SSRIs do not worsen Parkinson's disease: evidence from an open-label, prospective study

Treatment options for depression in Parkinson's disease: a mini-review

Depression is a common comorbidity in Parkinson's disease (PD), significantly reducing patients' quality of life. This mini-review examines pharmacological and nonpharmacological therapies for managing depression in PD, analyzing their benefits, and limitations. Pharmacological options include tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), levodopa, dopaminergic agonists, and monoamine oxidase B inhibitors. Nonpharmacological strategies involve brief psychodynamic therapy, cognitive-behavioral therapy (CBT), physical exercise, phytomedicine, massage therapy, music therapy, phototherapy, yoga, repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation, electroconvulsive therapy (ECT), and deep brain stimulation. SSRIs, SNRIs, and some dopamine agonists have shown effectiveness and good tolerability, especially when combined with CBT or rTMS. For severe or refractory cases, ECT remains a viable option. Although many of these therapies show promise, the limited number and scale of studies for each treatment restrict the strength of current evidence. Further large-scale, multicenter randomized-controlled trials are essential to validate these preliminary findings and establish evidence-based guidelines. In addition, the potential benefits of social support and brief psychodynamic therapy in the context of PD-related depression require further exploration to provide holistic care strategies for this population.

The effect of serotonin reuptake and serotonin-noradrenaline reuptake inhibitors on motor symptoms in Parkinson's disease: A PPMI-based matched-subject study

Background: Depression often co-occurs with Parkinson's disease (PD) and is effectively treated with selective serotonin reuptake inhibitors (SSRI) and serotonin and noradrenaline reuptake inhibitors (SNRI), but their effect on motor symptoms has not yet been conclusively demonstrated. Objective: To assess the impact of the SSRI/SNRI on the motor symptoms of PD. Methods: We used data from the Parkinson's Progression Markers Initiative database, in a matched subject design with a target group (N = 47) which had been taking SSRI/SNRI medication and a control group (N = 90) which had not. Matching criteria included Movement Disorders Society Unified Parkinson's Disease Rating Scale part III (MDS-UPDRS-III) total score and its subscales' scores, and levodopa equivalent daily dose (LEDD) at the time of the first examination (initial LEDD). For the target group, we compared the MDS-UPDRS-III score before and after taking the SSRI/SNRI medication, while for the control group we compared two equally spaced examinations. Results: In the target group, we found a greater worsening of motor scores, which was associated with lower values of initial LEDD. In addition, apathy was an independent predictor of motor worsening. Conclusions: SSRI/SNRI-use seems to be characterized by a steeper worsening of motor symptoms, which can be predicted by a lower initial LEDD. Further research should continue to investigate the effect of SSRI/SNRI-use on motor symptoms in PD.

Selective Serotonin Reuptake Inhibitors for the Treatment of Depression in Parkinson's Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Although selective serotonin reuptake inhibitors (SSRIs) are usually considered safe to use in patients with Parkinson's disease (PD), there are mixed data about their effectiveness, and only a few investigations have led to a total improvement of depressive symptoms in patients with PD.

OBJECTIVES

We aimed to conduct a comprehensive systematic review and meta-analysis of all studies that investigated the effectiveness of SSRIs in treating depression in the context of PD.

METHODS

From its commencement to June 2024, the databases of MEDLINE via PubMed, Scopus, Embase, and Google Scholar were electronically searched for the relevant papers. All full-text journal articles assessing the effectiveness of SSRIs in treating depression in patients with PD were included. The tool developed by the Cochrane Collaboration was utilized to evaluate the bias risk. Data were analyzed utilizing a pair-wise comparison meta-analysis using the standardized mean difference.

RESULTS

A total of 19 articles and 22 separate interventions were included. We found that SSRI treatment attenuated depression in patients with PD (1.242 standardized mean difference, 95% confidence interval 0.956, 1.529, p < 0.001). The general heterogeneity of the studies was medium (ϰ2 = 72.818, T2 = 0.317, df = 21, I2 = 71.15%, p < 0.001). The funnel plot was reasonably symmetrical. However, three studies were trimmed to the left of the mean. Begg's test (p = 0.080), Egger's test (p = 0.121), and funnel plot showed no significant risk of publication bias. The meta-regression showed that the treatment effect increased as a function of paroxetine treatment duration (slope p = 0.001) but decreased as a function of sertraline treatment duration (slope p = 0.019).

CONCLUSIONS

There are few controlled antidepressant trials on the PD population, even though patients with PD frequently experience depression and use antidepressants. Clinical studies that are larger and better structured are needed in the future to determine if antidepressants are useful for treating patients with PD with depression.

Serotonin as a biomarker of toxin-induced Parkinsonism

BACKGROUND

Loss of dopaminergic neurons underlies the motor symptoms of Parkinson's disease (PD). However stereotypical PD symptoms only manifest after approximately 80% of dopamine neurons have died making dopamine-related motor phenotypes unreliable markers of the earlier stages of the disease. There are other non-motor symptoms, such as depression, that may present decades before motor symptoms.

METHODS

Because serotonin is implicated in depression, here we use niche, fast electrochemistry paired with mathematical modelling and machine learning to, for the first time, robustly evaluate serotonin neurochemistry in vivo in real time in a toxicological model of Parkinsonism, 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP).

RESULTS

Mice treated with acute MPTP had lower concentrations of in vivo, evoked and ambient serotonin in the hippocampus, consistent with the clinical comorbidity of depression with PD. These mice did not chemically respond to SSRI, as strongly as control animals did, following the clinical literature showing that antidepressant success during PD is highly variable. Following L-DOPA administration, using a novel machine learning analysis tool, we observed a dynamic shift from evoked serotonin release in the hippocampus to dopamine release. We hypothesize that this finding shows, in real time, that serotonergic neurons uptake L-DOPA and produce dopamine at the expense of serotonin, supporting the significant clinical correlation between L-DOPA and depression. Finally, we found that this post L-DOPA dopamine release was less regulated, staying in the synapse for longer. This finding is perhaps due to lack of autoreceptor control and may provide a ground from which to study L-DOPA induced dyskinesia.

CONCLUSIONS

These results validate key prior hypotheses about the roles of serotonin during PD and open an avenue to study to potentially improve therapeutics for levodopa-induced dyskinesia and depression.

Vortioxetine Improved Depressive State In Parkinson's Disease

We report the case of a 67-year-old Japanese Parkinson's disease (PD) patient with depression who was successfully treated with vortioxetine. The patient's PD was being treated with levodopa (100 mg/day). As improvement was noted in PD symptoms, levodopa was continued. Subsequently, she was referred to our department due to worsening of her depressive symptoms, including depressed mood, anhedonia, decreased energy, decreased concentration, decreased motivation, insomnia, hopelessness, and worthlessness. The patient did not respond to paroxetine and escitalopram. Finally, vortioxetine improved her depressive state without worsening PD.

