Suicidal and death ideation in Parkinson's disease

Risk of Parkinson's disease and depression severity in different populations: A two-sample Mendelian randomization analysis

BACKGROUND

Depression is widely recognized as a common non-motor symptom of Parkinson's disease (PD). Across different studies, the reported prevalence of depression in PD varies widely, ranging from 2.7% to 90%, but it is unclear whether this association is due to genetic or acquired factors. Whether there is a causal relationship remains unknown. The aim of this study was to use a two-sample Mendelian randomization (MR) approach to investigate the causal effect of PD on depression.

METHODS

Analyses were conducted separately for individuals of European and East Asian ancestry using publicly available summary data from genome-wide association studies. Depression was divided into two categories: ever depressed for a whole week and major depressive disorder (MDD). PD data were used as the exposure and were obtained from the International Parkinson's Disease Genomics Consortium and the BioBank Japan PheWeb, while depression data were used as the outcome and were obtained from the ntegrative Epidemiology Unit (IEU) Open GWAS Project(A public GWAS database） and the Psychiatric Genomics Consortium. The influence of PD on depression was assessed using inverse variance weighted (IVW), weighted median, MR-Egger, and weighted mode methods. Heterogeneity and pleiotropy were tested, and the results were validated using FinnGen GWAS data from version R9.

RESULTS

In individuals of European ancestry, there was a causal relationship between PD and ever depressed for a whole week (IVW method, odds ratio [OR] = 0.990; 95% CI, 0.984-0.996; p = .002), but no causal relationship was observed between PD and MDD (IVW method, OR = 0.974; 95% CI, 0.942-1.009; p = .141). In individuals of East Asian ancestry, no causal relationship was observed between PD and ever depressed for a whole week (IVW method, OR = 1.001; 95% CI, 0.829-1.209; p = .990) and between PD and MDD (IVW method, OR = 1.017; 95% CI, 0.982-1.052; p = .342). The results of the three additional analysis methods were similar to those of the IVW method, and there was no heterogeneity according to Cochran's Q-test. There was no evidence of pleiotropy based on MR-Egger intercept test and MR-PRESSO. The FinnGen validation dataset supported these findings. The results are stable and reliable.

CONCLUSION

The observed increase in depression among PD patients could potentially be attributed to modifiable acquired factors. Consequently, there is an urgent need to strengthen the management of PD patients in order to prevent the development of depression in the future.

Neuronavigated repetitive transcranial magnetic stimulation improves depression, anxiety and motor symptoms in Parkinson's disease

Background

Repetitive transcranial magnetic stimulation (rTMS) is a potential treatment option for Parkinson's disease patients with depression (DPD), but conflicting results in previous studies have questioned its efficacy.

Method

To investigate the safety and efficacy of neuronavigated high-frequency rTMS at the left DLPFC in DPD patients, we conducted a randomized, double-blind, sham-controlled study (NCT04707378). Sixty patients were randomly assigned to either a sham or active stimulation group and received rTMS for ten consecutive days. The primary outcome was HAMD, while secondary outcomes included HAMA, MMSE, MoCA and MDS-UPDRS-III. Assessments were performed at baseline, immediately after treatment, 2 weeks, and 4 weeks post-treatment.

Results

The GEE analysis showed that the active stimulation group had significant improvements in depression, anxiety, and motor symptoms at various time points. Specifically, there were significant time-by-group interaction effects in depression immediately after treatment (β, -4.34 [95% CI, -6.90 to -1.74; P = 0.001]), at 2 weeks post-treatment (β, -3.66 [95% CI, -6.43 to -0.90; P = 0.010]), and at 4 weeks post-treatment (β, -4.94 [95% CI, -7.60 to -2.29; P < 0.001]). Similarly, there were significant time-by-group interaction effects in anxiety at 4 weeks post-treatment (β, -2.65 [95% CI, -4.96 to -0.34; P = 0.024]) and in motor symptoms immediately after treatment (β, -5.72 [95% CI, -9.10 to -2.34; P = 0.001] and at 4 weeks post-treatment (β, -5.43 [95% CI, -10.24 to -0.61; P = 0.027]).

Conclusion

The study suggested that neuronavigated high-frequency rTMS at left DLPFC is effective for depression, anxiety, and motor symptoms in PD patients.

Suicidal ideation among people with Parkinson's disease and comparison with a control group

BACKGROUND

Detection of suicidal ideation (SI) is key for trying to prevent suicide. The aim of this study was to analyze the frequency of SI and related factors in Spanish people with Parkinson's Disease (PwPD) and to compare them with a control group.

METHODS

PD patients and controls recruited from the Spanish cohort COPPADIS from January 2016 to November 2017 were included. Two visits were conducted: V0 (baseline); V2 (2-year ± 1 month follow-up). SI was defined as a score ≥1 on item nine of the Beck Depression Inventory-II (BDI-II). Regression analyses were conducted to identify factors related to SI.

RESULTS

At baseline, 693 PwPD (60.2% males; 62.59 ± 8.91 years old) and 207 controls (49.8% males; 60.99 ± 8.32 years old) were included. No differences between PwPD and controls were detected in SI frequency at either V0 (5.1% [35/693] vs. 4.3% [9/207]; p = 0.421) or at V2 (5.1% [26/508] vs. 4.8% [6/125]; p = 0.549). Major depression (MD) and a worse quality of life were associated with SI at both visits in PwPD: V0 (MD, OR = 5.63; p = 0.003; PDQ-39, OR = 1.06; p = 0.021); V2 (MD, OR = 4.75; p = 0.027; EUROHIS-QOL8, OR = 0.22; p = 0.006). A greater increase in the BDI-II total score from V0 to V2 was the only factor predicting SI at V2 (OR = 1.21; p = 0.002) along with an increase in the total number of non-antiparkinsonian drugs (OR = 1.39; p = 0.041).

CONCLUSION

The frequency of SI (5%) in PwPD was similar to in controls. Depression, a worse quality of life, and a greater comorbidity were related to SI.

High frequency of Depressive Disorders and Suicidal Phenomena in Late-Stage Parkinson´s Disease - A Cross-Sectional Study

BACKGROUND

Depressive disorders (DD) are widely recognized as one of the most frequent neuropsychiatric disorders in Parkinson´s disease. Patients with late-stage Parkinson´s disease (LSPD) continue to be a neglected population, and little is known about DD frequency in LSPD.

OBJECTIVES

To determine the frequency of DD in LSPD patients through a clinical diagnostic interview (CDI) and according to diagnostic DSM- 5 criteria. Secondary objectives were to determine the predictive ability of depressive scales to detect DD, to identify potential predictors of DD in LSPD and, to evaluate suicidal phenomena in LSPD.

METHODS

A cross-sectional study including LSPD patients (≥7 years from symptom onset and Hoehn and Yahr scale score >3 or a Schwab and England scale score <50% in the ON condition) was conducted. Patients were subjected to psychiatric, neurological, and neuropsychological evaluations. Six depression scales were applied.

RESULTS

92 LSPD patients were included. 59.78% of LSPD patients had a current diagnosis of DD according to CDI, 38.04% patients had a diagnosis of major depressive disorder, and 21.72% non-major depressive disorder. Suicidal ideation was present in 36.96% of patients. All applied scales were able to detect depressive disorders.

CONCLUSIONS

More than half of LSPD patients met DD diagnostic criteria and over one-third were diagnosed with major depressive disorder. Overall, the LSPD population seem to have a unique clinical phenotype regarding the frequency and features of DD, whose early identification and treatment could improve the quality of life of patients and caregivers.

