Modifying Cancer-Related Fatigue by Optimizing Sleep Quality

Cancer-related fatigue is reported by patients to be the most distressing and persistent symptom experienced during and after treatment. Unrelieved fatigue often accompanies other symptoms and leads to decreased physical functioning and lower health-related quality of life. Various factors, including daytime sleepiness and sleep disturbances, have been reported to influence perceptions of fatigue. This article shares current knowledge about the relationships among cancer-related fatigue, sleep disturbances, and daytime sleepiness, and makes recommendations for routine screening, assessment, and interventions to modify fatigue through optimizing sleep quality in adult cancer patients. Evidence is reviewed for nonpharmacologic and pharmacologic interventions for optimizing sleep quality in patients with acute or chronic insomnia secondary to medical illnesses, including cancer. A summary of interventions is presented that focuses on optimizing sleep quality in attempt to lower fatigue. These interventions may be helpful for adult cancer patients experiencing insomnia but will require further testing to establish their efficacy in this population. Recommendations for research are provided, including the need to increase knowledge on the relationships among fatigue, sleep disturbances, daytime sleepiness, and other symptoms in various disease sites, stages, and treatments of cancer and the need for further testing of the measurements used for the evaluation of sleep quality in clinical practice and research.

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Correspondence: Ann M. Berger, PhD, RN, AOCN, 985330 Nebraska Medical Center, Omaha, NE 68198-5330. E-mail: aberger@unmc.edu

References

  • 1.

    PrueGRankinJAllenJ. Cancer-related fatigue: a critical appraisal. Eur J Cancer2006;42:846863.

  • 2.

    MockVAbernethyAPAtkinsonA. NCCN Clinical Practice Guidelines in Oncology — Cancer-Related Fatigue v.2.2007. Available at: http://www.nccn.org/. Accessed September 26 2007.

    • Search Google Scholar
    • Export Citation
  • 3.

    PiperB. Fatigue. In: Carrieri-Kohlman V Lindsey A West C eds.Pathophysiological Phenomena in Nursing 3rd ed.St Louis, MO: Saunders; 2003:209234.

    • Search Google Scholar
    • Export Citation
  • 4.

    HofmanMRyanJLFigueroa-MoseleyCD. Cancer-related fatigue: the scale of the problem. Oncologist2007;12(Suppl 1):410.

  • 5.

    BarsevickAMWhitmerKNailLM. Symptom cluster research: conceptual, design, measurement, and analysis issues. J Pain Symptom Manage2006;31:8595.

    • Search Google Scholar
    • Export Citation
  • 6.

    DavidsonJRMacLeanAWBrundageMD. Sleep disturbance in cancer patients. Soc Sci Med2002;54:13091321.

  • 7.

    SavardJMorinCM. Insomnia in the context of cancer: a review of a neglected problem. J Clin Oncol2001;19:895908.

  • 8.

    American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders 4th Text Revision: DSM-IV-TR. Washington, DC: American Psychiatric Association; 2000.

    • Search Google Scholar
    • Export Citation
  • 9.

    DevineEBHakimZGreenJ. A systematic review of patient-reported outcome instruments measuring sleep dysfunction in adults. Pharmacoeconomics2005;23:889912.

    • Search Google Scholar
    • Export Citation
  • 10.

    LeeKAWardTM. Critical components of a sleep assessment for clinical practice settings. Issues Ment Health Nurs2005;26:739750.

  • 11.

    SavardMHSavardJSimardS. Empirical validation of the Insomnia Severity Index in cancer patients. Psychooncology2005;14:429441.

  • 12.

    BergerAParkerKYoung-McCaughanS. Sleep wake disturbances in people with cancer and their caregivers: state of the science. Oncol Nurs Forum2005;32:E98E126.

    • Search Google Scholar
    • Export Citation
  • 13.

    National Cancer Institute. Sleep Disorders (PDQ®) 02/16/2006. Available at: http://www.cancer.gov/cancertopics/pdq/supportivecare/sleepdisorders/healthprofessional/. Accessed September 26 2007.

    • Search Google Scholar
    • Export Citation
  • 14.

    BuysseDJAncoli-IsraelSEdingerJD. Recommendations for a standard research assessment of insomnia. Sleep2006;29:11551173.

  • 15.