Treatment of psychiatric disturbances in hypokinetic movement disorders

Introduction: We reviewed studies that assessed the treatment of psychiatric disturbances in Parkinson's disease and atypical parkinsonisms. Neuropsychiatric disturbances in these conditions are frequent and have a profound impact on quality of life of patients and of their caregivers. It is therefore important to be familiar with the appropriate pharmacological and non-pharmacological interventions for treating these disorders. Areas covered: The authors searched for papers in English in Pubmed using the following keywords: Parkinson's disease, multiple system atrophy, progressive supranuclear palsy, corticobasal degeneration, Lewy body dementia, depression, apathy, anxiety, fatigue, sleep disorders, obsessive compulsive disorders, psychosis, hallucinations, delusions, impulse control disorders. Expert opinion: In Parkinson's disease, depression may benefit from the optimization of dopaminergic therapy, from the use of antidepressants acting on both the serotoninergic and noradrenergic pathways and from cognitive behavioral therapy. Psychosis in Parkinson's disease may improve with the use of clozapine; the serotonin inverse agonist pimavanserin has been shown to be effective. Treatment of impulse control disorders is primarily based on the removal of dopamine agonists. No controlled studies have investigated the treatment of neuropsychiatric disorders in multiple system atrophy, progressive supranuclear palsy or corticobasal degeneration. Acethylcholinesterase inhibitors may be used to treat hallucinations in Lewy body dementia.

A review of citalopram dose restrictions in the treatment of neuropsychiatric disorders in older adults

Introduction

Neuropsychiatric disorders affect millions of older adults. Despite this, there are relatively few older adults included in clinical trials evaluating treatments for psychiatric disorders. Citalopram has been evaluated in older adults with neuropsychiatric disorders and has largely been found beneficial, making the 2011 US Food and Drug Administration (FDA) safety advisory on citalopram extremely impactful.

Methods

A literature search was completed using the PubMed database. Results were limited to clinical trials conducted in older adults that were published in English.

Results

Review of the literature confirms the efficacy of citalopram in depression, anxiety, depression associated with Parkinson disease, and behavioral and psychological symptoms of dementia. Additionally, no adverse cardiac outcomes have been described related to citalopram.

Discussion

The FDA's evidence for applying this safety advisory to citalopram is minimal and largely based on surrogate markers, such as the QTc interval rather than clinical and safety outcomes. Citalopram is known to increase the QTc, but this increase has not been linked to adverse cardiac outcomes. The evidence for efficacy and against adverse outcomes suggests that a reevaluation of the dosing restrictions in older adults with neuropsychiatric disorders is needed.

Evidence of Repurposing Drugs and Identifying Contraindications from Real World Study in Parkinson's Disease

There is great unmet need in discovering novel treatment for Parkinson's disease (PD) and identifying the new agents potentially causing drug-induced parkinsonism. New indications and contraindications of drugs are typically approved following rigorous randomized controlled trial (RCT) evaluation. However, RCTs have their inherent limitations, since they are usually conducted in ideal conditions, with high cost and limited follow-up periods. In the past decade, large cohort studies with long follow-up outcome data was derived from a PD database in a real-world setting. Studies based on real world data (RWD) can help to augment and extrapolate data obtained in RCTs and provide information about the safety and effectiveness of a medication in heterogeneous, large populations. In the present review, we focus on the published real world studies designed to develop new treatment strategies for repurposing drugs and identifying contraindications for PD. We also outline the challenges and limitations in these studies. Subsequently we introduce PaWei app platform, which hopefully can facilitate PD management and address real-world problems associated with PD. Better understanding of RWD collection and analysis is needed if RWD is to achieve its full potential.

Reversible Valproate Induced Pisa Syndrome and Parkinsonism in a Neuro-Oncology Patient with Depression and Epilepsy

Neurological and psychiatric conditions frequently overlap in neuro-oncology. This overlapping negatively affects patients' quality of life and decreases the ability of providers to manage specific symptoms by therapy modulation, especially when psychopharmacotherapy needs to be prescribed. We describe here a patient with recurrent brain tumor, symptomatic epilepsy and depression who developed Pisa syndrome and parkinsonism after several months of valproic acid use. An accurate recognition of symptoms and treatment side effect allowed an appropriate clinical approach so as to rapidly improve both movement disorder and depression without increasing the risk of developing seizure. This has improved the autonomy and quality of life in a patient with poor prognosis.

Antidepressants in Parkinson's disease. Recommendations by the movement disorder study group of the Neurological Association of Madrid

INTRODUCTION

Although antidepressants are widely used in Parkinson's disease (PD), few well-designed studies to support their efficacy have been conducted.

DEVELOPMENT

These clinical guidelines are based on a review of the literature and the results of an AMN movement disorder study group survey.

CONCLUSIONS

Evidence suggests that nortriptyline, venlafaxine, paroxetine, and citalopram may be useful in treating depression in PD, although studies on paroxetine and citalopram yield conflicting results. In clinical practice, however, selective serotonin reuptake inhibitors are usually considered the treatment of choice. Duloxetine may be an alternative to venlafaxine, although the evidence for this is less, and venlafaxine plus mirtazapine may be useful in drug-resistant cases. Furthermore, citalopram may be indicated for the treatment of anxiety, atomoxetine for hypersomnia, trazodone and mirtazapine for insomnia and psychosis, and bupropion for apathy. In general, antidepressants are well tolerated in PD. However, clinicians should consider the anticholinergic effect of tricyclic antidepressants, the impact of serotonin-norepinephrine reuptake inhibitors on blood pressure, the extrapyramidal effects of antidepressants, and any potential interactions between monoamine oxidase B inhibitors and other antidepressants.

Depression in Parkinson's disease: the effectiveness and risk of pharmacotherapy. Clinical review

Parkinson's disease (PD) is a neurological disease with a heterogeneous pattern of neurological symptoms and concomitant psychiatric syndromes. These syndromes are triggered by alterations to neurotransmission that are likely common for both neurological and psychiatric symptoms. Syndromes such as depression, anxiety, or cognitive impairment can precede motor symptoms of PD and delay its diagnosis. Recently, questions related to aetiological factors and treatment strategies of depression in PD have become a growing concern of PD researchers. This article describes the main features of depression in PD and presents current hypotheses on its aetiology and recommended treatment modes.

Antidepressive treatments for Parkinson's disease: A systematic review and meta-analysis

CONTEXT

Depression affects 50-70% of patients with Parkinson's disease resulting in significant comorbidity, executive dysfunction, and poorer quality of life. Divergent results from studies of different treatments preclude definite treatment recommendations.

OBJECTIVE

To perform a systematic review and meta-analysis of published randomized controlled trials (RCTS) evaluating the efficacy of pharmacologic and behavioral interventions, and repetitive transcranial magnetic stimulation (rTMS) for depression among patients with idiopathic Parkinson's disease.