Identifying Depression in Parkinson's Disease by Using Combined Diffusion Tensor Imaging and Support Vector Machine

Objective

To investigate white matter microstructural alterations in Parkinson's disease (PD) patients with depression using the whole-brain diffusion tensor imaging (DTI) method and to explore the DTI–based machine learning model in identifying depressed PD (dPD).

Methods

The DTI data were collected from 37 patients with dPD and 35 patients with non-depressed PD (ndPD), and 25 healthy control (HC) subjects were collected as the reference. An atlas-based analysis method was used to compare fractional anisotropy (FA) and mean diffusivity (MD) among the three groups. A support vector machine (SVM) was trained to examine the probability of discriminating between dPD and ndPD.

Results

As compared with ndPD, dPD group exhibited significantly decreased FA in the bilateral corticospinal tract, right cingulum (cingulate gyrus), left cingulum hippocampus, bilateral inferior longitudinal fasciculus, and bilateral superior longitudinal fasciculus, and increased MD in the right cingulum (cingulate gyrus) and left superior longitudinal fasciculus-temporal part. For discriminating between dPD and ndPD, the SVM model with DTI features exhibited an accuracy of 0.70 in the training set [area under the receiver operating characteristic curve (ROC) was 0.78] and an accuracy of 0.73 in the test set (area under the ROC was 0.71).

Conclusion

Depression in PD is associated with white matter microstructural alterations. The SVM machine learning model based on DTI parameters could be valuable for the individualized diagnosis of dPD.

Association between new-onset Parkinson's disease and suicide risk in South Korea: a nationwide cohort study

BACKGROUND

Parkinson's disease (PD) is an increasingly common neurodegenerative disease in an aging society. Whether PD is associated with an increased suicide risk is unclear. Thus, we investigated the effect of new-onset PD on suicide.

METHODS

Using the National Health Insurance Service Senior Sample Cohort of South Korea, 17,143 incident PD patients and 17,143 risk set controls, matched by propensity score, were selected for follow-up. The incidence rate of suicide and 95% confidence interval (CI) were calculated based on a generalized linear model of the Poisson distribution. Effect sizes were expressed as hazard ratios (HRs) using the Cox proportional hazards model with a robust variance estimator that incorporated clustering within matched pairs.

RESULTS

The incidence rate of suicide was 206.7 cases per 100,000 person-years (95% CI, 172.8-246.9) among the PD cohort. Compared to the matched controls, patients with PD were 2.64 times (HR, 2.64; 95% CI, 1.31-5.30) more likely to commit suicide during the first 180 days of follow-up and 2.47 times (HR, 2.47; 95% CI, 1.42-4.28) within the first 365 days of follow-up. During the entire follow-up period, patients with PD were 2.26 times more likely to commit suicide than were their matched controls (HR, 2.26; 95% CI, 1.67-3.06).

CONCLUSION

Our findings indicated an increased risk of suicide in patients with new-onset PD, regardless of the period after diagnosis. Incorporating mental health care with social and environmental interventions into primary care and PD-specialized care can help reduce suicide risk in people with PD, improving suicide prevention, identification, and risk assessment.

Parkinson and depression: review and outlook

Depression in Parkinson's Disorder (DPD) has been estimated to appear in up to 40% of people with PD and negatively impacts quality of life, motor and cognitive deficits and functional disability. Knowledge of the pathophysiology of DPD is unclear, DPD may be related to dysfunction in subcortical nuclei and the prefrontal cortex, striatal-thalamic-prefrontal and basotemporal limbic circuits, brainstem monoamine, and indolamine (i.e. dopamine, serotonin, and norepinephrine) systems. DPD is characterized by sadness, loss of interest, increased exhaustibility, feelings of helplessness, reduced drive, dysphoria, irritability, and pessimism about future. The diagnosis is complicated by overlap with PD symptoms, Detection of depression in PD should be made by psychometric depression scales. DPD is underrecognized and undertreated in clinical practice. Treatment mainly includes antidepressive medications and behavioral interventions as psychotherapy. Dopamine agonists showed some antidepressant effects, there are no sufficient numbers of RCTs. Important randomized clinical trials (RCTs) are summarized. SSRIs and SNRIs have a satisfying efficacy in DPD. TCAs are also good for improving depression. Side effects of different antidepressants (e.g. TCAs, SSRIs, SNRIs, bupropion, MAOIs) and potential interactions should be considered. In existing guidelines so far no statements, algorithms and recommendations are given for diagnosis and treatment of DPD. Methodologically adequate designed RCTs and comparative studies (NIS) which offer evidence-based results are urgently needed having the impact of DPD in mind.

Suicidal Ideations and Behavior in Patients With Young and Late Onset Dementia

Background and Objectives: Data on suicidal ideation, behavior and the risk factors in patients with dementia is scarce. To evaluate the prevalence of death wishes, suicidal ideation, and suicidal behavior of young (YOD) and late onset dementia (LOD) and to identify risk factors for suicidal ideation and behavior. Methods: We interviewed 157 family caregivers of patients with advanced dementia using questions from the Columbia-Suicide Severity Rating Scale to gather information about suicidal ideation and behavior before the onset of symptoms of dementia, after the onset of dementia and within 30 days prior to the interview. At the time of the interview, we also assessed disease severity, cognitive function, and other psychological, behavioral and physical symptoms of the patients as well as the caregivers' psychological well-being. Results: Forty four (28%) of the patients expressed suicidal ideation or behavior at some time after the onset of symptoms, and 14 (9%) of these within the month prior to the assessment. Two patients had attempted suicide after the onset of dementia. There were no statistically significant differences between patients with and without suicidal ideations or behavior with regards to demographics or age at onset of dementia. In patients with advanced dementia, Alzheimer's disease (rather than frontotemporal lobar degeneration), better cognitive function, more severe psychological, behavioral, and physical symptoms, and a reduced quality of life were associated with the expression of suicidal ideation. Conclusions: According to caregivers' reports, majority of patients with dementia did not express suicidal ideation or show suicidal behavior. Patients who expressed suicidal ideation during early stages of dementia often stopped expressing them in advanced stages. It remains unclear if this was due to reduced communication abilities, a reduction of disease awareness, and/ or an adjustment to their situation.

Assisted Suicide in Parkinsonian Disorders

Background: Due to the high prevalence of suicidal ideation in Parkinson's Disease (PD) and exploratory data indicating a similar prevalence in atypical Parkinsonian disorders (APD), we sought to determine the frequency of assisted suicide (AS) as well as factors driving these decisions in PD and APD.

Methods: Retrospective chart analysis (2006-2012) at a Swiss Right-to-Die organization. Patients with PD and APD who completed AS were analyzed concerning disease state, symptom burden, medication, and social factors.

Results: We identified 72 patients (PD = 34, PSP = 17, MSA = 17, CBS = 4; 7.2% of all AS cases), originating mainly from Germany (41.7%), Great Britain (29.2%), and the US (8.3%). Predominant symptoms at the time of application were immobility (PD/APD: 91%/97%), helplessness (63%/70%), pain (69%/19%), dysarthria (25%/32%), and dysphagia (19%/59%). APD patients generally showed a higher symptom burden and a higher frequency of diagnosed depression (8.8%/28.9%). While most patients with diagnosed depression received antidepressants (80%), other symptoms such as pain (59%) were treated less consistently. Of note, time from diagnosis to application differed greatly between PD (8.5 ± 6.8 years) and APD (1.5 ± 1.3 years, p < 0.0001).

Conclusions: In our analysis, Parkinsonian disorders appeared to be overrepresented as a cause of AS considering the prevalence of these diseases. The observation that assisted suicide is sought early after initial diagnosis in APD implies the need for early comprehensive psychological support of these patients and their relatives.