    LeeKA. Impaired sleep. In: Carrieri-Kohlman V Lindsey A West C eds.Pathophysiological Phenomena in Nursing 3rd ed.St. Louis, MO: Saunders; 2003:363385.

    • Search Google Scholar
    • Export Citation
  • 16.

    SpielmanAJGlovinskyP. A conceptual framework of insomnia for primary care practitioners: predisposing, precipitating and perpetuating factors. Sleep Medicine Alerts2004;9:16.

    • Search Google Scholar
    • Export Citation
  • 17.

    BorbelyAAAchermannP. Sleep homeostasis and models of sleep regulation. J Biol Rhythms1999;14:557568.

  • 18.

    VenaCParkerKCunninghamM. Sleep-wake disturbances in people with cancer part I: an overview of sleep, sleep regulation, and effects of disease and treatment. Oncol Nurs Forum2004;31:735746.

    • Search Google Scholar
    • Export Citation
  • 19.

    PayneJK. A neuroendocrine-based regulatory fatigue model. Biol Res Nurs2004;6:141150.

  • 20.

    BowerJEGanzPADickersonSS. Diurnal cortisol rhythm and fatigue in breast cancer survivors. Psychoneuroendocrinology2005;30:92100.

  • 21.

    DantzerRKelleyKW. Twenty years of research on cytokine-induced sickness behavior. Brain Behav Immun2007;21:153160.

  • 22.

    LeeBNDantzerRLangleyKE. A cytokine-based neuroimmunologic mechanism of cancer-related symptoms. Neuroimmunomodulation2004;11:279292.

    • Search Google Scholar
    • Export Citation
  • 23.

    PayneJK. A neuroendocrine-based regulatory fatigue model. Biol Res Nurs2004;6:141150.

  • 24.

    BowerJE. Cancer-related fatigue: links with inflammation in cancer patients and survivors. Brain Behav Immun2007;21:863871.

  • 25.

    RyanJLCarrollJKRyanEP. Mechanisms of cancer-related fatigue. Oncologist2007;12(Suppl 1):2234.

  • 26.

    WoodLJNailLMGilsterA. Cancer chemotherapy-related symptoms: evidence to suggest a role for proinflammatory cytokines. Oncol Nurs Forum2006;33:535542.

    • Search Google Scholar
    • Export Citation
  • 27.

    BergerAMSankaranarayananJWatanabe-GallowayS. Current methodological approaches to the study of sleep disturbances and quality of life in adults with cancer: a systematic review. Psychooncology2007;16:401420.

    • Search Google Scholar
    • Export Citation
  • 28.

    American Academy of Sleep Medicine. International Classification of Sleep Disorders: Diagnostic & Coding Manual 2nd ed.Westchester, IL: American Academy of Sleep Medicine; 2005.

    • Search Google Scholar
    • Export Citation
  • 29.

    CarpenterJSElamJLRidnerSH. Sleep, fatigue, and depressive symptoms in breast cancer survivors and matched healthy women experiencing hot flashes. Oncol Nurs Forum2004;31:591598.

    • Search Google Scholar
    • Export Citation
  • 30.

    NIH. National Institutes of Health State of the Science Conference statement on Manifestations and Management of Chronic Insomnia in Adults, June 13-15, 2005. Sleep2005;28:10491057.

    • Search Google Scholar
    • Export Citation
  • 31.

    AlfanoCMRowlandJH. Recovery issues in cancer survivorship: a new challenge for supportive care. Cancer J2006;12:432443.

  • 32.

    BardwellWAProfantJCasdenDR. The relative importance of specific risk factors for insomnia in women treated for early-stage breast cancer. Psychooncology2007; epub ahead of print.

    • Search Google Scholar
    • Export Citation
  • 33.

    JohnsMW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep1991;14:540545.

  • 34.

    Ancoli-IsraelS. Sleep and fatigue in cancer patients. In: Kryger MH Roth T Dement WC eds.Principles and Practice of Sleep Medicine. Philadelphia: Saunders; 2005:12181224.

    • Search Google Scholar
    • Export Citation
  • 35.

    RoscoeJAKaufmanMEMatteson-RusbySE. Cancer-related fatigue and sleep disorders. Oncologist2007:12(Suppl 1):3542.

  • 36.

    Barton-BurkeM. Cancer-related fatigue and sleep disturbances. Cancer Nurs2006;29;2(Suppl 2):7277.