DATA SOURCES

Trial registers and the following databases were searched: PubMed, CINAHL, EMBASE, and PsycInfo. Bibliographies of relevant articles were cross-referenced.

STUDY SELECTION AND DATA EXTRACTION

RCTs comparing pharmacologic, behavioral, or rTMS with a placebo/other drugs or methods with no restrictions on participant age, gender, and duration or setting of treatment were included. Eligibility assessment was performed independently. Identified records were sequentially screened according to eligibility criteria. Differences in mean depression score and 95% confidence intervals were calculated.

RESULTS

A total of 893 idiopathic Parkinson's disease patients with clinical depression across 20 RCTs were included. The overall standard mean difference for all pharmacologic interventions was 0.30 (95% CI -0.00, 0.61, p = 0.054). On stratification, there was a distinct difference in effect between antidepressants (SMD of 0.54, 95%CI 0.24, 0.83, p = 0.000) and non-antidepressants (SMD of -0.29, 95% CI -0.86, 0.29, p = 0.328). Behavioral interventions demonstrated significant efficacy with an effect size of 0.87 (95% CI 0.41, 1.33, p = 0.000).

CONCLUSIONS

This meta-analysis demonstrates that pharmacologic treatment with antidepressant medications, specifically the selective serotonin reuptake inhibitors (SSRIs), and behavioral interventions (CBT) significantly improved depression among Parkinson's disease patients.

Effect of serotonin transporter blockade on L-DOPA-induced dyskinesia in animal models of Parkinson's disease

Serotonin transporter blockade with selective serotonin reuptake inhibitors (SSRIs) was recently shown to counteract L-DOPA-induced dyskinesia in 6-hydroxydopamine (6-OHDA)-lesioned rats. However, this effect has never been described in Parkinson's disease (PD) patients, despite that they often receive SSRIs for the treatment of depression. In the present study, we investigated the efficacy of the SSRI citalopram against dyskinesia in two experimental models of PD, the 6-OHDA-lesioned rat and 1-methyl-4-phenyl 1,2,3,6-tetrahydropyridine (MPTP)-treated macaque. First, we studied the acute and chronic effect of citalopram, given at different time points before L-DOPA, in L-DOPA-primed parkinsonian rats. Moreover, the acute effect of citalopram was also evaluated in dyskinetic MPTP-treated macaques. In L-DOPA-primed rats, a significant and long-lasting reduction of L-DOPA-induced dyskinesia (LID) was observed only when citalopram was given 30 min before L-DOPA, suggesting that the time of injection relative to L-DOPA is a key factor for the efficacy of the treatment. Interestingly, an acute challenge with the 5-HT1A/1B receptor agonist eltoprazine, given at the end of the chronic study, was equally effective in reducing LID in rats previously chronically treated with L-DOPA or L-DOPA plus citalopram, suggesting that no auto-receptor desensitization was induced by chronic citalopram treatment. In MPTP-treated macaques, citalopram produced a striking suppression of LID but at the expense of L-DOPA therapeutic efficacy, which represents a concern for possible clinical application.

Monoamine reuptake inhibitors in Parkinson's disease

The motor manifestations of Parkinson's disease (PD) are secondary to a dopamine deficiency in the striatum. However, the degenerative process in PD is not limited to the dopaminergic system and also affects serotonergic and noradrenergic neurons. Because they can increase monoamine levels throughout the brain, monoamine reuptake inhibitors (MAUIs) represent potential therapeutic agents in PD. However, they are seldom used in clinical practice other than as antidepressants and wake-promoting agents. This review article summarises all of the available literature on use of 50 MAUIs in PD. The compounds are divided according to their relative potency for each of the monoamine transporters. Despite wide discrepancy in the methodology of the studies reviewed, the following conclusions can be drawn: (1) selective serotonin transporter (SERT), selective noradrenaline transporter (NET), and dual SERT/NET inhibitors are effective against PD depression; (2) selective dopamine transporter (DAT) and dual DAT/NET inhibitors exert an anti-Parkinsonian effect when administered as monotherapy but do not enhance the anti-Parkinsonian actions of L-3,4-dihydroxyphenylalanine (L-DOPA); (3) dual DAT/SERT inhibitors might enhance the anti-Parkinsonian actions of L-DOPA without worsening dyskinesia; (4) triple DAT/NET/SERT inhibitors might exert an anti-Parkinsonian action as monotherapy and might enhance the anti-Parkinsonian effects of L-DOPA, though at the expense of worsening dyskinesia.

A Case of SSRI Induced Irreversible Parkinsonism

Serotonin specific reuptake inhibitors (SSRI) are widely used antidepressants for variety of clinical conditions and have found popularity. They are sometimes associated with extrapyramidal side effects including Parkinsonism. We report a case of generalized anxiety disorder on treatment with SSRI (fluoxetine / sertraline) who developed irreversible Parkinsonism. SSRI are known to cause reversible or irreversible motor disturbances through pathophysiological changes in basal ganglion motor system by altering the dopamine receptors postsynaptically. Clinician should keep risk benefit ratio in mind and change of antidepressant of different class may be considered. Case is reported to alert physicians to possibility of motor system damage while treating with SSRI.

Anxiety in Parkinson's disease: identification and management

Anxiety disturbances are recognized as common psychiatric comorbidities in Parkinson's disease (PD) and contribute to significant impairments in areas of cognitive, functional, motor and social performance. Anxiety in PD results in reduced quality of life, higher levels of care dependency and increased caregiver burden. Surprisingly, there is a paucity of treatment data. In one randomized, controlled study, bromazepam was found to be effective for anxiety in PD. However, usage of benzodiazepines in the PD population is limited by potential risk of confusion and falls. There are no controlled studies of selective serotonin reuptake inhibitors (SSRIs) for anxiety in PD. However, results from uncontrolled studies suggest that SSRIs are effective for anxiety in PD, although in these studies anxiety outcomes were secondary. This review underscores that, given the high prevalence of anxiety disturbances in PD, there is a significant paucity of treatment data for this population. Additional studies are warranted. In the meantime, clinicians should rely on empiric assessments of known risks and putative benefits to guide treatment decisions. Cognitive and behavioral therapies (with or without pharmacotherapy) have demonstrated efficacy and warrant consideration. When feasible, a targeted and individualized multimodal approach utilizing psychotherapeutic interventions along with pharmacologic therapies should be considered.

Parkinson's disease--the debate on the clinical phenomenology, aetiology, pathology and pathogenesis

The definition of Parkinson’s disease (PD) is changing with the expansion of clinical phenomenology and improved understanding of environmental and genetic influences that impact on the pathogenesis of the disease at the cellular and molecular level. This had led to debate and discussion with as yet, no general acceptance of the direction that change should take either at the level of diagnosis or of what should and should not be sheltered under an umbrella of PD. This article is one contribution to this on-going discussion. There are two different themes running through the article - widening the definition of PD/LBD/synucleinopathies and the heterogeneity that exists within PD itself from a clinical, pathological and genetic per-spective. The conclusion reached is that in the future, further diagnostic categories will need to be recognized. These are likely to include - Parkinson’s syndrome, Parkinson’s syndrome likely to be Lewy body PD, clinical PD (defined by QSBB criteria), Lewy body disease (PD, LBD, REM SBD) and synucleinopathies (including LBD, MSA).