Suicidal ideation in early-onset Parkinson's disease

OBJECTIVE

Patients with early-onset Parkinson's disease (EOPD) often suffer from more frequent depression than those with late-onset Parkinson's disease (LOPD). However, the clinical characteristics of suicidal ideation (SI) in EOPD remains unknown. This study aimed to explore the prevalence, related factors, and predictive factors of SI in EOPD patients as well as comparison of the prevalence in LOPD patients.

METHODS

We conducted a case-control, cross-sectional, and longitudinal study. Propensity score matching (PSM) was used to balance the characteristics between EOPD (N = 577) and LOPD patients (N = 2973). The diagnosis of SI was based on the assessment of the Beck Depression Inventory (BDI). EOPD patients with a disease duration < 5 years (N = 96) were prospectively followed-up for exploring the predictors for the development of SI. Two forward binary logistic regression models were respectively used to explore the associated and predictive factors of SI.

RESULTS

After PSM, EOPD patients showed significantly higher prevalence of SI than LOPD patients (22.0 vs. 13.3%, P < 0.001). Twenty EOPD patients (20.8%) developed SI and none of them reported suicidal behaviors after a median of 2.7 (IQR = 1.6-4.1) years. Depression, dyskinesia, non-smoking, lower education, and higher Non-Motor Symptoms Scale (NMSS) score were independently associated with the presence of SI. Depression at baseline was the only independent risk factor for the future occurrence of SI.

CONCLUSIONS

Our study highlights the necessity to screen SI in patients with EOPD especially for those with depression.

Suicidal and death ideation in patients with progressive supranuclear palsy and corticobasal syndrome

OBJECTIVE

A large proportion of patients with atypical parkinsonian syndromes suffer from depression, an antecedent of suicide. This study aimed to explore the prevalence and clinical correlates of suicidal and death ideation (SDI) in patients with Progressive Supranuclear Palsy (PSP) and Corticobasal Syndrome (CBS), as well as compare the differences with patients with Parkinson's disease (PD).

METHODS

This was a case-control, cross-sectional study. SDI was diagnosed based on the assessment of the Hamilton Depression Rating Scale (HRDS). The prevalence of SDI among patients with PD, PSP, and CBS (n = 3400, 268, and 65 respectively) were compared before and after propensity score matching (PSM). A forward binary logistic regression model was used to explore the associated factors of SDI.

RESULTS

None of the patients reported suicide attempts. The prevalence of SDI in patients with PSP and CBS were 27.2% and 29.2%, respectively, which was significantly higher than that in patients with PD before and after PSM (P < 0.05). The prevalence of SDI was not significantly different among patients with PSP with different subtypes (Richardson syndrome, Parkinsonism, and other), both before and after PSM (P > 0.05). Multivariate analysis indicated that higher gait and midline score and depression were independently associated with an increased risk of SDI in patients with PSP (P < 0.05), while higher non-motor symptoms score and depression were independently associated with the occurrence of SDI in patients with CBS (P < 0.05).

CONCLUSIONS

Our study highlights the importance of screening SDI in patients with PSP and CBS.

Electroconvulsive Therapy for Parkinson's Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Electroconvulsive therapy (ECT) is a well-established treatment for psychiatric disorders, including depression and psychosis. ECT has been reported to be effective in treating such psychiatric symptoms in patients with Parkinson's disease (PD) and has been also reported to be effective in treating motor symptoms. The aim of the study is to summarize previous clinical studies investigating the efficacy of ECT for symptoms in patients with PD.

METHODS

A systematic review and meta-analysis of any study designs assessing motor and/or non-motor symptoms in patients with PD before and after ECT. Co-primary outcomes were set as motor manifestations assessed using the Unified Parkinson's Disease Rating Scale or other rating scales, and non-motor symptoms included depression and psychosis. Secondary outcomes were wearing-off phenomenon and cognitive function. The impact of ECT on those symptoms was examined by comparing the severity of the symptoms before and after ECT using a random effect model and was expressed in standardized mean difference.

RESULTS

Of 1219 identified citations, 14 studies (n = 129; 1 randomized controlled study, 9 prospective observational studies, and 4 retrospective studies) were analyzed. The findings were as follows: ECT significantly improved motor manifestations in patients with PD, and the improvement was significant in the subpopulation without psychiatric symptoms; ECT significantly improved depression and psychosis; and ECT significantly relieved wearing-off phenomenon and did not worsen cognitive functioning.

CONCLUSION

The current meta-analysis suggests the potential benefit of ECT on motor and non-motor symptoms in presumably complicated and difficult-to-treat subgroups. © 2020 International Parkinson and Movement Disorder Society.

Management of psychiatric disorders in Parkinson's disease : Neurotherapeutics - Movement Disorders Therapeutics

Affective disorders (depression and anxiety), psychosis, impulse control disorders, and apathy are common and sometimes disabling psychiatric conditions in Parkinson disease (PD). Psychiatric aspects of PD are associated with numerous adverse outcomes, yet in spite of this and their high frequency, there remains incomplete understanding of epidemiology, presentation, risk factors, neural substrate, and management strategies. Psychiatric features are typically co- or multimorbid, and there is great intra- and interindividual variability in presentation [1]. The neuropathophysiological changes that occur in PD, as well as the association between PD treatment and particular psychiatric disorders, suggest a neurobiological contribution to many psychiatric symptoms. There is evidence that psychiatric disorders in PD are still under-recognized and undertreated, and although psychotropic medication use is common, randomized controlled trials demonstrating efficacy and tolerability are largely lacking. Future research on neuropsychiatric complications in PD should be oriented toward determining modifiable correlates or risk factors, and most importantly, establishing efficacious and well-tolerated treatment strategies.

Suicide in Parkinson's Disease: A Systematic Review

Psychiatric disorders and suicide have been reported in patients suffering from Parkinson's disease. The aims of the present paper were to determine whether patients with Parkinson's disease have an increased rate of suicide and to identify the clinical features possibly associated with suicide risk in Parkinson's disease. We also reviewed the studies on suicide risk in Parkinson's disease in patients after deep brain stimulation. We performed a Medline, Excerpta Medica, PsycLit, PsycInfo and Index Medicus search to identify all articles published on this topic from 1970 to 2019. The following search terms were used: suicide OR suicide attempt OR suicidal ideation OR suicide risk AND Parkinson's disease AND Parkinson's disease and deep brain stimulation. The studies we identified that assessed the suicide rate associated with Parkinson's disease yielded contrasting results, although an increase in suicidal ideation did emerge. The studies on the effect of deep brain stimulation on suicide risk in Parkinson's disease also reported mixed findings. Psychiatric symptoms, including depression, appear to be associated with suicide risk in patients with Parkinson's disease undergoing medical and after surgical treatment. The studies reviewed suggest that suicidal ideation is increased in Parkinson's disease. Further longitudinal studies designed to assess suicidality in this condition are still needed.

Depression Comorbid With Stroke, Traumatic Brain Injury, Parkinson's Disease, and Multiple Sclerosis: Diagnosis and Treatment

Depression is common among patients with neurologic disorders, and it has long been considered more difficult to treat than depression in the general population. In this review, the authors consider challenges in the diagnosis and treatment of depression among patients with stroke, traumatic brain injury, Parkinson's disease, and multiple sclerosis. For each disorder, the authors discuss the epidemiology and time course of depression as well as review the physiologic and psychological etiologies of depression. In addition, for each disorder, they review screening tools and diagnostic considerations, including differential diagnosis; discuss etiological factors, both neurobiological and psychological; and assess evidence for various depression treatments, including pharmacologic, psychosocial, and neuromodulatory therapies. The evidence suggests that depression is common among patients with neurologic disorders and that it is crucial for general psychiatrists to provide treatment for this population.