  • 37.

    de JongNCourtensAMAbu-SaadHH. Fatigue in patients with breast cancer receiving adjuvant chemotherapy: a review of the literature. Cancer Nurs2002;25:283297; quiz 298–289.

    • Search Google Scholar
    • Export Citation
  • 38.

    DonovanKAJacobsenPB. Fatigue, depression, and insomnia: evidence for a symptom cluster in cancer. Semin Oncol Nurs2007;23:127135.

  • 39.

    FiorentinoLAncoli-IsraelS. Insomnia and its treatment in women with breast cancer. Sleep Med Rev2006;10:419429.

  • 40.

    LeeKChoMMiaskowskiC. Impaired sleep and rhythms in persons with cancer. Sleep Med Rev2004;8:199212.

  • 41.

    TheobaldDE. Cancer pain, fatigue, distress, and insomnia in cancer patients. Clin Cornerstone2004;6(Suppl 1D):S1521.

  • 42.

    Ancoli-IsraelSLiuLMarlerMR. Fatigue, sleep, and circadian rhythms prior to chemotherapy for breast cancer. Support Care Cancer2006;14:201209.

    • Search Google Scholar
    • Export Citation
  • 43.

    BergerAMFarrLAKuhnBR. Values of sleep/wake, activity/rest, circadian rhythms, and fatigue prior to adjuvant breast cancer chemotherapy. J Pain Symptom Manage2007;33:398409.

    • Search Google Scholar
    • Export Citation
  • 44.

    JacobsenPBHannDMAzzarelloLM. Fatigue in women receiving adjuvant chemotherapy for breast cancer: characteristics, course, and correlates. J Pain Symptom Manage1999;18:233242.

    • Search Google Scholar
    • Export Citation
  • 45.

    BergerAMFarrL. The influence of daytime inactivity and night-time restlessness on cancer-related fatigue. Oncol Nurs Forum1999;26:16631671.

    • Search Google Scholar
    • Export Citation
  • 46.

    KuoHHChiuMJLiaoWC. Quality of sleep and related factors during chemotherapy in patients with stage I/II breast cancer. J Formos Med Assoc2006;105:6469.

    • Search Google Scholar
    • Export Citation
  • 47.

    Barton-BurkeM. Cancer-related fatigue and sleep disturbances. Further research on the prevalence of these two symptoms in long-term cancer survivors can inform education, policy, and clinical practice. Am J Nurs2006;106(Suppl 3):7277.

    • Search Google Scholar
    • Export Citation
  • 48.

    BowerJEGanzPADesmondKA. Fatigue in breast cancer survivors: occurrence, correlates, and impact on quality of life. J Clin Oncol2000;18:743753.

    • Search Google Scholar
    • Export Citation
  • 49.

    BroeckelJAJacobsenPBHortonJ. Characteristics and correlates of fatigue after adjuvant chemotherapy for breast cancer. J Clin Oncol1998;16:16891696.

    • Search Google Scholar
    • Export Citation
  • 50.

    ServaesPVerhagenCBleijenbergG. Fatigue in cancer patients during and after treatment: prevalence, correlates and interventions. Eur J Cancer2002;38:2743.

    • Search Google Scholar
    • Export Citation
  • 51.

    BuysseDJReynoldsCFMonkTH. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res1989;28:193213.

    • Search Google Scholar
    • Export Citation
  • 52.

    MiaskowskiCLeeKA. Pain, fatigue, and sleep disturbances in oncology outpatients receiving radiation therapy for bone metastasis: a pilot study. J Pain Symptom Manage1999;17:320332.

    • Search Google Scholar
    • Export Citation
  • 53.

    MystakidouKParpaETsilikaE. Sleep quality in advanced cancer patients. J Psychosom Res2007;62:527533.

  • 54.

    BergerAM. Patterns of fatigue and activity and rest during adjuvant breast cancer chemotherapy. Oncol Nurs Forum1998;25:5162.

  • 55.

    BergerAMHigginbothamP. Correlates of fatigue during and following adjuvant breast cancer chemotherapy: a pilot study. Oncol Nurs Forum2000;27:14431448.

    • Search Google Scholar
    • Export Citation
  • 56.

    RoscoeJAMorrowGRHickokJT. Temporal interrelationships among fatigue, circadian rhythm and depression in breast cancer patients undergoing chemotherapy treatment. Support Care Cancer2002;10:329336.

