Seminars in Oncology Nursing 38 (2022) 151251

Contents lists available at ScienceDirect

Seminars in Oncology Nursing

journal homepage: https://www.journals.elsevier.com/seminars-in-oncology-nursing

Symptom Management in Oncology: Depression and Anxiety

Barbara J. Henry, APRN, DNP*
Psychiatric APRN Lifestance Health, Milford, Ohio

A R T I C L E I N F O A B S T R A C T

Key Words: Objective: To describe nursing symptom management of depression and anxiety in patients with cancer.
Depression Data Sources: Journal articles, online resources, and personal experience in providing mental health care to
Anxiety cancer survivors with depression and/or anxiety.
Symptom management Conclusion: Nurses can provide emotional support for patients with cancer and depression or anxiety. Nurses
Nonpharmacologic symptom management
can become aware of nonpharmacologic and pharmacologic treatment for depression and anxiety to help
Pharmacologic symptom management
patients decrease their emotional distress. Nurses can also refer patients with cancer to psychiatric professio-
Antidepressant
Antianxiety medications nals and emotional support programs.
Post-traumatic stress disorder Implications for Nursing Practice: Nurses do not have to be experts in psychiatry to manage symptoms of
Distress depression and anxiety in patients with cancer. Nurses can listen empathically, guide patients in relaxation
Treatment-resistant depression techniques, and advocate if they need psychotropic medications or psychiatric referrals.
© 2022 Elsevier Inc. All rights reserved.

Introduction
Depression is defined as a mood disorder that causes a persistent
feeling of sadness and loss of interest.1 Anxiety is defined as an emo-
tion characterized by feelings of tension as well as worried thoughts.2
Nurses often observe depression in patients with cancer, which can
include presentations of being very quiet, tearful, or sad, individuals
articulate that they are depressed, or family members report a drop
in mood. When the depression lasts 2 weeks or more with symptoms
present every day, patients may have a major depressive disorder
and will most likely need medication or professional psychiatric serv-
ices.3 Patients with cancer who have anxiety may display symptoms
such as shortness of breath, sweating, heart palpitations, tremors, dif-
ficulty putting thoughts into words, restlessness, and tension.2 This
article aim to describe nursing symptom management of depression
and anxiety in patients with cancer.
Prevalence of Depression and Anxiety
According to the National Alliance on Mental Illness (NAMI), 8% of
US adults have a major depressive disorder and 19.1% have an anxi-
ety disorder.4 The Substance Abuse and Mental Health Services
Administration (SAMHSA) reports that 1 in 12 US adults have a sub-
stance use disorder; 1 in 5 have a mental illness, and more than
8.5 million US adults have both a substance abuse disorder and a
mental illness.5
* Address correspondence to Barbara J. Henry, DNP, ARNP-BC, 1228 Parkside Drive,
Batavia, OH, 45103.
E-mail address: Barbara.henry@lifestance.com
The most current statistics among US adults with mental illness or
substance abuse may be low given that often people do not seek
mental health or substance abuse disorder treatment.5 Estimates of
psychological disorder in patients with cancer range from 30% to
60%.6 Psychiatric disorders and substance abuse can escalate in indi-
viduals who receive a cancer diagnosis.7 The most common psychiat-
ric issues in patients with cancer are depression and anxiety.8
Evidence identified that as many as 60% of patients with cancer have
depression and anxiety, but only 10% or less are referred for mental
health treatment.8
Assessment
Oncology nurses at the bedside or chairside frequently observe
patients with cancer longer than other professionals. Many nurses
can pick up cues in conversations with patients that they are having
symptoms of anxiety or depression. Nurses can use the National
Comprehensive Cancer Network (NCCN) Distress Thermometer and
Problem List to assess and document these issues and refer patients
to appropriate treatment resources (see Figure 1).9 Additional assess-
ment tools used to measure depression and anxiety, which are used
more in research than clinical practice include The Patient Health
Questionnaire (PHQ-9), Beck Depression Inventory, Hamilton Rating
Scale for Depression (HAM-D), Montgomery-Asberg Depression Rat-
ing scale (MADRS), Hamilton Rating Scale of Anxiety (HAM-A), and
the Generalized Anxiety Disorder Assessment (GAD-7).3,10,11
The term distress was chosen by the NCCN because the term is less
stigmatizing and more acceptable than psychiatric, psychosocial, and
emotional.9 When assessing symptom management, nurses can say
they are assessing emotional distress, so the patient is aware what is

https://doi.org/10.1016/j.soncn.2022.151251
0749-2081/© 2022 Elsevier Inc. All rights reserved.