Characterizing the phenomenology of passive suicidal ideation: a systematic review and meta-analysis of its prevalence, psychiatric comorbidity, correlates, and comparisons with active suicidal ideation

BACKGROUND

Compared to active ideation, passive ideation remains relatively understudied and its clinical importance poorly defined. The weight that should be accorded passive ideation in clinical risk assessment is therefore unclear.

METHODS

We conducted a systematic review and meta-analysis of the prevalence of passive ideation, its psychiatric comorbidity, associated sociodemographic characteristics, as well as psychological and environmental correlates. For reference, pooled effects were also calculated for direct comparisons of passive and active ideation with respect to potential correlates. Relevant articles published since inception to 9 September 2019 were identified through a systematic search of MEDLINE and PsycINFO.

RESULTS

A total of 86 studies were included in this review. The prevalence of passive ideation was high across sample types, ranging from 5.8% for 1-year prevalence to 10.6% for lifetime prevalence in the general population. Passive ideation was strongly associated with sexual minority status, psychiatric comorbidity, psychological characteristics implicated in risk, and suicide attempts. Preliminary evidence exists for a large association with suicide deaths. The effect sizes for individual correlates of passive and active ideation were largely equivalent and mostly non-significant in head-to-head comparisons.

CONCLUSIONS

Passive ideation is a prevalent clinical phenomenon associated with significant psychiatric comorbidity. Current evidence also suggests notable similarities exist between passive and active ideation in terms of psychiatric comorbidity and psychological and other characteristics traditionally associated with risk.

The Neuropsychiatry of Parkinson Disease: A Perfect Storm

Affective disorders, cognitive decline, and psychosis have long been recognized as common in Parkinson disease (PD), and other psychiatric disorders include impulse control disorders, anxiety symptoms, disorders of sleep and wakefulness, and apathy. Psychiatric aspects of PD are associated with numerous adverse outcomes, yet in spite of this and their frequent occurrence, there is incomplete understanding of epidemiology, presentation, risk factors, neural substrate, and management strategies. Psychiatric features are typically multimorbid, and there is great intra- and interindividual variability in presentation. The hallmark neuropathophysiological changes that occur in PD, plus the association between exposure to dopaminergic medications and certain psychiatric disorders, suggest a neurobiological basis for many psychiatric symptoms, although psychological factors are involved as well. There is evidence that psychiatric disorders in PD are still under-recognized and undertreated and although psychotropic medication use is common, controlled studies demonstrating efficacy and tolerability are largely lacking. Future research on neuropsychiatric complications in PD should be oriented toward determining modifiable correlates or risk factors and establishing efficacious and well-tolerated treatment strategies.

Anxiety spectrum disorders are common in patients with orthostatic tremor

Background

Orthostatic Tremor (OT) is a rare movement disorder characterized by a sensation of unsteadiness while standing and associated with high frequency tremors. Patients with OT commonly report a fear of falling and significant limitations in everyday activities. The prevalence of psychiatric comorbidities in OT patients has not been well-studied.

Methods

Subjects were evaluated by trained psychiatry researchers using the Mini International Neuropsychiatric Interview (M.I.N.I.). The M.I.N.I is a validated screening tool for psychiatric disorders. A standardized history covering previous psychiatric symptoms and illnesses was also obtained.

Results

29 OT subjects were evaluated. The mean age was 67.7 years with female preponderance (89.3%). The average disease symptom duration was 18.2 years. 58.6% of the subjects had seen a mental health professional during the course of their OT illness. 24.1% of the subjects had a past history of depression, and 10.3% reported a family history of any psychiatric condition. 37.9% of the subjects screened positive for agoraphobia. Two of 29 subjects (6.9%) were classified as having a current major depressive episode and one subject (3.4%) was at risk for suicide.

Conclusions

Psychiatric comorbidities are highly prevalent in OT patients, especially anxiety-spectrum disorders. Further studies are needed to understand if psychiatric disorders appear as a secondary response to the patient's symptoms, or are a primary non-motor manifestation of OT.

Suicide in Parkinson's disease

Persons with Parkinson's disease (PwP) have many known risk factors for suicide and suicidal ideation (SI). Despite this, there is limited understanding of suicidality in this population. We conducted a systematic review to synthesise the available literature on suicidality in PwP and highlight areas for potential intervention and further research. We identified 116 articles discussing SI, suicidal behaviours, suicide attempts and/or fatal suicide in PwP. These articles describe prevalence, suicide methods, risk factors for suicide and SI and treatment of suicidality. In this review, we summarise the current literature and provide suggestions for how clinicians can identify and treat PwP who are at risk for suicide, for example, through aggressive treatment of depression and improved screening for access to lethal means.

Depression Screening from Voice Samples of Patients Affected by Parkinson's Disease

Depression is a common mental health problem leading to significant disability world wide. Depression is not only common but also commonly co-occurs with other mental and neurological illnesses. Parkinson's Disease gives rise to symptoms directly impairing a person's ability to function. Early diagnosis and detection of depression can aid treatment, but diagnosis typically requires an interview with a health provider or structured diagnostic questionnaire. Thus, unobtrusive measures to monitor depression symptoms in daily life could have great utility in screening depression for clinical treatment. Vocal biomarkers of depression are a potentially effective method of assessing depression symptoms in daily life, which is the focus of the current research. We have a database of 921 unique patients with Parkinson's disease and their self assessment of whether they felt depressed or not. Voice recordings from these patients were used to extract paralinguistic features, which served as inputs to machine-learning and deep learning techniques to predict depression. The results are presented here and the limitations are discussed given the nature of the recordings which lack language content. Our models achieved accuracies as high as 0.77 in classifying depressed and non-depressed subjects accurately using their voice features and PD severity. We found depression and severity of Parkinson's Disease had a correlation coefficient of 0.3936, providing a valuable feature when predicting depression from voice. Our results indicate a clear correlation between feeling depressed and the severity of the Parkinson's disease. Voice may be an effective digital biomarker to screen for depression among patients suffering from Parkinson's Disease.

Psychiatric Manifestation in Patients with Parkinson's Disease

Parkinson's disease (PD) is the second most common neurodegenerative disorder. Although its major manifestation is motor symptoms, resulting from the loss of dopaminergic neurons in the substantia nigra, psychiatric symptoms, such as depression, anxiety, hallucination, delusion, apathy and anhedonia, impulsive and compulsive behaviors, and cognitive dysfunction, may also manifest in most patients with PD. Given that the quality of life - and the need for institutionalization - is so highly dependent on the psychiatric well-being of patients with PD, psychiatric symptoms are of high clinical significance. We reviewed the prevalence, risk factors, pathophysiology, and treatment of psychiatric symptoms to get a better understanding of PD for improved management.

Suicidal ideation, perceived disability, hopelessness and affective temperaments in patients affected by Parkinson's disease

BACKGROUND

Previous studies investigating the risk of suicide in patients with Parkinson's disease (PD) have reported conflicting results. This study evaluated suicide risk in PD and investigated the relationship between suicide risk and perceived disability, hopelessness and affective temperaments in PD.

METHODS

One-hundred and twenty PD patients were consecutively enrolled. The diagnosis of PD was based on clinical criteria. All patients underwent a psychiatric evaluation that included the administration of the Columbia-Suicide Severity Rating Scale, the Italian Perceived Disability Scale, the Beck Hopelessness Inventory and the TEMPS-A questionnaire. The results were compared with those of a control group of 91 patients affected by another chronic disease, ie, open angle glaucoma.

RESULTS

Parkinson's disease patients had higher suicidal ideation, higher perceived disability and lower hyperthymia than the control group. In PD, higher perceived disability was associated with higher current and lifetime suicidal ideation, lower hyperthymia, older age and higher scores on negative temperaments. Suicidal ideation, negative temperaments and hopelessness were risk factors for perceived disability, while hyperthymia was a protective factor for perceived disability.

