Desipramine in treatment of Parkinson's disease. A placebo-controlled study

Depression and Parkinson's disease: a Chicken-Egg story

Parkinson's disease (PD) is a neurodegenerative disease, however, besides the motor symptoms, such as rest tremor, hypokinesia, postural instability and rigidity, PD patients have also non-motor symptoms, namely neuropsychiatric disorders. Apart from the required motor symptoms, psychopathological symptoms are very common and include mood disorders, anxiety disorders, hallucinations, psychosis, cognitive deterioration and dementia. The underlying pathophysiological process in PD is mainly due to the loss of dopaminergic neural cells and thereby causes the shortage of nigrostriatal dopamine content in them. In addition, it may involve other neurotransmitter systems such as the noradrenergic, serotonergic, cholinergic and noradrenergic systems as well. Depression can result from any unhealthy conditions making the diagnosis a challenging task. The manifestation of depression associated with or without PD is inadequate. The co-occurrence of depression and PD often leads to the conceptual discussion on whether depressive symptoms appear before or after PD develops. This paper will discuss the conceptual mechanism of PD and depression. Keep in mind both conditions belong to two separate entities but share some similar aspects in their pathophysiology.

Synergistic anticataleptic effect of imipramine and nicotine in a rotenone-induced rat model

RATIONALE

Some antidepressants have been previously found to produce anti-parkinsonian effect; nicotine was known to mitigate experimental neurotoxic lesions. The anticataleptic efficacy of antidepressant-nicotine co-administration is unstudied.

OBJECTIVES

This work aimed to evaluate anticataleptic action of imipramine-nicotine combination in rotenone model.

METHODS

Catalepsy was measured by the bar test. Concentrations of tyrosine hydroxylase, dopamine, and DOPAC were determined in the substantia nigra and dorsal striatum using ELISA and HPLC techniques; additionally, dopamine/DOPAC ratio was calculated for both areas.

RESULTS

Imipramine and nicotine alone were ineffective; however, co-administration of the drugs significantly (p < 0.01) inhibited rotenone-induced catalepsy and mitigated neurochemical changes in the nigrostriatal system. Anticataleptic effect of the combination exceeded that of levodopa, a standard drug for anti-parkinsonian treatment.

CONCLUSION

The combined use of imipramine and nicotine at relatively low doses inhibits neurotoxin-induced catalepsy and nigrostriatal neurochemical changes. The co-administration of these drugs might be a new approach to the treatment of extrapyramidal dysfunctions.

Nonmotor symptoms of Parkinson’s disease

Nonmotor symptoms occur commonly in Parkinson's disease (PD) patients and are frequently under-recognized and undertreated. Symptoms include sleep abnormalities, fatigue, autonomic disturbances, mood disorders and cognitive dysfunction. Early recognition and treatment of nonmotor symptoms in PD is critical to providing optimal management. A new screening questionnaire and the revised Unified PD Rating Scale should assist healthcare providers to better identify and evaluate these symptoms. This article reviews the identification and treatment of nonmotor symptoms in PD.

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.

The noradrenaline transporter as site of action for the anti-Parkinson drug amantadine

Amantadine is an established antiparkinsonian drug with a still unclear molecular site of action. In vivo studies on rodents, in vitro studies on tissue of rodents as well as binding studies on post mortem human tissue implicate monoamine transporters and NMDA receptors. In order to re-examine its action at human variants of these proteins on intact cells we established cells stably expressing the human NR1/2A NMDA-receptor, noradrenaline transporter (NAT) or dopamine transporter (DAT) and tested the activity of amantadine in patch-clamp, uptake, release, and cytotoxicity experiments. Amantadine was less potent in blockade of NMDA-induced inward currents than in blockade of noradrenaline uptake and in induction of inward currents in NAT expressing cells. It was 30 times more potent in blocking uptake in NAT- than in DAT cells. Amantadine induced NAT-mediated release at concentrations of 10-100 μM in superfusion experiments and blocked NAT-mediated cytotoxicity of the parkinsonism inducing neurotoxin 1-methyl-4-phenyl-pyridinium (MPP(+)) at concentrations of 30-300 μM, whereas 300-1000 μM amantadine was necessary to block NMDA-receptor mediated cytotoxicity. Similar to amphetamine, amantadine was inactive at α(2A)-adrenergic receptors and induced reverse noradrenaline transport by NAT albeit with smaller effect size. Thus, amantadine acted as "amphetamine-like releaser" with selectivity for the noradrenergic system. These findings and differences with memantine, which had been reported as less efficient antiparkinsonian drug than amantadine but in our hands was significantly more potent at the NMDA-receptor, suggest contributions from a noradrenergic mechanism in the antiparkinsonian action of amantadine.