2 B.J. Henry / Seminars in Oncology Nursing 38 (2022) 151251
FIGURE 1. NCCN Screening Tool for Measuring Distress, with Permission from NCCN.9
being assessed. The emotional problems listed on the tool are the
symptoms of depression and anxiety, which included depression,
fears, nervousness, sadness, worry, and loss of interest in usual activi-
ties.9 The other problems listed in the tool impact emotional distress
as well practical problems, family problems, and physical problems.
Symptoms
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edi-
tion (DSM-V)12 lists symptoms of major depression and includes
depressed mood, loss of interest/pleasure, weight loss or gain, insom-
nia or hypersomnia, psychomotor agitation or retardation, fatigue,
feeling worthless or excessive/inappropriate guilt, and decreased
concentration.3 Anxiety symptoms include feeling nervous, restless,
or tense; having a sense of impending danger, panic, or doom; having
an increased heart rate; breathing rapidly (hyperventilation); sweat-
ing, trembling, feeling weak or tired; and trouble concentrating or
thinking about anything other than the present worry.2
The most common symptom experienced by patients with breast
cancer in one study was fatigue, which is also a symptom of both
depression and anxiety in the DSM-V.12 Fear of recurrence is another
common symptom reported by cancer survivors. Fear and worry can
lead to anxiety disorders.13 Providing the opportunity for patients
with cancer to voice their fears can help to enable timely intervention
to support them in coping with anxiety. Nurses can provide educa-
tion on cancer and treatments, which may also alleviate anxiety.14
Symptom Management
Nonpharmacological symptom management
Nurses can use the same nonpharmacologic symptom management
approaches as psychotherapists in helping patients with cancer to cope
with anxiety and depression. Often, an interpersonal therapy (IPT) style
can be used to help patients learn coping skills, set appropriate bound-
aries, and deal with immediate stressors and achieve short- and long-
term goals.15 Issues are explored, and interventions suggested by
nurses as they engage in conversation while giving treatment to
patients with cancer. Nurses focus mostly on here and now problems
and can refer to psychiatric professionals for more intense treatment,
especially for psychiatric illness that existed prior to the cancer diagno-
sis. Nurses who use this approach are openly supportive and optimistic
to the patient in providing care in partnership.15 The positive reframing
advice from the nurse decreases negative transference and strengthens
the therapeutic relationship so that the patient and nurse work
together to help the patient manage with interpersonal issues.15
Transference and countertransference are concepts of psychiatry
originally described by Sigmund Freud.16 An example of positive trans-
ference would be when the patient feels connected to the nurse
because the nurse reminds the patient of a friend, sister, or other posi-
tive relationship. Whereas an example of positive countertransference
is when the nurse has the same positive feelings about a patient that
reminds them of a friend, family member, or other positive relation-
ship. Negative transference and countertransference can also develop
in which case the nurse may have to look harder for the positive char-
acteristics in a patient who may be perceived as difficult. Sometime,
individuals who are perceived as difficult patients may have negative
traits or personality disorders in addition to depression and anxiety.