DISCUSSION

Patients with PD have an increased risk of suicidal ideation. Increased suicidal ideation in PD is associated with the increased perceived disability. A psychiatric assessment that includes the investigation of suicide risk and perceived disability is recommended in patients with PD.

Amantadine Extended-Release (GOCOVRI™): A Review in Levodopa-Induced Dyskinesia in Parkinson's Disease

Amantadine extended-release (ER) capsules (GOCOVRI^™) are approved in the USA for the treatment of dyskinesia in patients with Parkinson's disease (PD) receiving levodopa-based therapy, with or without concomitant dopaminergic medications. With a recommended dosage of 274 mg once daily at bedtime, this new formulation of amantadine allows a more gradual time to peak plasma amantadine concentration and higher drug concentrations in the morning and throughout the day, the time period when levodopa-induced dyskinesia (LID) is the most problematic. In 13-week (EASE LID 3) and 25-week (EASE LID), randomized, double-blind phase III trials, once-daily amantadine ER 274 mg capsules significantly improved levodopa-induced dyskinesia (LID), while also increasing ON time without troublesome dyskinesia and reducing OFF time and ON time with troublesome dyskinesia from the morning and throughout the day, compared with placebo. In the ongoing, longer-term EASE LID 2 study (with interim results reported for up to 64 weeks), patients previously treated with amantadine ER maintained improvements in LID, as per patient-reported Unified Dyskinesia Rating Scale (UDysRS) scoring and ON/OFF times. Amantadine ER was generally well tolerated, with most adverse events (AEs) being transient and mild or moderate in severity. The most common (incidence > 15%) treatment-related AEs in the placebo-controlled trials were hallucinations, dizziness, dry mouth and peripheral oedema. While long-term data are needed to establish durability of response and safety, including the completion of the ≈ 2-year EASE LID 2 study, current evidence indicates that amantadine ER is an effective treatment option to consider in the management of LID in PD patients.

The Impact of Living with Parkinson's Disease: Balancing within a Web of Needs and Demands

This study explores the impact of living with Parkinson's disease (PD). Nineteen persons (11 women) aged 55–84 diagnosed with PD 3–27 years ago participated. Data were collected through semistructured interviews, which were recorded, transcribed verbatim, and analysed by qualitative content analysis. Four categories represented the impact of living with PD: “Changed prerequisites for managing day-to-day demands,” “Loss of identity and dignity,” “Compromised social participation,” and “The use of practical and psychological strategies.” There was a shift from an internal to an external locus of control in managing, control, competence, relatedness, and autonomy. According to self-determination theory, a shift towards extrinsically motivated behaviours may occur when these basic needs are thwarted, leading to compensatory strategies or needs substitutes with negative consequences on health and well-being. We suggest a needs-based approach as an important starting point to better understand the consequences of living with PD and to explore the means for people with PD to acquire an improved quality of life on their own terms. In conclusion, our findings suggest for a shift in focus, from a biomedical to a needs-based approach to understand the impact of living with PD and facilitate more person-centred care and person-centred outcome measurement.

Validation of the PHQ-9 for Suicidal Ideation in Persons with Inflammatory Bowel Disease

BACKGROUND

Suicide is a leading cause of death worldwide. Transition from suicidal ideation (SI) to suicide attempt is high within a year of SI onset. The risk of suicide and SI is elevated in persons with inflammatory bowel disease (IBD) versus the general population. We aimed to validate the Patient Heath Questionnaire (PHQ)-9 as a screening tool for SI in IBD and to determine factors associated with SI in IBD.

METHODS

IBD participants (n = 247) recruited from the community and clinics completed the PHQ-9 and participated in the Structured Clinical Interview for DSM-IV (SCID). We determined the sensitivity, specificity, and positive and negative predictive value (PPV and NPV) of the PHQ-9 in identifying SI as compared to the SCID. Using logistic regression we examined the association of SI with demographic and clinical factors.

RESULTS

SI was endorsed by 24 (9.7%) participants on the PHQ-9 and 5 (2.0%) based on the SCID. The PHQ-9 had good sensitivity (100%), specificity (92.2%), and NPV (100%) but low PPV (20.8%) for SI. On univariate analysis, factors strongly associated with SI were depression (OR 13.1; 95%CI: 4.46, 40.5), anxiety (OR 11.3; 95%CI: 4.46, 28.6), and active disease (OR 3.87; 95%CI: 1.54, 9.71). On multivariable analysis, depression (OR 5.54; 95%CI: 1.67, 18.4) and pain (OR 1.14; 95%CI: 1.03, 1.25) were associated with SI.

CONCLUSIONS

Overall the PHQ-9 is a valid screening tool for SI in IBD patients, and routine implementation of this tool would support screening for depression and SI effectively and efficiently in clinical practice.

Perceived Treatment Status of Fluctuations in Parkinson Disease Impacts Suicidality

OBJECTIVE

On/off motor fluctuations in Parkinson disease (PD) can be associated with extreme mood fluctuations and severe dysphoria. The impact of these affective symptoms may be overlooked in the treatment of motor fluctuations. Our goal was to examine the relationship between motor fluctuations, their treatment status, and suicidality in PD participants.

METHODS

We analyzed data from the Methods of Optimal Depression Detection in Parkinson's Disease (MOOD-PD) study of 223 individuals with PD. Suicidality was measured using items from four depression scales: Hamilton Depression Rating Scale (HAM-D-17); Montgomery-Åsberg Depression Rating Scale (MADRS); Inventory for Depressive Symptomatology (IDS-C); and the self-rated Beck Depression Inventory (BDI). Multivariable Poisson regression analyses tested whether self-reported motor fluctuations and their treatment status were associated with suicidality while controlling for recognized risk factors.

RESULTS

Thirty-seven participants (16.6%) self-reported suicidality and 89 (39.5%) self-reported motor fluctuations, of whom 21 (23.6%) perceived their fluctuations as untreated. Participants reporting untreated motor fluctuations more frequently had a current depressive disorder (p < 0.001) and endorsed suicidality (p = 0.006) than participants with treated or no fluctuations. They also had significantly higher total scores on the HAM-D-17, MADRS, IDS-C, and BDI depression scales (p < 0.001 for each). Regression analyses showed significant associations between untreated motor fluctuations and higher scores on suicide questions extracted from the HAM-D-17, MADRS, and IDS-C (p < 0.01 for each).

CONCLUSIONS

PD patients with untreated motor fluctuations are at increased risk for suicidal thoughts and should be monitored for mood changes as treatment is adapted.

ADS-5102 (Amantadine) Extended-Release Capsules for Levodopa-Induced Dyskinesia in Parkinson's Disease (EASE LID 2 Study): Interim Results of an Open-Label Safety Study

Background:

Medical treatment of levodopa-induced dyskinesia (LID) in Parkinson’s disease (PD) is an unmet need. ADS-5102 (amantadine) extended-release capsules is being developed for the treatment of LID in patients with PD.

Objective:

Evaluate the long-term safety and tolerability of 274 mg ADS-5102 for LID in PD.

Methods:

In an ongoing, open-label safety study (NCT02202551), PD patients with LID received 274 mg of ADS-5102 once daily at bedtime. Patients were recruited from previous ADS-5102 trials. In addition, patients were enrolled who were ineligible for previous ADS-5102 trials due to previous implantation of deep-brain stimulation (DBS) devices. The primary outcome measure was safety assessed through adverse events (AEs). Efficacy was assessed using the Movement Disorder Society–Unified Parkinson’s Disease Rating Scale (MDS-UPDRS), Part IV and its subparts.