A matter of motion or an emotional matter? Management of depression in Parkinson’s disease

Depression is one of the most frequent comorbidities occurring in Parkinson's disease, affecting up to 50% of patients. Depression is associated with severe negative symptoms and has been shown to contribute to an increased rate of decline of both cognitive and motor function, profoundly impacting on the patient's quality of life. The symptoms of depression overlap with the motor features of Parkinson's disease, making detection difficult. Moreover, the lack of specialized screening tools means that depression remains undiagnosed and untreated in a high percentage of patients. However, depression in Parkinson's disease, when identified early, can be effectively treated with a variety of antidepressant medications, improving quality of life and preserving daily function. The focus of this review is to provide an overview of current knowledge regarding depression in Parkinson's disease, followed by a practical discussion addressing the issues of the detection, diagnosis and treatment.

Depression in Parkinson's disease: identification and management

Depression is a common psychiatric comorbidity in Parkinson's disease (PD) and contributes to significant impairments in cognitive, functional, motor, and social performance. This results in reduced quality of life, higher levels of care dependency, and increased caregiver burden. When treating depression, it is important to ensure that the patient's response to treatment will be adequately monitored. This can be accomplished in neurology or primary care settings, or in clinical settings with interdisciplinary treatment teams. Mental health services should be engaged early as a component of ongoing comprehensive care. This article reviews a general approach to treating the pharmacotherapy of depression in PD. Ultimately, clinicians should rely on empiric assessments of known risks and putative benefits to guide treatment decisions and should include a targeted and individualized multimodal approach that utilizes psychotherapeutic interventions along with pharmacologic therapies.

A non-comparative assessment of tolerability and efficacy of duloxetine in the treatment of depressed patients with Parkinson's disease

OBJECTIVE

Depression is a comorbidity affecting quality of life (QoL) in patients with Parkinson's disease (PD) and requires appropriate treatment. This study evaluated the tolerability, safety, and efficacy of duloxetine 60 mg once daily for 12 weeks in PD patients with major depressive disorder (MDD).

RESEARCH AND DESIGN METHODS

Non-comparative, open-label, multi-center study.

MAIN OUTCOME MEASURES

Tolerability was evaluated by discontinuation rate (acceptable if ≤ 19%) due to treatment-emergent adverse events (TEAEs) and motor symptoms (UPDRS). Safety measures were TEAEs, the UKU side effect rating scale, vital signs, weight, laboratory tests, and ECG. Efficacy measures included HAMD-17, BDI, CGI-S, PGI-I, and pain VAS. QoL was measured by PDQ-39.

RESULTS

Of the 151 patients enrolled, 8.6% (95% upper CI: 13.3%) discontinued the study due to TEAEs. Worsening in PD-related tremor and rigidity was not observed, activities of daily living significantly improved and UKU subscales progressively decreased. Clinically significant abnormalities in laboratory findings were limited to four cases of hypercholesterolemia and one increase of total bilirubin, CPK, and fasting glucose. Blood pressure, weight, and ECG did not change from baseline. HAMD-17 and PDQ-39 total score and individual domains, BDI, CGI-S, and PGI-I total scores significantly improved.

CONCLUSIONS

Duloxetine seems well tolerated and likely effective in the treatment of depression associated with PD, with no detrimental effects in PD signs and symptoms.

Psychiatric care in Parkinson's disease

OBJECTIVE

Parkinson's disease (PD) is a degenerative and disabling disease in which medical providers focus mainly on ameliorating problems in day-to-day functioning. This review summarizes current knowledge about the efficacy and tolerability of psychopharmacological agents in the treatment of depression, anxiety, psychosis, and insomnia in patients with PD. Recommended or promising nonpharmacological interventions are also reviewed.

METHOD

Studies were identified using computerized searches, with further references obtained from the bibliographies of the reviewed articles.

RESULT

Findings in the research literature provide growing evidence concerning the antidepressant treatment of patients with PD. Psychoeducational interventions for managing depression and anxiety symptoms also appear promising. Music therapy has proven to be particularly effective for patients with PD. Psychosis is common in patients with PD. When psychosis is induced by antiparkinson drugs, a dose reduction can be considered, but it is seldom successful. Patients with PD do not generally tolerate conventional antipsychotic medications, justifying evaluation of newer atypical agents in this population. Cholinesterase inhibitors have also become increasingly important in the treatment of PD in recent years. Finally, insomnia is a very frequent complaint in patients with PD and may also contribute to the development of depression. Patients should be encouraged to improve sleep hygiene and use behavioral interventions. Definitive trials of treatments for sleep disorders in this population are also warranted.

CONCLUSION

Therapeutic approaches to the treatment of PD and its associated psychiatric symptoms must be individualized and may involve a combination of antiparkinson drugs, psychopharmacological treatment, and/or psychotherapeutic interventions.

The pharmacologic management of depression in Parkinson's disease

Depression in Parkinson's disease (PD) is common, and it appears to worsen the motor and cognitive progression of the disease, and limits the patient's quality of life. In this paper, we review the pharmacotherapy of depression in people with PD. We find that evidence is sparse when it comes to this patient population. There is some evidence that older tricyclic antidepressants (nortriptyline and desipramine) may be effective in this population. There is also growing evidence that newer antidepressants like paroxetine and venlafaxine may be effective. We will also review a number of other promising medication treatments. What is apparent is the need for more research identifying the most effective medications for treating depression in this population. We provide recommendations that fall in line with current evidence-based practice for managing depression in the general population. Also, we suggest that collaborative models of depression care may be a promising approach to support the identification and effective treatment of those with PD also suffering from depressive disorders.

Nonmotor symptoms in Parkinson's disease

The recognition and treatment of nonmotor symptoms are increasingly emphasized in the care of Parkinson's disease (PD) patients. This manuscript will review signs and symptoms localized, generally, to the cortex, basal ganglia, brainstem, spinal cord, and peripheral nervous system. Cortical manifestations include dementia, mild cognitive impairment, and psychosis. Apathy, restlessness (akathisia), and impulse control disorders will be linked as basal ganglia symptoms. Symptoms attributed to the brainstem comprise depression, anxiety, and sleep disorders. Peripheral nervous system disturbances may lead to orthostatic hypotension, constipation, pain, and sensory disturbances.

Citalopram versus other anti-depressive agents for depression

BACKGROUND

Recent US and UK clinical practice guidelines recommend that second-generation antidepressants should be considered amongst the best first-line options when drug therapy is indicated for a depressive episode. Systematic reviews have already highlighted some differences in efficacy between second-generation antidepressants. Citalopram, one of the first selective serotonin reuptake inhibitors (SSRI) introduced in the market, is one of these antidepressant drugs that clinicians use for routine depression care.