The challenges in dealing with difficult psychiatric issues may
require limit setting, consistency, firm boundaries as well as flexibil-
ity, tailored to the individual. Nurses work as a team often in conjunc-
tion with social workers, psychologists, psychiatrists, and advanced
practice psychiatric nurses. Those professionals may be limited in
smaller cancer treatment centers or rural areas. Some patients may
prefer an internet-based psychiatric consultation, though many prac-
titioners find face-to-face therapeutic relationships are more effective
in helping patients with cancer cope with depression and anxiety.17
Nurses are better able to address psychiatric issues in patients
with cancer when their own mental health is stable.18 Nursing can
be a stressful job especially during events such as the coronavirus
disease 2019 (COVID-19) pandemic. Many nurses can experience
burnout if they are not attentive to self-care.18 Individual psycho-
therapy, group therapy, grief work, and stress management can be
helpful to nurses as well as patients. Complementary therapies,
such as yoga, tai chi, qi gong, healing touch, reiki, and breathing
techniques, can alleviate stress.18 Simply taking three deep breaths
on the way to and from work can help relieve tension. Nurses and
patients can use phone applications like Calm, Breathe, or Head-
space to listen to relaxing nature sounds and remind them to take
deep breaths at intervals throughout the day.19 Mindfulness is an
important concept in stress relief. Simply defined, mindfulness is
living in the moment rather than worrying about the past or future,
that is, focusing on your feelings in the moment without judgment
or interpretation.20
 B.J. Henry / Seminars in Oncology Nursing 38 (2022) 151251 3

Alcohol and drug usage may increase for people coping with can- TABLE 3
cer as a maladaptive coping strategy. Nurses can use a simple assess- Antidepressants-Atypical Antidepressants

ment tool to assess substance use in patients with cancer. Questions Generic name Trade name Starting dose Maintenance dose
from the CAGE Questions Adapted to Include Drug Use (CAGE-AID)21
Bupropion Wellbutrin 75 mg/d 300-450 mg/d
are:
Bupropion SR and XL Wellbutrin SR or XL 150 mg/d 300-450 mg/d
Mirtazapine Remeron 15 mg/hs 15-45 mg/hs
1. Have you ever felt you ought to cut down on your drinking or Vilazodone Viibryd 20 mg/d 20 to 40 mg/d
drug use? hs, at night; SR, sustained release; XL, extended release.
2. Have people annoyed you by criticizing your drinking or drug
use?
3. Have you felt bad or guilty about your drinking or drug use? When a patient has symptoms of depression or anxiety, daily for 2
4. Have you ever had a drink or used drugs first thing in the morning weeks or more, it is appropriate to consider psychotropic medica-
to steady your nerves or to get rid of a hangover (eye opener)? tions.26 Medications should be started at a low dose that can be
increased every 2 weeks until symptoms are relieved. These medica-
tions are often prescribed for at least 6 months or until symptoms are
The CAGE acronym refers to the symptoms: Cut back on drinking, relieved. Often when patients with depression decrease their medica-
Annoyed by others criticizing drinking, Guilt you have felt about your tions or try to discontinue treatment, they sometimes report that
drinking or drug use, and Eye opener have you had a drink/drug in they had better quality of life on antidepressants, so lifetime treat-
the morning.21 There is a more extensive alcohol abuse assessment ment is often necessary. Benzodiazepines or antianxiety medications
tool called Alcohol Use Disorders Identification Test (AUDIT) used by are controlled drugs and meant for short-term use; however, they
substance abuse professionals.22 If patients are at risk of increased may be used in combination with antidepressants for severe chronic
use of alcohol and drug misuse, there are a number of nonpharmaco- anxiety and depression.27
logical interventions available. First-line pharmacologic interventions for anxiety are serotonin
Nonpharmacologic interventions for patients can include patient reuptake inhibitors, serotonin norepinephrine inhibitors, or atypical
education, social support, psychotherapy/counseling, support groups, antidepressant agents (see Tables 1, 2, 3, and 4). Second-line options
music therapy, physical exercise programs for cancer survivors, and are tricyclic antidepressants, antipsychotic agents, benzodiazepines,
more. Nurses can become familiar with these types of programs to or pregabalin.27 Combinations of these and other drugs are often
provide patients with easy access and referral.23,24 used to treat both depression and anxiety in patients with cancer.