Results:

For this interim analysis, 223 patients received ADS-5102 for a mean duration of 348 (SD 182) days. The most common AEs included falls (25.1%), visual hallucinations (19.3%), peripheral edema (13.0%), and constipation (12.6%). Overall, 32 patients (14.3%) discontinued due to an AE. In patients receiving placebo in previous studies, the mean MDS-UPDRS, Part IV scores decreased by 3.4 points from baseline (n = 78) to week 8 and remained stable through week 64 (n = 21). In patients receiving ADS-5102 in previous studies, the mean baseline (n = 61) MDS-UPDRS, Part IV score was low due to the response to ADS-5102 in previous studies and remained stable through week 64 (total of 88 weeks; n = 21). The effect was primarily due to reduction in item 4.2 (functional impact of dyskinesia) and item 4.4 (functional impact of motor fluctuations).

Conclusions:

ADS-5102 was generally well tolerated in all groups, including DBS patients, and the safety profile was consistent with previous controlled studies. Long-term durability and tolerability were shown from the double-blind studies through participation in the open-label study up to 88 weeks.

Patterns and Predictors of Depression Treatment among Older Adults with Parkinson's Disease and Depression in Ambulatory Care Settings in the United States

Little is known regarding depression treatment patterns and predictors among older adults with comorbid Parkinson's disease and depression (dPD) in the United States (US). The objective of this study was to assess the patterns and predictors of depression treatment among older adults with dPD in the US. We adopted a cross-sectional study design by pooling multiple-year data (2005-2011) from the National Ambulatory Medical Care Survey (NAMCS) and the outpatient department of the National Hospital Ambulatory Medical Care Survey (NHAMCS). The final study sample consisted of visits by older adults with dPD. Depression treatment was defined as antidepressant use with or without psychotherapy. To identify predictors of depression treatment, multivariate logistic regression analysis was conducted adjusting for predisposing, enabling, and need factors. Individuals with dPD and polypharmacy were 74% more likely to receive depression treatment (odds ratio = 1.743, 95% CI 1.376-2.209), while dPD subjects with comorbid chronic conditions were 44% less likely (odds ratio = 0.559, 95% CI 0.396-0.790) to receive depression treatment. Approximately six out of ten older adults with PD and depression received depression treatment. Treatment options for dPD are underutilized in routine clinical practice, and further research should explore how overall medical complexity presents a barrier to depression treatment.

Suicide in Parkinson's Disease

BACKGROUND

Suicide is a potentially preventable event. Suicidal ideation is common in Parkinson's disease (PD), but literature on completed suicides is scarce. In this case-control study, we compared the clinical characteristics of PD subjects who completed suicide (case) with those who died from natural causes (control).

METHODS

PD patients from the National Neurosciences Institute's movement disorders database from 2002 till 2012 were identified. The database was linked to the Singapore National Registry of Disease Office for mortality information, and suicide deaths were confirmed with the coroner's office. The demographic and clinical variables were compared between the cases and controls and the significant factors were further analyzed using logistic regression analysis.

RESULTS

During the study period, 366 deaths were recorded and suicide accounted for 11 deaths. Ten subjects with suicide deaths with complete clinical information were compared with randomly selected 30 PD subjects who had died from natural causes. PD suicide patients were younger (65.9 vs. 74.48 years), had less comorbidities (CWI: 2.6 vs. 4.63), better cognition (MMSE: 25.75 vs. 21.36), lower 'ON' UPDRS motor scores (20.83 vs. 41.63), lower H &Y stage (2.16 vs. 3.86), and higher use of Entacapone than the PD non-suicide group.

CONCLUSION

Suicide is potentially preventable tragedy. PD patients with the identified clinical characteristics should be closely monitored for suicide ideations. Motor fluctuation is a treatable factor in such patients and should be aggressively managed.

Neuropsychiatric Issues in Parkinson Disease

PURPOSE OF REVIEW

This article reviews the recognition and management of neuropsychiatric issues in Parkinson disease (PD), including mood disorders, cognitive impairment, and behavioral disturbances.

RECENT FINDINGS

Patients with PD frequently develop neuropsychiatric issues, and these issues can greatly affect their quality of life. In recent years, mood, cognitive, and behavioral issues in PD have received greater recognition, with increasing attention directed toward improved screening and therapeutic interventions for symptomatic treatment. Taken together as a group, neuropsychiatric issues can be found throughout the whole course of PD, from early in the disease, potentially even in a premotor stage, to the time of diagnosis and later in the course with more advanced disease.

SUMMARY

In the comprehensive care of patients with PD, recognition of neuropsychiatric issues is critical. Advances in therapeutics for the different neuropsychiatric symptoms are still needed, although several pharmacologic and nonpharmacologic options are available. Patient management frequently requires a multidisciplinary approach, with collaboration of neurologists with neuropsychologists, psychologists, psychiatrists, and other health professionals.

Hospital care for mental health and substance abuse conditions in Parkinson's disease

OBJECTIVE

The objective of this study was to examine mental health conditions among hospitalized individuals with Parkinson's disease in the United States.

METHODS

This was a serial cross-sectional study of hospitalizations of individuals aged ≥60 identified in the Nationwide Inpatient Sample dataset from 2000 to 2010. We identified all hospitalizations with a diagnosis of PD, alcohol abuse, anxiety, bipolar disorder, depression, impulse control disorders, mania, psychosis, substance abuse, and attempted suicide/suicidal ideation. National estimates of each mental health condition were compared between hospitalized individuals with and without PD. Hierarchical logistic regression models determined which inpatient mental health diagnoses were associated with PD, adjusting for demographic, payer, geographic, and hospital characteristics.

RESULTS

We identified 3,918,703 mental health and substance abuse hospitalizations. Of these, 2.8% (n = 104, 437) involved a person also diagnosed with PD. The majority of mental health and substance abuse patients were white (86.9% of PD vs 83.3% of non-PD). Women were more common than men in both groups (male:female prevalence ratio, PD: 0.78, 0.78-0.79, non-PD: 0.58, 0.57-0.58). Depression (adjusted odds ratio 1.32, 1.31-1.34), psychosis (adjusted odds ratio 1.25, 1.15-1.33), bipolar disorder (adjusted odds ratio 2.74, 2.69-2.79), impulse control disorders (adjusted odds ratio 1.51, 1.31-1.75), and mania (adjusted odds ratio 1.43, 1.18-1.74) were more likely among PD patients, alcohol abuse was less likely (adjusted odds ratio 0.26, 0.25-0.27). We found no PD-associated difference in suicide-related care.

CONCLUSIONS

PD patients have unique patterns of acute care for mental health and substance abuse. Research is needed to guide PD treatment in individuals with pre-existing psychiatric illnesses, determine cross provider reliability of psychiatric diagnoses in PD patients, and inform efforts to improve psychiatric outcomes. © 2016 International Parkinson and Movement Disorder Society.

[Anxiety and depressive disorders in Parkinson's disease]

This review presents the most recent data of worldwide research on anxiety and depressive disorders in patients with Parkinson's disease. Their characteristics and epidemiology, pathogenetic and clinical features, methods of diagnosis and treatment are presented. Depression occurs in 40-50% of patients with PD, anxiety in 17-43% of patients. Pramipexole, a dopamine agonist, is only one drug recommended for depression treatment. Nortriptyline and desipramine, belonging to the group of tricyclic antidepressants (TCAs), are considered to be possibly effective. There are no clear recommendations for treatment of anxiety. In general, methods of therapy of anxiety and depressive disorders in PD are not well understood which determines the conduct of large-scale studies in the future.