    • Search Google Scholar
    • Export Citation
  • 57.

    LevinRDDaehlerMAGrutschJF. Circadian function in patients with advanced non-small-cell lung cancer. Br J Cancer2005;93:12021208.

  • 58.

    RichTInnominatoPFBoernerJ. Elevated serum cytokines correlated with altered behavior, serum cortisol rhythm, and dampened 24-hour rest-activity patterns in patients with metastatic colorectal cancer. Clin Cancer Res2005;11:17571764.

    • Search Google Scholar
    • Export Citation
  • 59.

    GlausABoehmeCHThűrlimannB. Fatigue and menopausal symptoms in women with breast cancer undergoing hormonal cancer treatment. Ann Oncol1006;17:801806.

    • Search Google Scholar
    • Export Citation
  • 60.

    GivenBGivenCAzzouzF. Physical functioning of elderly cancer patients prior to diagnosis and following initial treatment. Nurs Res2001;50:222232.

    • Search Google Scholar
    • Export Citation
  • 61.

    FoxSWLyonDFaraceE. Symptom clusters in patients with high-grade glioma. J Nurs Scholarsh2007;39:6167.

  • 62.

    BarsevickAMDudleyWNBeckSL. Cancer-related fatigue, depressive symptoms, and functional status: a mediation model. Nurs Res2006;55:366372.

    • Search Google Scholar
    • Export Citation
  • 63.

    MorinCMBootzinRRBuysseDJ. Psychological and behavioral treatment of insomnia: update of the recent evidence (1998–2004). Sleep2006;29:13981414.

    • Search Google Scholar
    • Export Citation
  • 64.

    MorgenthalerTKramerMAlessiC. Practice parameters for the psychological and behavioral treatment of insomnia: an update. An American Academy of Sleep Medicine report. Sleep2006;29:14151419.

    • Search Google Scholar
    • Export Citation
  • 65.

    SackettDL. Rules of evidence and clinical recommendations for the management of patients. Can J Cardiol1993;9:487489.

  • 66.

    BartonSed.Clinical Evidence Concise: The International Source of the Best Available Evidence for Effective Health Care 7th ed.Kingsport, TN: BMJ Publishing Group; 2002.

    • Search Google Scholar
    • Export Citation
  • 67.

    MitchellSAFrieseCR. Weight of evidence. Available at: http://www.ons.org/outcomes/tables/documents/woevidence.pdf. Accessed September 26 2007.

    • Search Google Scholar
    • Export Citation
  • 68.

    GobelBHBeckSLO'LearyC. Nursing-sensitive patient outcomes: the development of the putting evidence into practice resources for nursing practice. Clin J Oncol Nurs2006;10:621624.

    • Search Google Scholar
    • Export Citation
  • 69.

    MitchellSABeckSLHoodLE. Putting evidence into practice: evidence-based interventions for fatigue during and following cancer and its treatment. Clin J Oncol Nurs2007;11:99113.

    • Search Google Scholar
    • Export Citation
  • 70.

    PageMSBergerAMJohnsonLB. Putting evidence into practice: evidence-based interventions for sleep-wake disturbances. Clin J Oncol Nurs2006;10:753767.

    • Search Google Scholar
    • Export Citation
  • 71.

    MorinCMCulbertJPSchwartzSM. Nonpharmacological interventions for insomnia: a meta-analysis of treatment efficacy. Am J Psychiatry1994;151:11721180.

    • Search Google Scholar
    • Export Citation
  • 72.

    BelangerLSavardJMorinCM. Clinical management of insomnia using cognitive therapy. Behav Sleep Med2006;4:179198.

  • 73.

    SzubaMPKlossJEDingesDF. Insomnia Principles and Management. New York: Cambridge University Press; 2003.

  • 74.

    CurrieSRWilsonKGPontefractAJ. Cognitive-behavioral treatment of insomnia secondary to chronic pain. J Consult Clin Psycho2000;68:407416.

    • Search Google Scholar
    • Export Citation
  • 75.

    LichsteinKLWilsonNMJohnsonCT. Psychological treatment of secondary insomnia. Psychol Aging2000;15:232240.

  • 76.

    CurrieSRClarkSHodginsDC. Randomized controlled trial of brief cognitive-behavioural interventions for insomnia in recovering alcoholics. Addiction2004;99:11211132.