Stimulants such as Ritalin, Adderall, and Modafinil may be used for
Pharmacological symptom management cancer fatigue.28

Medications most often prescribed for depression include tricyclic Case Vignettes
antidepressants, monoamine oxidase inhibitors (rarely used), selec-
tive serotonin reuptake inhibitors (SSRIs), and serotonin norepineph- The following vignettes illustrate some common pharmacologic
rine inhibitors (SNRIs) (Tables 1 and 2). There are many possible side treatment of depression and anxiety in people with cancer. Many
effects of antidepressants such as decreased libido, orgasm or ejacula- cases are complex and require psychiatric referral in addition to nurs-
tion delay, weight gain, nausea, insomnia, or fatigue.25 Experienced ing symptom management.
psychiatric prescribers are aware of the nuances of these medications Case 1: Mary is a 60-year-old divorced female survivor of lung
and individualization of care based on patient response. Therefore, cancer currently in remission. She became depressed after the
collaboration between oncology professionals and psychiatric pre- divorce 5 years ago but never sought treatment. Her oncologist
scribers before starting or changing medications for patients with referred her to an Advanced Practice Registered Nurse (APRN) for
cancer is critical. assessment. Mary has never taken antidepressants. Following clinical
assessment, she was identified to have mild depression and has no
TABLE 1 suicide ideation. The APRN started her on escitalopram 10 mg/d,
Antidepressants-Selective Serotonin Reuptake Inhibitors (SSRIs) which initially helped and then the required dose was increase to 20
Generic name Trade name Usual starting dose Maintenance dose mg/d after 1 month. Her depression is in remission with medication
and psychotherapy.
Citalopram Celexa 20 mg/d 20-60 mg/d
Case 2: Phil is a 39-year-old, divorced male survivor of acute mye-
Escitalopram Lexapro 10 mg/d 10-20 mg/d
Fluoxetine Prozac 20 mg/d 20-80 mg/d logenous leukemia and is 1-year post stem cell transplant, who has
Sertraline Zoloft 50 mg/d 50-200 mg/d significant fatigue. He has post-traumatic stress disorder from the
Vortioxetine Trintellix 5 mg/d 5-20 mg/d extensive pre- and post-transplant complications, though his mood is
Fluvoxamine Luvox 50 mg/d 50-300 mg/d
stable. The APRN prescribed Adderall 10 mg twice a day and Phil starts
Paroxetine Paxil 20 mg/d 20-50 mg/d
with 5 mg the first morning. He reports his stamina and fatigue are
improved as well as his cognitive function at work. His blood pressure
is stable, and he is sleeping well with no side effects from the stimu-
lant. He works through his post-traumatic stress disorder in psycho-
therapy and physical exercise, which reduces his anxiety level.
TABLE 2
Antidepressants-Serotonin Norepinephrine Inhibitors (SNRIs)
Case 3: Marilyn is a 60-year-old widowed female with a long his-
tory of alcohol and drug abuse and reports she is sober now after
Generic name Trade name Starting dose Maintenance dose completing treatment for ovarian cancer. She states she still drinks
Venlafaxine IR Effexor 75 mg/d 150-225 mg/d only a few nights a week. She has had two driving under the influ-
Venlafaxine XR Effexor XR 75 mg/d 150-225 mg/d ence (DUI) convictions, most recently a month ago. She states she is
Desvenlafaxine Pristiq 25 mg/d 50-100 mg/d anxious though appears calm externally. She requests alprazolam for
Duloxetine Cymbalta 30 mg/d 60-120 mg/d
anxiety and states she took 6 mg/d in the past. The APRN explains
Levomilnacipran Fetzima 20 mg/d 40-120 mg/d
that given the history of DUIs it is not appropriate for Marilyn to take
IR, immediate release; XR, extended release.