OBJECTIVES

To assess the evidence for the efficacy, acceptability and tolerability of citalopram in comparison with tricyclics, heterocyclics, other SSRIs and other conventional and non-conventional antidepressants in the acute-phase treatment of major depression.

SEARCH METHODS

We searched The Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register and the Cochrane Central Register of Controlled Trials up to February 2012. No language restriction was applied. We contacted pharmaceutical companies and experts in this field for supplemental data.

SELECTION CRITERIA

Randomised controlled trials allocating patients with major depression to citalopram versus any other antidepressants.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data. Information extracted included study characteristics, participant characteristics, intervention details and outcome measures in terms of efficacy (the number of patients who responded or remitted), patient acceptability (the number of patients who failed to complete the study) and tolerability (side-effects).

MAIN RESULTS

Thirty-seven trials compared citalopram with other antidepressants (such as tricyclics, heterocyclics, SSRIs and other antidepressants, either conventional ones, such as mirtazapine, venlafaxine and reboxetine, or non-conventional, like hypericum). Citalopram was shown to be significantly less effective than escitalopram in achieving acute response (odds ratio (OR) 1.47, 95% confidence interval (CI) 1.08 to 2.02), but more effective than paroxetine (OR 0.65, 95% CI 0.44 to 0.96) and reboxetine (OR 0.63, 95% CI 0.43 to 0.91). Significantly fewer patients allocated to citalopram withdrew from trials due to adverse events compared with patients allocated to tricyclics (OR 0.54, 95% CI 0.38 to 0.78) and fewer patients allocated to citalopram reported at least one side effect than reboxetine or venlafaxine (OR 0.64, 95% CI 0.42 to 0.97 and OR 0.46, 95% CI 0.24 to 0.88, respectively).

AUTHORS' CONCLUSIONS

Some statistically significant differences between citalopram and other antidepressants for the acute phase treatment of major depression were found in terms of efficacy, tolerability and acceptability. Citalopram was more efficacious than paroxetine and reboxetine and more acceptable than tricyclics, reboxetine and venlafaxine, however, it seemed to be less efficacious than escitalopram. As with most systematic reviews in psychopharmacology, the potential for overestimation of treatment effect due to sponsorship bias and publication bias should be borne in mind when interpreting review findings. Economic analyses were not reported in the included studies, however, cost effectiveness information is needed in the field of antidepressant trials.

Serotonin-dependent depression in Parkinson's disease: a role for the subthalamic nucleus?

Depression is the most common neuropsychiatric co-morbidity in Parkinson's disease (PD). The underlying mechanism of depression in PD is complex and likely involves biological, psychosocial and therapeutic factors. The biological mechanism may involve changes in monoamine systems, in particular the serotonergic (5-hydroxytryptamine, 5-HT) system. It is well established that the 5-HT system is markedly affected in the Parkinsonian brain, with evidence including pathological loss of markers of 5-HT axons as well as cell bodies in the dorsal and median raphe nuclei of the midbrain. However, it remains unresolved whether alterations to the 5-HT system alone are sufficient to confer vulnerability to depression. Here we propose low 5-HT combined with altered network activity within the basal ganglia as critically involved in depression in PD. The latter hypothesis is derived from a number of recent findings that highlight the close interaction between the basal ganglia and the 5-HT system, not only in motor but also limbic functions. These findings include evidence that clinical depression is a side effect of deep brain stimulation (DBS) of the subthalamic nucleus (STN), a treatment option in advanced PD. Further, it has recently been demonstrated that STN DBS in animal models inhibits 5-HT neurotransmission, and that this change may underpin depressive-like side effects. This review provides an overview of 5-HT alterations in PD and a discussion of how these changes might combine with altered basal ganglia network activity to increase depression vulnerability.

Dopamine receptor agonists and depression in Parkinson's disease

Depression is one of the most common non-motor symptoms in Parkinson's disease (PD). It is associated with a more rapid progression of physical symptoms, greater decline in cognitive skills, and a poorer quality of life. Despite the high prevalence of depression and antidepressant use in PD, validated guidelines for the treatment of PD-associated depression (dPD) are lacking. Several methodological limitations have been recognized in the available studies examining the treatment of dPD. Some studies support a relevant role of the catecholaminergic systems in the pathogenesis of dPD. In open-label studies, the dopamine receptor agonists pramipexole and pergolide have shown antidepressant effects in PD patients. A placebo-controlled study of pramipexole in dPD is ongoing. The combined results of data from animal models and evidence in human studies support the strategy of dopaminergic stimulation as a treatment of depression. Treatment strategies for depressive symptoms in PD should include optimization of dopaminergic treatment prior to the addition of classic antidepressant drugs, thus reducing the risk of side-effects associated with multi-drug therapies.

Pathological considerations in the treatment of Parkinson's disease: more than just a wiring diagram

Parkinson's disease (PD) represents a common but challenging condition in which an increasing number of therapeutic options have evolved over the course of the last 50 years. The introduction of dopaminergic therapies has dramatically improved outcomes but life expectancies remain significantly curtailed. Currently, all available treatment options are directed towards the amelioration of symptoms. However, it is hoped that a greater understanding of the distinctive pathology underlying PD might offer some novel therapeutic approaches. The identification of degeneration within the nigrostriatal tract as the most prominent pathological process in PD has led to the development of a number of therapies. However, despite initially good symptomatic control it has become clear that the longer-term use of these medications is associated with a number of debilitating motor complications. The management of these drug-related issues has necessitated a further tier of therapeutic options based largely on a greater understanding of the basal ganglia circuitry involved. Indeed, surgical interventions targeting these neural circuits have provided increased control of motor symptoms in patients with advanced disease, however, such techniques still fail to slow or reverse the disease. To this end, a number of novel approaches focussed on restoration or repair of the diseased brain have received increasing attention. Nevertheless, there are multiple symptoms that are unresponsive to any of these therapies, highlighting the involvement of other neurotransmitter systems and the complexities of the disease beyond the basal ganglia circuitry. An appreciation of the ongoing neurodegenerative processes at the core of PD and the burden of disease associated with them, emphasises the need for increased research into more effective and comprehensive treatment methodologies.