    • Search Google Scholar
    • Export Citation
  • 77.

    RybarczykBLopezMBensonR. Efficacy of two behavioral treatment programs for comorbid geriatric insomnia. Psychol Aging2002;17:288298.

    • Search Google Scholar
    • Export Citation
  • 78.

    BergerAMVonEssenSKuhnBR. Feasibility of a sleep intervention during adjuvant breast cancer chemotherapy. Oncol Nurs Forum2002;29:14311441.

    • Search Google Scholar
    • Export Citation
  • 79.

    BergerAMVon EssenSKuhnBR. Adherence, sleep, and fatigue outcomes after adjuvant breast cancer chemotherapy: results of a feasibility intervention study. Oncol Nurs Forum2003;30:513522.

    • Search Google Scholar
    • Export Citation
  • 80.

    DavidsonJRWaisbergJLBrundageMD. Nonpharmacologic group treatment of insomnia: a preliminary study with cancer survivors. Psychooncology2001;10:389397.

    • Search Google Scholar
    • Export Citation
  • 81.

    QuesnelCSavardJSimardS. Efficacy of cognitive-behavioral therapy for insomnia in women treated for nonmetastatic breast cancer. J Consult Clin Psychol2003;71:189200.

    • Search Google Scholar
    • Export Citation
  • 82.

    SavardJSimardSIversH. Randomized study on the efficacy of cognitive-behavioral therapy for insomnia secondary to breast cancer, part I: sleep and psychological effects. J Clin Oncol2005;23:60836096.

    • Search Google Scholar
    • Export Citation
  • 83.

    CarlsonLEGarlandSN. Impact of mindfulness-based stress reduction (MBSR) on sleep, mood, stress and fatigue symptoms in cancer outpatients. Int J Behav Med2005;12:278285.

    • Search Google Scholar
    • Export Citation
  • 84.

    KimYRoscoeJAMorrowGR. The effects of information and negative affect on severity of side effects from radiation therapy for prostate cancer. Support Care Cancer2002;10:416421.

    • Search Google Scholar
    • Export Citation
  • 85.

    MockVDowKHMearesCJ. Effects of exercise on fatigue, physical functioning, and emotional distress during radiation therapy for breast cancer. Oncol Nurs Forum1997;24:9911000.

    • Search Google Scholar
    • Export Citation
  • 86.

    CulpepperL. Secondary insomnia in the primary care setting: review of diagnosis, treatment, and management. Curr Med Res Opin2006;22:12571268.

    • Search Google Scholar
    • Export Citation
  • 87.

    HirstASloanR. Benzodiazepines and related drugs for insomnia in palliative care. Cochrane Database Syst Rev2004;4:CD003346.

  • 88.

    TaibiDMLandisCAPetryH. A systematic review of valerian as a sleep aid: safe but not effective. Sleep Med Rev2007;11:209230.

  • 89.

    BainKT. Management of chronic insomnia in elderly persons. Am J Geriatr Pharmacother2006;4:168192.

  • 90.

    DolderCNelsonMMcKinseyJ. Use of non-benzodiazepine hypnotics in the elderly: are all agents the same?CNS Drugs2007;21:389405.

  • 91.

    DundarYDoddSStroblJ. Comparative efficacy of newer hypnotic drugs for the short-term management of insomnia: a systematic review and meta-analysis. Hum Psychopharmacol2004;19:305322.

    • Search Google Scholar
    • Export Citation
  • 92.

    GlassJLanctotKLHerrmannN. Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. BMJ2005;331:11691173.

    • Search Google Scholar
    • Export Citation
  • 93.

    BrueraEDriverLBarnesEA. Patient-controlled methylphenidate for the management of fatigue in patients with advanced cancer: a preliminary report. J Clin Oncol2003;21:44394443.

    • Search Google Scholar
    • Export Citation
  • 94.

    BrueraEStrasserFShenL. The effect of donepezil on sedation and other symptoms in patients receiving opioids for cancer pain: a pilot study. J Pain Symptom Manage2003;26:10491054.

    • Search Google Scholar
    • Export Citation
  • 95.

    BrueraEValeroVDriverL. Patient-controlled methylphenidate for cancer fatigue: a double-blind, randomized, placebo-controlled trial. J Clin Oncol2006;24:20732078.