Diagnosis and treatment of major depressive disorder

Major depressive disorder is a common illness, particularly in patients with medical and neurologic conditions. This article summarizes current data on the epidemiology, diagnosis, and treatment of major depression, with special emphasis on the diagnosis and treatment of depression in medical and neurologic patients. We reviewed the role of pharmacotherapies, psychotherapies, somatic treatments, and alternative remedies and we included practical advice for clinician regarding the timing and sequence of these treatments, the role of standardized depression scales, and the criteria for referrals to specialty consultants.

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.

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.

Comparison of desipramine and citalopram treatments for depression in Parkinson's disease: a double-blind, randomized, placebo-controlled study

Depression is one of the most common psychiatric disturbances in Parkinson's disease (PD). Recent reviews have highlighted the lack of controlled trials and the ensuing difficulty in formulating recommendations for antidepressant use in PD. We sought to establish whether antidepressants provide real benefits and whether tricyclic and selective serotonin reuptake inhibitor (SSRI) antidepressants differ in their short-term efficacy, because the time to onset of therapeutic benefit remains an important criterion in depression. The short-term efficacy (after 14 and 30 days) of two antidepressants (desipramine, a predominantly noradrenergic reuptake inhibitor tricyclic and citalopram, a SSRI) was assessed in a double-blind, randomized, placebo- controlled study of 48 nondemented PD patients suffering from major depression. After 14 days, desipramine prompted an improvement in the Montgomery Asberg Depression Rating Scale (MADRS) score, compared with citalopram and placebo. Both antidepressants produced significant improvements in the MADRS score after 30 days. Mild adverse events were twice as frequent in the desipramine group as in the other groups. A predominantly noradrenergic tricyclic antidepressant induced a more intense short-term effect on parkinsonian depression than did an SSRI. However, desipramine's lower tolerability may outweigh its slight short-term clinical advantage.

The effects of antidepressants in Parkinson's disease: a meta-analysis

This study explored the therapeutic effect of antidepressants in Parkinson's disease (PD) using a meta-analysis. Altogether, 24 placebo-controlled trials qualified for inclusion and revealed that tricyclic antidepressants (TCAs) had a greater antidepressant effect relative to selective serotonin reuptake inhibitors (SSRIs), Qb(1) = 8.87, p < .01, and the mono-amine-oxidase inhibitor, selegiline, Qb(1) = 7.90, p < .01. Whereas TCAs produced a significant side effect profile (odds ratio = 3.07), adverse events were negligible with SSRIs (odds ratio = 1.83) and selegeline (odds ratio = 1.63). Antidepressants can be beneficial for patients with PD. However, the choice of antidepressants needs to take depressive symptomatologies into account while monitoring side effects.

The neuropathological basis for depression in Parkinson's disease

Depression is found in 30-40% of all patients with Parkinson's disease (PD), but its etiology is unclear. Using neuropathology as a signpost for neurotransmitter function, we investigated the prevalence of pathological features found at postmortem and sought to uncover differences between depressed (n=11) and non-depressed (n=9) elderly PD patients. The results indicate a higher prevalence of pathological features in depressed compared to non-depressed PD patients, particularly in catecholamine areas of the brain; the locus coeruleus (neuronal loss: odds ratio=7.2, p=08; gliosis: odds ratio=18.0, p=008); dorsal vagus nerve (gliosis: odds ratio=7.63, p<0.05), and substantia nigra pars compacta (gliosis: odds ratio=2.85, ns). However, neuropathological differences were absent in the dorsal raphe nuclei, amygdala, and cortical regions. Our evidence suggests that depression in PD is related more to catecholaminergic than serotonergic system dysfunction.

Depression in Parkinson's disease: health risks, etiology, and treatment options

Depression is found in about 30%-40% of all patients with Parkinson's disease (PD), but only a small percentage (about 20%) receive treatment. As a consequence, many PD patients suffer with reduced health-related quality of life. To address quality of life in depressed PD patients, we reviewed the literature on the health correlates of depression in PD (eg, cognitive function), etiology of depression in PD, and treatment options (ie, antidepressants, electroconvulsive therapy, and psychotherapy). The current review is unique in its focus on psychosocial aspects, as well as neuropathological factors, of depression in PD. Overall, we conclude that neurochemical (eg, serotonin) and psychosocial factors (eg, coping style, self-esteem, and social support) contribute to the affective disturbances found in this neuropsychiatric population. Therefore, we recommend that a multidisciplinary (eg, pharmacotherapeutic, psychoeducational, and/or psychotherapeutic) approach to treatment be taken with depressed PD patients.