controlled drugs. She prescribes Fluoxetine 20 mg/d to help with
4 B.J. Henry / Seminars in Oncology Nursing 38 (2022) 151251
TABLE 4
Anxiety Medications
Class of drug Generic name
Benzodiazepines Lorazepam, Alprazolam, Clonazepam, Diazepam
Buspirone Buspar
Antidepressants
Tricyclics Trazodone, Doxepin, Amitriptyline
MAOIs Nardil
SSRIs See Table 1
SNRIs See Table 2
Atypical antidepressants See Table 3
Antihistamines Vistaril
Beta-blockers Inderal
bid, twice a day; hs, at night; MAOIs, monoamine oxidase inhibitors; prn, as needed; q, every; qid, four times a day; SNRIs, serotonin and norepinephrine reuptake inhibitors;
SSRIs, selective serotonin reuptake inhibitors; tid, three times a day.
depression and anxiety as well as Hydroxyzine/Vistaril 25 mg twice a
day as needed for anxiety and alcohol withdrawal. She was initially
dissatisfied with having to wean off her current benzodiazepine;
however, she began attending Alcoholics Anonymous (AA) and
worked with a sponsor and has maintained sobriety from alcohol and
benzodiazepines. Her sobriety as well as mental health treatment
helped improve her anxiety and lifestyle.
Treatment-Resistant Depression
Depression and anxiety can become resistant to treatment, mean-
ing patients do not improve with medications, combinations of medi-
cations, or psychotherapy. Electroconvulsive therapy (ECT) has been
used for decades to help treat resistant depression.29 More recently,
transmagnetic stimulation (TMS), a less invasive option for treat-
ment-resistant depression has shown positive outcomes.30 Oncology
patients with preexisting treatment-resistant depression may have
had or explore ECT or TMS options, as well as emerging treatments
for depression and anxiety. ECT and TMS are thought to work by
increasing neurotransmitter availability or changing receptor
sensitivity.29
Another drug for treatment resistant-depression and anxiety is
ketamine.30 Ketamine is administered as an infusion or as nasal
spray.31 It is unclear how ketamine works; however, it has been
hypothesized that it binds with N-methyl-D-aspartate (NMDA)
receptors in the brain releasing glutamate, an excitatory chemical.25
Side effects of ketamine treatment include nausea and vomiting,
hypertension, perceptual disturbances, and dissociation.31 A recent
study found that ketamine produced a rapid response in more than
50% of adults with treatment-resistant depression.32 Long-term data
on nasal esketamine efficacy is not yet available.
Emerging Treatments for Depression and Anxiety
Some of the newest emerging treatments for depression and anxi-
ety are the use of psychedelic drugs.33 Examples of psychedelics are
psilocybin for mood and anxiety disorders and 3,4-methylendioxy-
methamphetamine (MDMA) for post-traumatic stress disorder. Psilo-
cybin is the ingredient in ‘magic mushrooms’ and MDMA is com-
monly referred to as the street drug ‘ecstasy’.34 These drugs are a
radical approach to treating depression and anxiety and remain in
the clinical trial setting. The emerging benefit of such treatments
should be viewed with some caution because these are small and
underpowered studies.34 The Food and Drug Administration granted
breakthrough therapy status to psilocybin in 2017 and for MDMA in
2018, though the drugs will require larger studies to be approved by
the Food and Drug Administration for treatment-resistant depression
and anxiety disorders.35
Starting dose Maintenance dose
0.5-1 mg bid/prn max 0.5 mg-1 mg tid prn
Diazepam 2-10 mg qid/prn 40 mg/day max Diazepam 2-10 mg bid prn
7.5 mg prn Up to 60 mg total/day
Trazodone 50 mg q hs 50-300 mg/hs
Doxepin 10 mg q hs 10-300 mg/hs
Amitriptyline 10 mg/hs 10-150 mg/hs
2-week washout from other antidepressants before starting 15-90 mg/day
— —
— —
— —
25 mg prn 25-200 mg/day max
10 mg/prn 80 mg/day max
Implications for Practice and Conclusion
Oncology nurses do not have to be experts in psychiatry to be able
to help patients with cancer cope with depression and anxiety. Lis-
tening skills, empathy, and patience are important in helping patients
cope with the emotional consequence of a cancer diagnosis and its
treatment. Managing nurses’ own emotions are important to be able
to care for others. Self-care techniques such as psychotherapy, peer
support, vacation, and relaxation techniques can help prevent burn-
out and compassion fatigue common in oncology nurses.19 Familiar-
ity with commonly prescribed psychotropics for depression and
anxiety can help nurses advocate for patients who may need medica-
tion as well as psychotherapy. Nurses must also become familiar
with support professionals and agencies that can help patients with
cancer cope with depression and anxiety.