Increased suicide risk and clinical correlates of suicide among patients with Parkinson's disease

INTRODUCTION

Parkinson's disease (PD) is a debilitating, neurodegenerative condition frequently complicated by psychiatric symptoms. Patients with PD may be at higher risk for suicide than the general population, but previous estimates are limited and conflicting. The aim of this study is to estimate the suicide rate based on the clinical case registry and to identify risk factors for suicide among patients diagnosed with PD.

METHODS

The target sample consisted of 4362 patients diagnosed with PD who were evaluated at a general hospital in Seoul, South Korea, from 1996 to 2012. The standardized mortality ratio for suicide among PD patients was estimated. In order to identify the clinical correlates of suicide, case-control study was conducted based on retrospective chart review. The 29 suicide cases (age: 62.3 ± 13.7 years; females: 34.5%) were matched with 116 non-suicide controls (age: 63.5 ± 9.2 years; females 56.9%) by the year of initial PD evaluation.

RESULTS

The SMR for suicide in PD patients was 1.99 (95% CI 1.33-2.85). Mean duration from time of initial diagnosis to suicide among cases was 6.1 ± 3.5 years. Case-control analysis revealed that male, initial extremity of motor symptom onset, history of depressive disorder, delusion, any psychiatric disorder, and higher L-dopa dosage were significantly associated with suicide among PD patients. Other PD-related variables such as UPDRS motor score were not significantly associated with death by suicide.

CONCLUSION

Suicide risk in PD patients is approximately 2 times higher than that in the general population. Psychiatric disorders, and also L-dopa medication need further attention with respect to suicide.

Levodopa-Carbidopa Intestinal Gel in Patients with Parkinson's Disease: A Systematic Review

BACKGROUND

Levodopa-carbidopa intestinal gel (LCIG) is available in several countries for the treatment of advanced levodopa-responsive Parkinson's disease (PD) with severe motor fluctuations and dyskinesia when other treatments have not given satisfactory results.

OBJECTIVE

Our objective was to summarize the present evidence base for LCIG therapy through a systematic review of the literature.

METHODS

Studies were identified from the PubMed and EMBASE databases up to 12 March 2016 using the following search terms: Parkinson disease, duodopa, levodopa/carbidopa intestinal gel, levodopa-carbidopa intestinal gel, LCIG, l-dopa infusion, levodopa infusion, duodenal l-dopa infusion, and duodenal levodopa infusion. Data extraction focused on whether LCIG therapy improves motor and non-motor outcomes as well as quality of life in PD patients compared with conventional therapy, apomorphine infusion, or deep brain stimulation. Randomized controlled trials (RCTs) and observational studies, with or without a control group, that included more than ten patients were included. The search was limited to peer-reviewed articles published in full in the English language and involving humans.

RESULTS

Infusion of LCIG reduced "off" time, increased "on" time without increasing troublesome dyskinesias, and improved quality of life in three RCTs (one double-blind). Open-label follow-ups confirm these findings. The data evaluating long-term efficacy and safety are still limited.

CONCLUSIONS

The quality of evidence that LCIG is effective in reducing fluctuating motor symptoms and improving quality of life is moderate. Quality of evidence for reduction of non-motor symptoms is very low. Safety issues mainly relate to the intestinal infusion system. LCIG might be a useful treatment option in PD patients with severe motor fluctuations.

Electroconvulsive therapy for depression in Parkinson's disease: systematic review of evidence and recommendations

AIM

We performed a systematic review of evidence regarding treatment of depression in Parkinson's disease (PD) utilizing electroconvulsive therapy.

METHODS

The search led to the inclusion of 43 articles, mainly case reports or case series, with the largest number of patients totaling 19.

RESULTS

The analysis included 116 patients with depression and PD; depression improved in 93.1%. Where motor symptoms' severity was reported, 83% of patients improved. Cognition did not worsen in the majority (94%). Many patients experienced delirium or transient confusion, sometimes necessitating discontinuation of electroconvulsive therapy (ECT). Little is known about maintenance ECT in this population.

CONCLUSION

ECT can benefit patients suffering from PD and depression. We recommend an algorithm for treatment of depression in PD, utilizing ECT sooner rather than later.

Stressful life events, hopelessness, and suicidal intent in patients admitted with attempted suicide in a tertiary care general hospital

BACKGROUND

Suicide is a psychiatric emergency. Stressors in life and social variables (like marital status, family, and social support) are among the determinants of suicide. Hopelessness and suicidal intent are among the psychological variables that have shown promise in the prediction of suicide.

AIMS AND OBJECTIVES

To assess stressful life events, hopelessness, suicidal intent, and sociodemographic variables in patients of attempted suicide.

MATERIALS AND METHODS

Fifty consecutive patients admitted with attempted suicide were interviewed. Presumptive Stressful Life Event Scale, Beck Hopelessness Scale, and Beck Suicidal Intent Scale were used along with a semistructured pro forma for interview. Data were analyzed with statistical tests.

RESULTS

Sixty-six percent of the participants were females, 72% were less than 30 years of age. Sixty-six percent of the patients had stressful life event score between 101 and 200 with the mean score of 127. The stressful life event score in those who considered they are in need of psychiatric help was significantly high. Most of the patients had mild (34%) and moderate (40%) degrees of hopelessness, and the mean score was 9.64. The mean suicidal intent in the participants was 25.14, when correlated with hopelessness score significant positive correlation was found.

CONCLUSION

Lethality of the attempt increases with the increase in hopelessness.

Psychiatric Conditions in Parkinson Disease: A Comparison With Classical Psychiatric Disorders

Psychiatric conditions often complicate the outcome of patients affected by Parkinson disease (PD), but they differ from classical psychiatric disorders in terms of underlying biological mechanisms, clinical presentation, and treatment response. The purpose of the present review is to illustrate the biological and clinical aspects of psychiatric conditions associated with PD, with particular reference to the differences with respect to classical psychiatric disorders. A careful search of articles on main databases was performed in order to obtain a comprehensive review about the main psychiatric conditions associated with PD. A manual selection of the articles was then performed in order to consider only those articles that concerned with the topic of the review. Psychiatric conditions in patients with PD present substantial differences with respect to classical psychiatric disorders. Their clinical presentation does not align with the symptom profiles represented by Diagnostic and Statistical Manual for Mental Disorders and International Classification of Diseases. Furthermore, psychiatry treatment guidelines are of poor help in managing psychiatric symptoms of patients with PD. Specific diagnostic tools and treatment guidelines are needed to allow early diagnosis and adequate treatment of psychiatric conditions in comorbidity with PD.

Considerations for the assessment of suicidal ideation and behavior in older adults with cognitive decline and dementia

Introduction

Better understanding of suicide risk and its management in older adults with cognitive impairment and/or dementia remain significant unmet public health needs. Urgency to address them derives from concern that CNS treatments for dementia may impact suicide risk. Regulatory guidances requiring assessment of emergent suicidal ideation and behavior (SI/SB) at every clinical trial visit emphasize the need for understanding their prevalence.

Methods

The literature regarding SI/SB in older persons with cognitive impairment or dementia was reviewed by an Alzheimer's Association Taskforce with emphasis on epidemiology, classification, assessment, and regulatory requirements.

Results

Gaps in our knowledge were identified, challenges discussed and recommendations for future work provided.

Discussion

Currently available SI/SB data from geriatric persons with dementia do not provide adequate understanding of its epidemiology, identification, assessment, or management. The growing public health burden of this population requires greater attention from clinicians and researchers on tactics and assessment tools to meet these needs.

Integrated safety of levodopa-carbidopa intestinal gel from prospective clinical trials

BACKGROUND

Continuous administration of levodopa-carbidopa intestinal gel (carbidopa-levodopa enteral suspension) through a percutaneous endoscopic gastrojejunostomy is a treatment option for advanced Parkinson disease (PD) patients with motor fluctuations resistant to standard oral medications. Safety data from 4 prospective studies were integrated to assess the safety of this therapy.