    • Search Google Scholar
    • Export Citation
  • 96.

    CullumJLWojciechowskiAEPelletierG. Bupropion sustained release treatment reduces fatigue in cancer patients. Can J Psychiatry2004;49:139144.

    • Search Google Scholar
    • Export Citation
  • 97.

    HannaASledgeGMayerML. A phase II study of methylphenidate for the treatment of fatigue. Support Care Cancer2006;14:210215.

  • 98.

    MossELSimpsonJSPelletierG. An open-label study of the effects of bupropion SR on fatigue, depression and quality of life of mixed-site cancer patients and their partners. Psychooncology2006;15:259267.

    • Search Google Scholar
    • Export Citation
  • 99.

    SarhillNWalshDNelsonKA. Methylphenidate for fatigue in advanced cancer: a prospective open-label pilot study. Am J Hosp Palliat Care2001;18:187192.

    • Search Google Scholar
    • Export Citation
  • 100.

    SchwartzALThompsonJAMasoodN. Interferon-induced fatigue in patients with melanoma: a pilot study of exercise and methylphenidate. Oncol Nurs Forum2002;29:E85E90.

    • Search Google Scholar
    • Export Citation
  • 101.

    ShawEGRosdhalRD'AgostinoRBJr. Phase II study of donepezil in irradiated brain tumor patients: effect on cognitive function, mood, and quality of life. J Clin Oncol2006;24:14151420.

    • Search Google Scholar
    • Export Citation
  • 102.

    SugawaraYAkechiTShimaY. Efficacy of methylphenidate for fatigue in advanced cancer patients: a preliminary study. Palliat Med2002;16:261263.

    • Search Google Scholar
    • Export Citation
  • 103.

    CapuronLGumnickJFMusselmanDL. Neurobehavioral effects of interferon-alpha in cancer patients: phenomenology and paroxetine responsiveness of symptom dimensions. Neuropsychopharmacology2002;26:643652.

    • Search Google Scholar
    • Export Citation
  • 104.

    MorrowGRHickokJTRoscoeJA. Differential effects of paroxetine on fatigue and depression: a randomized, double-blind trial from the University of Rochester Cancer Center Community Clinical Oncology Program. J Clin Oncol2003;21:46354641.

    • Search Google Scholar
    • Export Citation
  • 105.

    RoscoeJAMorrowGRHickokJT. Effect of paroxetine hydrochloride (Paxil) on fatigue and depression in breast cancer patients receiving chemotherapy. Breast Cancer Res Treat2005;89:243249.

    • Search Google Scholar
    • Export Citation
  • 106.

    WeitznerMAMoncelloJJacobsenPB. A pilot trial of paroxetine for the treatment of hot flashes and associated symptoms in women with breast cancer. J Pain Symptom Manage2002;23:337345.

    • Search Google Scholar
    • Export Citation
  • 107.

    CaraceniASimonettiF. Psychostimulants: new concepts for palliative care from the modafinil experience?J Pain Symptom Manage2004;28:9799.

    • Search Google Scholar
    • Export Citation
  • 108.

    CoxJMPappagalloM. Modafinil: a gift to portmanteau. Am J Hosp Palliat Care2001;18:408410.

  • 109.

    PrommerE. Modafinil: is it ready for prime time?J Opioid Manag2006;2:130136.

  • 110.

    RiveraVM. Modafinil for the treatment of diminished responsiveness in a patient recovering from brain surgery. Brain Inj2005;19:725727.

    • Search Google Scholar
    • Export Citation
  • 111.

    SpathisAMorrishEBoothS. Selective circadian rhythm disturbance in cerebral lymphoma. Sleep Med2003;4:583586.

  • 112.

    TortaRBerraCBinaschiL. Amisulpride in the short-term treatment of depressive and physical symptoms in cancer patients during chemotherapies. Support Care Cancer2007;15:539546.

    • Search Google Scholar
    • Export Citation
  • 113.

    Food and Drug Administration. (March 142007). FDA News March 14 2007. Available at: http://www.fda.gov/bbs/topics/NEWS/2007/NEW01587.html. Accessed September 26 2007.

    • Search Google Scholar
    • Export Citation
  • 114.

    MayersAGBaldwinDS. Antidepressants and their effect on sleep. Hum Psychopharmacol2005;20:533559.

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