decreasing
linear trend (p<0.0001). When restricting the analysis to the placebo group only, the linear
trend test revealed a significant decreasing trend (estimated mean = -1.05; p = 0.0002).
When restricting the analysis to the methylphenidate group only, the linear trend test also
revealed a significant decreasing trend (estimated mean = -1.57; p = 0.0007). The mean
decrease was slightly higher in the methylphenidate group.
Status: Project is complete.
Impact: Alternative study design may be needed to determine the effectiveness of
psychostimulants for depression in advanced cancer.
- Either enrolled in the OHSU radiology/oncology clinic or VA palliative care, and
living within 120 miles of the Portland VAMC.
- Life-limiting disease is any type of solid or blood cancer.
- Eighteen years of age or older.
- Life expectancy of 1 year or less as reflected by hospice admission or palliative
care status. Although exact life expectancy can not be predicted, actively dying
patients with estimated life expectancy of < 10 days are unlikely to be enrolled.
- Diagnosis of major depression disorder as determined by the Structured Clinical
Interview for Diagnosis (SCID).
- Significant depressive cognitive symptomatology as determined by a MADRS greater than
- Currently taking an SSRI but still depressed enough to meet eligibility criteria or
not taking SSRI but depressed enough to start on SSRI.
- Willing and able to give informed consent to participate in this study as
demonstrated by the MacArthur Competence Assessment Tool for clinical research.
- Speaks/understands English.
- For patients at home who cannot self-administer medications, has a caregiver who can
assist with administering medication.
- Dementia or Delirium as determined by the Short Portable Mental Status Questionnaire
(SPMSQ) score of less than 7.
- Diagnosis of delirium as determined by the Confusional Assessment Method (CAM).
- Any of the following Brief Psychiatric Rating Scale (BPRS) items rated 4 -, elated
mood, suspiciousness, hallucinations, excitement, distractibility or motor
- Severe insomnia.
- Severe anxiety.
- Significant suicidal ideation.
- History of current mental disorder in which depressive symptoms occur, but for which
psychostimulants are contraindicated (schizophrenia and bipolar disorder will be
based on history; active psychotic symptoms on selected BPRS items).
- History of stimulant abuse or other active, severe substance abuse.
- Contraindications to methylphenidate or an SSRI including significant
cardiacarrhythmias; uncontrolled, severe hypertension; moderate-severe angina;
seizure disorder; severe COPD; use of medications such as Levodopa, monoamine oxidase
inhibitors, and lithium; diagnosis of narrow-angle glaucoma; or history of
- Physical symptoms including increased blood pressure (DBP greater than 115, SBP
greater than 180), pulse greater than 120, irregular pulse, or chest pain consistent
- Treatment for depression with a non-SSRI antidepressant including Bupropion and
Venlafaxine during protocol.
- Known serum creatinine > 3.0, or severe liver disease as reflected by jaundice or
- Unable to swallow pills, however if patient has gastrostomy tube or feeding tube in
place the study medicines may be administered by this route. Pills may be poured
- Receiving hospice care in a skilled nursing facility.