METHODS

Safety data from 4 studies were summarized using 2 overlapping data sets, permitting the separation of procedure/device-associated (n = 395) from non-procedure/device adverse events (n = 412).

RESULTS

At the data cutoff, median exposure to levodopa-carbidopa intestinal gel was 911 days (range, 1-1980 days) with 963 total patient-years of exposure. Procedure/device adverse events occurred in 300 patients (76%), and serious adverse events occurred in 68 (17%); most frequently reported procedure/device adverse events and serious adverse events were complications of device insertion (41% and 8%, respectively) and abdominal pain (36% and 4%, respectively). Non-procedure/device adverse events occurred in 92% (379), with most frequently reported being insomnia (23%) and falls (23%); 42% (171) had non-procedure/device serious adverse events, with most frequently reported being pneumonia (5%) and PD symptoms (2%). Adverse events led to discontinuation in 17% (72), most frequently because of complication of device insertion (2.4%). There were 34 treatment-emergent deaths (8.3%) in the overlapping data sets, 2 of which (0.5%) were considered "possibly related" to the treatment system.

CONCLUSION

In the largest collection of levodopa-carbidopa intestinal gel safety data from prospective clinical studies, procedure/device events were frequently reported and occasionally life threatening. Most non-procedure/device events were typical for levodopa treatment and an elderly population. These factors combined with high treatment efficacy led to a relatively low discontinuation rate in advanced PD patients.

Measurement Scales of Suicidal Ideation and Attitudes: A Systematic Review Article

Background: The main aim of this study was to accumulate research evidence that introduce validated scales to measure suicidal attitudes and ideation and provide an empirical framework for adopting a relevant assessment tool in studies on suicide and suicidal behaviors.

Methods: Medical Subject Headings’ (MeSH) terms were used to search Ovid Medline, PROQUEST, Wiley online library, Science Direct and PubMed for the published articles in English that reported application of an scale to measure suicidal attitudes and ideation from January 1974 onward.

Results: Fourteen suicidal attitude scale and 15 scales for assessing suicidal ideation were identified in this systematic review. No gold standard approach was recognized to study suicide related attitudes and ideations.

Conclusion: Special focus on generally agreed dimensions of suicidal ideation and attitudes and cross-cultural validation of the introduced scales to be applicable in different ethnic and socially diverse populations could be a promising area of research for scholars.

Survey of Health Care Workers Suggests Unmet Palliative Care Needs in Parkinson's Disease

The aim of this study was to investigate the knowledge, attitudes, and previous training of Irish health care workers (HCWs) in palliative care in end-stage Parkinson's disease (PD). A survey was distributed to HCWs, including neurologists, geriatricians, general practitioners, nurses, and allied health professionals, in acute and community settings in the Republic of Ireland. Three-hundred and six surveys were returned (32% average response rate). Most HCWs (90%) believed that people with PD have palliative care needs; however, 76% of HCWs also said that these needs are "never" or only "sometimes" met. These unmet needs are reflected in relatively few people with PD being referred to specialist palliative care; 48% of hospital consultants had referred no patients in the previous 6 months, and just 7% had referred more than 10. Just 8% of the HCWs surveyed reported having any training on the palliative care aspects of PD, and 97% expressed an interest in receiving further education. Respondents wanted all topics pertinent to palliative care in PD covered, and many felt that they also needed further information on PD in general. People with PD are seen to have palliative care needs; however, the findings suggest that these needs are not being met. There is a discrepancy between best practice recommendations for palliative care in PD and the beliefs and practices of HCWs. Further education in palliative care in PD is needed to ensure better quality of care for people with PD.

Prevalence, clinical features and treatment of depression in Parkinson’s disease: An update

Parkinson’s disease (PD) is one of the most prevalent neurodegenerative diseases which typically affects individuals over 65 years. Although the symptomatology is predominantly motor, neuropsychiatric manifestations, e.g., depression, apathy, anxiety, and cognitive impairment occur in the course of the illness and can have a great impact on the quality of life in these patients. Parkinson’s disease is commonly comorbid with depression with prevalence rates of depression, generally higher than those reported in general population. Depression in PD is frequently underestimated and consequently undertreated, which have significant effects on the quality of life in these patients. The neurobiology of depression in PD is complex and involves alterations in dopaminergic, serotonergic, noradrenergic and possibly other neurotransmitter systems which are affected in the course of the disease. The tricyclic antidepressants and the selective serotonin reuptake inhibitors are the two classes of antidepressant drugs used for depressive symptoms in PD. Several published studies suggested that both classes are of comparable efficacy. Other serotonergic antidepressants, e.g., nefazodone and trazodone have also been of benefit. Meanwhile, there are limited data available on other drugs but these suggest a benefit from the serotonin and noradrenaline reuptake inhibitors such as mirtazapine, venlafaxine, atomoxetine and duloxetine. Some of the drugs used in symptomatic treatment of PD, e.g., the irreversible selective inhibitors of the enzyme monoamine oxidase-B, rasagiline and selegiline as well as the dopamine receptor agonist pramipexole are likely to have direct antidepressant activity independent of their motor improving action. This would make these drugs an attractive option in depressed subjects with PD. The aim of this review is to provide an updated data on the prevalence, clinical features of depression in subjects with PD. The effects of antiparkinsonian and antidepressant drugs on depressive symptoms in these patients are also discussed.

Neuropsychiatric co-morbidities in non-demented Parkinson's disease

OBJECTIVE

To evaluate neuropsychiatric co-morbidities (depression, psychosis and anxiety) in non-demented patients with Parkinson's disease (PD).

BACKGROUND

Non-motor symptoms like neuropsychiatric co-morbidities are common in Parkinson's disease and may predate motor symptoms. Currently there is scarcity of data regarding neuropsychiatry manifestations in Indian patients with PD.

METHODS

In this cross-sectional study consecutive 126 non-demented patients with PD (MMSE ≥25) were enrolled. They were assessed using Unified Parkinson's disease rating scale (UPDRS), Hoehn & Yahr (H&Y) stage, Schwab and England (S&E) scale of activity of daily life. Mini-international neuropsychiatric interview (MINI) was used for diagnosis of depression, psychosis and anxiety. Beck's depression inventory (BDI), Brief psychiatric rating scale (BSRS) and Hamilton rating scale for anxiety (HAM-A) scales were used for assessment of severity of depression, psychosis and anxiety respectively.

RESULTS

Mean age and duration of disease was 57.9 ± 10.9 years and 7.3 ± 3.6 years respectively. At least one of the neuropsychiatric co-morbidity was present in 64% patients. Depression, suicidal risk, psychosis and anxiety were present in 43.7%, 31%, 23.8% and 35.7% respectively. Visual hallucinations (20.6%) were most frequent, followed by tactile (13.5%), auditory (7.2%) and olfactory hallucinations (1.6%). Patients with depression had higher motor disability (UPDRS-motor score 33.1 ± 14.0 vs 27.3 ± 13.3; and UPDRS-total 50.7 ± 21.8 vs 41.0 ± 20.3, all p values <0.05). Patients with psychosis were older (63.6 ± 8.0 years vs 56.1 ± 11.1 years, p < 0.05) and had longer duration of illness (8.6 ± 3.4 years vs 6.9 ± 3.5, p < 0.05).

CONCLUSIONS

About two third patients with Parkinson's disease have associated neuropsychiatric co-morbidities. Depression was more frequent in patients with higher disability and psychosis with longer duration of disease and older age. These co-morbidities need to be addressed during management of patients with PD.