Chronic treatment with fluoxetine decreases cerebral metabolic responses to the 5-HT1A agonist 8-hydroxy-2(di-N-propylamino)tetralin and increases those to the 5-HT2A/2C agonist 1-(2,5-dimethoxy-4-iodophenyl)-2-aminopropane and to the dopaminergic agonist apomorphine

Fluoxetine is a selective serotonin (5-HT) reuptake inhibitor that, when given chronically, alters different neurotransmitter systems. To assess functional changes occurring in the 5-HT and dopaminergic systems, we investigated the effects of 5-HT(1A) agonist 8-hydroxy-2(di-N-propylamino)tetralin (8-OH-DPAT), of the 5-HT(2A/2C) agonist 1-(2,5-dimethoxy-4-iodophenyl)-2-aminopropane (DOI) and of the dopamine D(1/2) agonist apomorphine (APO) on behavior and on regional cerebral metabolic rates for glucose (rCMRglc) in rats pretreated for 3weeks with saline or fluoxetine (8mg/kg/day). Behavioral effects were assessed for 8-OH-DPAT by scoring the 5-HT syndrome, for DOI by counting head shakes and for APO with an activity monitor. rCMRglc were measured with quantitative autoradiographic [(14)C]2-deoxyglucose technique in 60 brain regions at 10min after acute administration of 8-OH-DPAT 1mg/kg, at 30min after DOI 5mg/kg or at 10min after APO 1mg/kg. Chronic fluoxetine did not alter the 5-HT syndrome by 8-OH-DPAT, decreased head shakes by DOI and enhanced hyperlocomotion by APO. 8-OH-DPAT produced rCMRglc increases in sensorimotor regions that were unaffected by fluoxetine pretreatment and diffuse metabolic decrements that were attenuated by fluoxetine in limbic and raphe areas (17% and 4% mean decreases, respectively, in saline control and fluoxetine-pretreated rats). DOI produced widespread rCMRglc declines that were intensified by fluoxetine (14% and 20% decreases, in control and fluoxetine rats). APO caused rCMRglc increases in 22 brain regions that were potentiated by fluoxetine in dopaminergic motor areas (10% and 25% increases, in control and fluoxetine rats). In conclusion, fluoxetine enhances 5-HT neurotransmission by blunting responsivity of 5-HT(1A) autoreceptors and increasing that of 5-HT(2A/2C) postsynaptic receptors and enhances dopaminergic D(1/2) receptor neurotransmission.

Destruction of dopaminergic neurons in the midbrain by 6-hydroxydopamine decreases hippocampal cell proliferation in rats: reversal by fluoxetine

Background

Non-motor symptoms (e.g., depression, anxiety, and cognitive deficits) in patients with Parkinson disease (PD) precede the onset of the motor symptoms. Although these symptoms do not respond to pharmacological dopamine replacement therapy, their precise pathological mechanisms are currently unclear. The present study was undertaken to examine whether the unilateral 6-hydroxydopamine (6-OHDA) lesion to the substantia nigra pars compacta (SNc), which represents a model of long-term dopaminergic neurotoxicity, could affect cell proliferation in the adult rat brain. Furthermore, we examined the effects of the selective serotonin reuptake inhibitor (SSRI) fluoxetine and the selective noradrenaline reuptake inhibitor maprotiline on the reduction in cell proliferation in the subgranular zone (SGZ) by the unilateral 6-OHDA lesion.

Methodology/Principal Findings

A single unilateral injection of 6-OHDA into the rat SNc resulted in an almost complete loss of tyrosine hydroxylase (TH) immunoreactivity in the striatum and SNc, as well as in reductions of TH-positive cells and fibers in the ventral tegmental area (VTA). On the other hand, an injection of vehicle alone showed no overt change in TH immunoreactivity. A unilateral 6-OHDA lesion to SNc significantly decreased cell proliferation in the SGZ ipsilateral to the 6-OHDA lesion, but not in the contralateral SGZ or the subventricular zone (SVZ), of rats. Furthermore, subchronic (14 days) administration of fluoxetine (5 mg/kg/day), but not maprotiline significantly attenuated the reduction in cell proliferation in the SGZ by unilateral 6-OHDA lesion.

Conclusions/Significance

The present study suggests that cell proliferation in the SGZ of the dentate gyrus might be, in part, under dopaminergic control by SNc and VTA, and that subchronic administration of fluoxetine reversed the reduction in cell proliferation in the SGZ by 6-OHDA. Therefore, SSRIs such as fluoxetine might be potential therapeutic drugs for non-motor symptoms as well as motor symptoms in patients with PD, which might be associated with the reduction in cell proliferation in the SGZ.

Non-motor symptoms in Parkinson's disease

Parkinson's disease is a hypokinetic movement disorder with cardinal motor features of bradykinesia, resting tremor and rigidity. However, non-motor symptoms, such as cognitive, neuropsychiatric, sleep, autonomic and sensory disturbances are gaining increasing attention. These non-motor symptoms may be intrinsic to the disease pathology or may be results of treatment with dopaminergic agents. Given that most, if not all, patients with Parkinson's disease will experience non-motor symptoms, it is important to be sensitive to these phenomena, especially since some non-motor signs may precede motor impairment. Treatment may include interventions independent of traditional, dopaminergic anti-Parkinson therapy or may be tailored to increase or reduce dopamine responsiveness of the symptom.

Medical treatment of Parkinson disease

The cardinal characteristics of Parkinson disease (PD) include resting tremor, rigidity, and bradykinesia. Patients may also develop autonomic dysfunction, cognitive changes, psychiatric symptoms, sensory complaints, and sleep disturbances. The treatment of motor and non-motor symptoms of Parkinson disease is addressed in this article.

Optimizing therapeutic effects in patients with comorbidities: drug-resistant tremor, autonomic dysfunction, psychiatric disorders, and cognitive impairment

Parkinsonism is a syndrome characterized by a combination of cardinal features including resting tremor, bradykinesia, rigidity, and loss of postural reflexes. The most common presentation of parkinsonism is the idiopathic variety first described by James Parkinson in 1817 now known as Parkinson's disease (PD). This article focuses on identifying the different subtypes of PD, with the recognition that treatment approaches may differ depending on the initial presenting feature. It also addresses issues related to the recognition and treatment of nonmotor comorbidities of PD, such as autonomic dysfunction and neuropsychiatric problems including depression and dementia.

Sertraline in the treatment of depressive disorders in patients with Parkinson's disease

We studied 54 idiopathic Parkinson's disease (PD) patients with depressive disorders (DD) to compare the efficacy and the effect of treatment with sertraline in the usual formulation and in the liquid oral concentrate (LOC) formulation. After 6 months of sertraline treatment, the Hamilton Depression Rating Scale and the Montgomery and Asberg Depression Rating Scale showed a decrement (p<0.001, for both formulations). Parkinson's Disease Questionnaire scores improved (p<0.005 for usual formulation and p<0.001 for LOC formulation), as did Clinical Global Impression-Severity of Illness scale and Clinical Global Impression-Global Improvement scale scores (p=0.1, for both formulations). Mini Mental State Examination and Unified Parkinson's Disease Rating Scale motor subscores did not change. These results suggest that sertraline LOC may also be a useful treatment for DD in PD patients, especially for those with swallowing problems, and have significant benefit for quality of life, without worsening of parkinsonian features.