References
1. Mayo Clinic. Depression: major depressive disorder. Available at: www.mayo
clinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007.
Accessed December 2, 2021.
2. American Psychological Association. Anxiety. Available at: www.apa.org/topics/
anxiety. Accessed December 2, 2021.
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disor-
ders. 5th ed. Arlington, VA: APA; 2013.
4. National Alliance on Mental Illness (NAMI). Mental health by the numbers 2020.
Available at: www.nami.org/mhstats. Accessed December 2, 2011.
5. Substance Abuse and Mental Health Services Administration (SAMHSA). 2020
National survey on drug use and mental health. Available at: www.samhsa.gov/
newsroom/press-announcements/202110260320. Accessed December 2, 2021.
6. Decker V, Tofthagen C. Depression screening, assessment, and interventions in
oncology nursing. Clin J Oncol Nurs. 2021;25:413–421. https://doi.org/10.1188/21.
CJON.413-421.
7. Moussas GI, Papadopoulou AG. Substance abuse and cancer. Psychiatriki.
2017;28:234–241.
8. Anuk D, Ozkan M, Kizir A, et al. The characteristics and risk factors for common
psychiatric disorders in patients with cancer seeking help for mental health. BMC
Psychiatry. 2019;19:269.
9. National Comprehensive Cancer Network (NCCN). Distress management guide-
lines. Available at: www.nccn.org/professionals/physician_gls/pdf/distress.pdf.
Accessed December 2, 2021.
10. Center for Addiction and Mental Health (CAMH). Depression: screening and
assessment. Available at: www.camh.ca/en/professionals/treating-conditions-and-
disorders/depression/depression—screening-and-assessment. Accessed December
6, 2021.
11. Patient UK. Generalized anxiety disorder assessment. Available at: https://patient.
info/doctor/generalised-anxiety-disorder-assessment-gad-7. Accessed December
6, 2021.
12. Henry B. Quality of life and resilience: Exploring a fly-fishing intervention for
breast cancer survivors. Clin J Oncol Nurs. 2017;21(1):E9–E14. https://doi.org/
10.1188/17.CJON.E9-E14.
13. Jur J, Smith JF, DeYoung KA, et al. Anxiety and neurobiology of temporally uncer-
tain threat anticipation. J Neurosci. 2020;40:7949–7964. https://doi.org/10.1523/
JNEUROSCI.0704-20.2020.
14. Garcia W. The effects of education on anxiety in patients receiving chemotherapy
for the first time: an integrative review. Clin J Oncol Nurs. 2014;18:516–529.
 B.J. Henry / Seminars in Oncology Nursing 38 (2022) 151251
15. Celestine P. What is interpersonal therapy (IPT): a case history 2021. Available at:
https://positivepsychology.com/interpersonal-psychotherapy-ipt/. Accessed
December 6, 2021.