Diagnosis and treatment of depression comorbid with neurologic disorders

Depression is common in patients with neurologic disorders such as Alzheimer disease, stroke, Parkinson disease, and multiple sclerosis. Diagnosing depression in the context of neurologic disease is challenging, given the overlap between many signs and symptoms of depression with those of the neurologic disorders. Cognitive impairment further complicates diagnostic evaluation. The etiology of depression in these patients is not well understood and variously has been attributed to emotional reaction to the diagnosis or disability associated with the neurologic condition, the anatomical and/or neurochemical outcomes of neurodegeneration, and the influence of other disease factors. Beyond the inherent burden depression places on patients and caregivers, it increases cognitive and functional disability and, depending on the neurologic disorder, poorer treatment adherence and recovery, earlier institutionalization, and increased suicide risk. Few controlled antidepressant trials are available to guide treatment. In the absence of validated diagnostic guidelines for depression in each neurologic condition, clinicians are urged to remain vigilant for this treatable comorbidity. Although more controlled trials clearly are needed, existing studies suggest that depression in patients with neurologic disorders responds to antidepressant medication and, in some disorders, to psychotherapeutic approaches. Investigating the neuroanatomical and neurochemical correlates of depression comorbid with neurologic conditions also may clarify depression etiology and treatment in the general population.

Therapeutic potential of fluoxetine in neurological disorders

The selective serotonin reuptake inhibitor (SSRI) fluoxetine, which is registered for a variety of psychiatric disorders, has been found to stimulate the cAMP-responsive element binding protein (CREB), increase the production of brain-derived neurotrophic factor (BNDF) and the neurotrophic peptide S100beta, enhance glycogenolysis in astrocytes, block voltage-gated calcium and sodium channels, and decrease the conductance of mitochondrial voltage-dependent anion channels (VDACs). These mechanisms of actions suggest that fluoxetine may also have potential for the treatment of a number of neurological disorders. We performed a Pubmed search to review what is known about possible therapeutic effects of fluoxetine in animal models and patients with neurological disorders. Beneficial effects of fluoxetine have been noted in animal models of stroke, multiple sclerosis, and epilepsy. Fluoxetine was reported to improve neurological manifestations in patients with Alzheimer's disease, stroke, Huntington's disease, multiple sclerosis, traumatic brain injury, and epilepsy. Clinical studies so far were small and often poorly designed. Results were inconclusive and contradictory. However, the available preclinical data justify further clinical trials to determine the therapeutic potential of fluoxetine in neurological disorders.

Depression rating scales in Parkinson's disease: critique and recommendations

Depression is a common comorbid condition in Parkinson's disease (PD) and a major contributor to poor quality of life and disability. However, depression can be difficult to assess in patients with PD due to overlapping symptoms and difficulties in the assessment of depression in cognitively impaired patients. As several rating scales have been used to assess depression in PD (dPD), the Movement Disorder Society commissioned a task force to assess their clinimetric properties and make clinical recommendations regarding their use. A systematic literature review was conducted to explore the use of depression scales in PD and determine which scales should be selected for this review. The scales reviewed were the Beck Depression Inventory (BDI), Hamilton Depression Scale (Ham-D), Hospital Anxiety and Depression Scale (HADS), Zung Self-Rating Depression Scale (SDS), Geriatric Depression Scale (GDS), Montgomery-Asberg Depression Rating Scale (MADRS), Unified Parkinson's Disease Rating Scale (UPDRS) Part I, Cornell Scale for the Assessment of Depression in Dementia (CSDD), and the Center for Epidemiologic Studies Depression Scale (CES-D). Seven clinical researchers with clinical and research experience in the assessment of dPD were assigned to review the scales using a structured format. The most appropriate scale is dependent on the clinical or research goal. However, observer-rated scales are preferred if the study or clinical situation permits. For screening purposes, the HAM-D, BDI, HADS, MADRS, and GDS are valid in dPD. The CES-D and CSDD are alternative instruments that need validation in dPD. For measurement of severity of depressive symptoms, the Ham-D, MADRS, BDI, and SDS scales are recommended. Further studies are needed to validate the CSDD, which could be particularly useful for the assessment of severity of dPD in patients with comorbid dementia. To account for overlapping motor and nonmotor symptoms of depression, adjusted instrument cutoff scores may be needed for dPD, and scales to assess severity of motor symptoms (e.g., UPDRS) should also be included to help adjust for confounding factors. The HADS and the GDS include limited motor symptom assessment and may, therefore, be most useful in rating depression severity across a range of PD severity; however, these scales appear insensitive in severe depression. The complex and time-consuming task of developing a new scale to measure depression specifically for patients with PD is currently not warranted.

Bright light therapy in Parkinson's disease: a pilot study

Several observations suggest a beneficial effect of melatonin antagonism for Parkinson's disease (PD). Although bright light therapy (BLT) suppresses melatonin release and is an established treatment for depression and sleep disturbances, it has not been evaluated in PD. We examined effects of BLT on motor symptoms, depression, and sleep in PD in a randomized placebo-controlled double-blind study in 36 PD patients, using Parkinson's Disease Rating Scale (UPDRS) I-IV, Beck's Depression Inventory, and Epworth Sleepiness Scale. All patients received BLT for 15 days in the morning, 30 min daily. Illuminance was 7.500 lux in the active treatment group and 950 lux in the placebo group. Although group differences were small, BLT led to significant improvement of tremor, UPDRS I, II, and IV, and depression in the active treatment group but not in the placebo group. It was very well tolerated. Follow up studies in more advanced patient populations employing longer treatment durations are warranted.

Management of the behavioral aspects of Parkinson's disease

Parkinson's disease is a progressive and debilitating movement disorder that is diagnosed by its motor signs. The behavioral manifestations of Parkinson's disease are prevalent and frequently complicate the course of the disease. These may be due to the illness itself or its treatment and are often more disabling than the motor symptoms. This review focuses on the management of the most common behavioral symptoms of Parkinson's disease, including depression, anxiety, psychosis, dementia, delirium, sleep disorders, fatigue, apathy, emotionalism and compulsive behaviors.

Influence of initial use of serotonergic antidepressants on antiparkinsonian drug use in levodopa-using patients

OBJECTIVE

To assess whether there is an association between initial use of serotonergic antidepressants and changes in antiparkinsonian drug treatment.

METHODS

A retrospective cohort study was performed with the PHARMO record linkage system. All patients from 1994 until 2004 of 40 years or older who were first time users of an antidepressant and who had used a levodopa-containing drug at least 180 days before initiation of the antidepressant were included. The maximum follow-up time was 180 days. The first change in antiparkinsonian drug treatment, defined as an increase in the daily dosage of any antiparkinsonian drug, the start of a new antiparkinsonian drug or a change in the dosage form during the follow-up period, was taken as an endpoint. Antidepressants were classified in two ways: according to their class [selective serotonin reuptake inhibitors (SSRI), tricyclic antidepressants (TCA) or other antidepressants] or by the extent of their inhibition of serotonin reuptake (high, intermediate or low).