16. Samuels A. Transference/countertransference. In: The Handbook of Jungian Psychol-
ogy: Theory, Practice, and Applications . 1st ed. London: Routledge; 2006.
17. Barthelemy T. Telemedicine vs. in-person visits: Which is higher quality? Available
at: https://www.healthitanswers.net/telemedicine-vs-in-person-visits-which-is-
higher-quality-2/. Accessed December 6, 2021.
18. Henry B. Nursing burnout interventions: what is being done? Clin J Oncol Nurs.
2014;18:211–214.
19. Knill K, Warren B, Melnyk B, Thrane S. Burnout and well-being: Evaluating percep-
tions in bone marrow transplant nurses using a mindfulness app. Clin J Oncol Nurs.
2021;25:547–554.
20. Mayo Clinic Staff. Mindfulness exercises: see how mindfulness may help you live
in the moment. Available at: https://www.mayoclinic.org/healthy-lifestyle/con
sumer-health/in-depth/mindfulness-exercises/art-20046356. Accessed December
6, 2021.
21. Ewing JA. Detecting alcoholism: the CAGE questionnaire. JAMA. 1984;252:1905–
1907.
22. Johnson LA, Vincent D, Seale P. Use of AUDIT-based measures to identify unhealthy
alcohol use and alcohol dependency in primary care: a validation study. Alcohol
Clin Exp Res. 2013;37(1):E253–E259.
23. American Cancer Society. ACS patient programs and services. Available at: https://
www.cancer.org/treatment/support-programs-and-services.html. Accessed
December 6, 2021.
24. Cancer Support Community. Emotional distress. Available at: https://www.cancer
supportcommunity.org/article/emotional-distress. Accessed December 6, 2021.
5
25. Li M, Kennedy EB, Byrne N, et al. Management of depression in patients with can-
cer: a clinical practice guideline. J Oncol Pract. 2016;12:747–756.
26. Garakani A, Murrough JW, Freire RC, et al. Pharmacotherapy of anxiety disorders:
Current and emerging treatment options. Front Psychiatry. 2020;11: 595584.
27. Strawn J, Geracioti L, Rajdev N, et al. Pharmacotherapy for generalized anxiety dis-
order in adult and pediatric patients: an evidence-based treatment review. Expert
Opin Pharmacother. 2018;19:1057–1070.
28. Breitbart W, Alici Y. Psychostimulants for cancer-related fatigue. J Natl Compre
Canc Netw. 2010;8:933–942.
29. Kellner CH, Greenberg RM, Murrough JW, et al. ECT in treatment resistant depres-
sion. Am J Psychiatry. 2012;169:1238–1244.
30. National Alliance on Mental Illness (NAMI). ECT, TMS and other brain stimulation
Therapies. Available at: https://www.nami.org/About-Mental-Illness/Treatments/
ECT,-TMS-and-Other-Brain-Stimulation-Therapies. Accessed December 6, 2021.
31. Meisner RC. Ketamine for major depression: new tool, new questions. Available at:
https://www.health.harvard.edu/blog/ketamine-for-major-depression-new-tool-
new-questions-2019052216673. Accessed December 6, 2021.
32. Siegel JS, Palanca BJA, Ances BM, et al. Prolonged ketamine infusion modulates lim-
bic connectivity and induces sustained remission of treatment-resistant depres-
sion. Psychopharmacology. 2021;238:1157–1169.
33. Kryst J, Kawalec P, Pilc A. Efficacy and safety of intranasal esketamine for the treat-
ment of major depression. Expert Opin Pharmacother. 2019;21(1):9–20.
34. Zagorski N. Is psychedelic medicine on the horizon? Available at: https://psy
chnews.psychiatryonline.org/doi/10.1176/appi.pn.2019.1b1. Accessed December
13, 2021.
35. Lampkin M. Prescription psychedelics: the road from FDA approval to clinical prac-
tice. Am J Med.. 2021;135(1):15–16. https://doi.org/10.1016/jamjmed.2021.07.033.