RESULTS

A total of 221 patients was included in our study. The adjusted hazard ratio for a change in antiparkinsonian drug treatment was 0.7 (95% CI 0.3-1.5) comparing SSRI with TCA users, and it was 0.9 (95% CI 0.4-2.1) comparing users of other antidepressants with TCA users. The adjusted hazard ratio for a change in antiparkinsonian drug treatment was 0.6 (95% CI 0.3-1.4) comparing users of antidepressants with high versus low extent of inhibition of serotonin reuptake, and it was 0.7 (95% CI 0.3-1.4) comparing users of antidepressants with intermediate versus low extent of inhibition of serotonin reuptake.

CONCLUSION

Based on these observations, we found no evidence to be more cautious using SSRIs or serotonergic antidepressants compared to other antidepressants in patients with Parkinson's disease.

Cognitive, Affective, and Psychiatric Features of Parkinson's Disease

Nonmotor symptoms, including cognitive deterioration and dementia, depression and apathy, and psychosis, are common in Parkinson's disease. Their presence is associated with a tremendous burden for the patient and family members. This article reviews the pathophysiololgy, risks, impact, major features, diagnosis, and treatment of these symptoms in Parkinson's disease.

Non-motor aspects of Parkinson's disease

Parkinson's disease is primarily considered to be a movement disorder and is defined by its motor signs. Yet, the behavioral manifestations of the disease are often more debilitating than its motor complications. This review will focus on the non-motor aspects of Parkinson's disease, including mood, psychosis, cognitive, sleep, fatigue, apathy, delirium, and repetitive disorders, that may occur. The phenomenology, pathology, and treatment of the behavioral symptoms of Parkinson's disease will be discussed.

Treatment of depression in Parkinson's disease

Depression is one of the most common nonmotor features observed in Parkinson's disease (PD), affecting approximately 40% of patients. Depression in Parkinson's disease (dPD) significantly affects quality of life of both patients and their families and has been shown to be more predictive of distress than motor disability. Depression frequently goes unrecognized in this population, however, in part because the diagnosis is often complicated by the overlap of psychiatric and PD symptoms. The etiology of dPD is unclear; dopaminergic, serotonergic, and noradrenergic systems may be implicated. Options for managing dPD include antidepressant medication; cognitive-behavioral therapy; behavioral lifestyle interventions such as exercise; and, in refractory cases, noninvasive brain stimulation (electroconvulsive therapy, transcranial magnetic stimulation). Randomized controlled trials are needed to evaluate the efficacy of interventional approaches for dPD; several trials are currently underway.

Initial treatment of Parkinson's disease

Initial treatment of early idiopathic Parkinson's disease (PD) begins with diagnosis based on clinical evaluation supplemented by laboratory studies and brain imaging to exclude causes of secondary parkinsonism. In most cases, testing is normal and the diagnosis of PD rests on clinical criteria. In patients with mild symptoms and signs, the diagnosis of PD may not initially be apparent, and follow-up evaluation is needed to arrive at a diagnosis. Once the diagnosis is made, pharmacologic treatment may not be the first step. First, patient education is essential, especially because PD is a high-profile disease for which information and misinformation are readily available to patients and families. Counseling concerning prognosis, future symptoms, future disability, and treatment must be provided. Questions from patients concerning diet, lifestyle, and exercise are especially common at this point. The decision of when to initiate treatment is the next major consideration. Much controversy but relatively little light has been brought to bear on this issue. L-dopa was the first major antiparkinson medication to be introduced and remains the "gold standard" of treatment. Next in efficacy are the dopamine agonists (DAs). A debate has raged concerning whether initial dopaminergic treatment should be with L-dopa or DAs. Physicians have been concerned about forestalling the appearance of dyskinesias and motor fluctuations, whereas patients have incorrectly understood that L-dopa and possibly other antiparkinson drugs have a finite duration of usefulness, making it important to defer treatment for as long as possible. This has created "L-dopa phobia," which may stand in the way of useful treatment. In spite of this controversy, there is uniform agreement that the appropriate time to treat is when the patient is beginning to be disabled. This varies from patient to patient and depends on age, employment status, nature of job, level of physical activity, concern about appearance, and other factors. The choice of a specific drug is sometimes dictated by the patient's symptoms. For example, L-dopa is preferable for severe akinesia, an anticholinergic may be useful when tremor is the most prominent symptom (especially in those aged younger than 70 years), and DAs may be indicated for younger patients, more prone to dyskinesias and fluctuations, with relatively mild symptoms. It is also important to manage non-motor symptoms in patients with early PD. Anxiety and depression are particularly common at this stage and may be presenting symptoms of PD. Where appropriate, counseling and/or treatment with anxiolytics and antidepressants should be considered.

Pramipexole versus sertraline in the treatment of depression in Parkinson's disease: a national multicenter parallel-group randomized study

In addition to treating the motor symptoms of Parkinson's disease, the dopamine agonist pramipexole has shown an antidepressant effect. The trials, however, included patients with motor complications, raising the question of whether the antidepressant benefit represented only a treatment-related motor improvement. To address this issue, we have conducted a 14-week randomized trial comparing pramipexole with an established antidepressant in patients without motor complications. At seven Italian centers, 67 Parkinsonian outpatients with major depression but no history of motor fluctuations and/or dyskinesia received open-label pramipexole (at 1.5 to 4.5 mg/day) or sertraline (at 50 mg/day). In both groups, the Hamilton Depression Rating Scale (HAM-D) score decreased throughout 12 weeks of treatment, but in the pramipexole group the proportion of patients who recovered, as defined by a final HAM-D score </= 8,was significantly higher, at 60.6% versus 27.3% (p = 0.006). Patients' self-ratings improved in both groups. All adverse events were mild or moderate, but five patients (14.7%) withdrew from the sertraline group. Despite the absence of motor complications, the pramipexole recipients showed improvement on the Unified Parkinson's Disease Rating Scale (UPDRS) motor subscore. We conclude that dopamine agonists may be an alternative to antidepressants in Parkinson's disease.

Serotonin as a modulator of glutamate- and GABA-mediated neurotransmission: implications in physiological functions and in pathology

The neurotransmitter serotonin (5-HT), widely distributed in the central nervous system (CNS), is involved in a large variety of physiological functions. In several brain regions 5-HT is diffusely released by volume transmission and behaves as a neuromodulator rather than as a "classical" neurotransmitter. In some cases 5-HT is co-localized in the same nerve terminal with other neurotransmitters and reciprocal interactions take place. This review will focus on the modulatory action of 5-HT on the effects of glutamate and gamma-amino-butyric acid (GABA), which are the principal neurotransmitters mediating respectively excitatory and inhibitory signals in the CNS. Examples of interaction at pre-and/or post-synaptic levels will be illustrated, as well as the receptors involved and their mechanisms of action. Finally, the physiological meaning of neuromodulatory effects of 5-HT will be briefly discussed with respect to pathologies deriving from malfunctioning of serotonin system.