Prise en charge médicale des patients atteints de syndromes parkinsoniens atypiques dégénératifs

Atypical degenerative parkinsonian syndromes (progressive supranuclar palsy, multiple system atrophy, corticobasal degeneration, Lewy body dementia) are an important differential diagnosis to idiopathic Parkinson's disease. However, because these disorders are characterized by the degeneration of multiple neuronal populations, treatment approaches are much less specific than in Parkinson's disease, where dopamimetic drugs represent the mainstay of therapy. Thus, and because the progression of these disorders is usually more aggressive than Parkinson's disease, many physicians face a form of therapeutic resignation when confronted with patients suffering from atypical degenerative parkinsonian syndromes. However, in the present article, we wish to show that a symptom-by-symptom approach can substantially relieve the patients and their caregivers by providing an overview of pharmacologic and non-pharmacologic treatment options.

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.

The effect of depression on motor function and disease severity of Parkinson's disease

OBJECTIVES

Approximately 40% of patients with Parkinson's disease (PD) experience symptoms of depression. Our aim was to evaluate the effect of depression on disease severity, motor function and other phenotypic characteristics of PD.

PATIENTS AND METHODS

We studied 32 PD patients with major depression (PD-D) according to the DSM-IV criteria and 32 PD patients with no depression (PD-C) matched for gender, age of onset and duration.

RESULTS

Major depression in PD patients was associated with increased disease severity, poorer motor function and worse performance in the activities of daily living as measured by UPDRS scores. Furthermore, there was an association of depression with the severity of bradykinesia and axial rigidity.

CONCLUSIONS

Depression in PD can have a profound negative impact on a patient's sense of wellbeing and motor functioning. Therefore, PD patients should be routinely and carefully screened for the presence of depression and appropriate management should be considered. Larger studies on the subject are warranted.

Antidepressant studies in Parkinson's disease: a review and meta-analysis

The objective of this study was to determine effect sizes for both antidepressant treatment and placebo for depression in Parkinson's disease (PD), and to compare the findings with those reported in elderly depressed patients without PD. Recent reviews have concluded that there is little empiric evidence to support the use of antidepressants in PD; however, available data has not been analyzed to determine the effect size for antidepressant treatment in PD depression. A literature review identified antidepressant studies in PD. Suitable studies were analyzed using meta-analytic techniques, and effect sizes were compared with those from antidepressant studies in elderly patients without PD. Large effect sizes were found for both active treatment and placebo in PD, but there was no difference between the two groups. In contrast, active treatment was superior to placebo in depressed elderly patients without PD. In PD, increasing age and a diagnosis of major depression were associated with better treatment response. Results also suggest that newer antidepressants are well tolerated in PD. Despite the high prevalence of depression and antidepressant use in PD, controlled treatment research has been almost nonexistent. Meta-analysis results suggest a large but nonspecific effect for depression treatment in PD. In addition, PD patients may benefit less from antidepressant treatment, particularly selective serotonin reuptake inhibitors, than do elderly patients without PD.

Mood disorders in the medically ill: scientific review and recommendations

OBJECTIVE

The purpose of this review is to assess the relationship between mood disorders and development, course, and associated morbidity and mortality of selected medical illnesses, review evidence for treatment, and determine needs in clinical practice and research.

DATA SOURCES

Data were culled from the 2002 Depression and Bipolar Support Alliance Conference proceedings and a literature review addressing prevalence, risk factors, diagnosis, and treatment. This review also considered the experience of primary and specialty care providers, policy analysts, and patient advocates. The review and recommendations reflect the expert opinion of the authors.

STUDY SELECTION/DATA EXTRACTION

Reviews of epidemiology and mechanistic studies were included, as were open-label and randomized, controlled trials on treatment of depression in patients with medical comorbidities. Data on study design, population, and results were extracted for review of evidence that includes tables of prevalence and pharmacological treatment. The effect of depression and bipolar disorder on selected medical comorbidities was assessed, and recommendations for practice, research, and policy were developed.

CONCLUSIONS

A growing body of evidence suggests that biological mechanisms underlie a bidirectional link between mood disorders and many medical illnesses. In addition, there is evidence to suggest that mood disorders affect the course of medical illnesses. Further prospective studies are warranted.

Treatment of behavioural symptoms and dementia in Parkinson's disease

Behavioural symptoms such as anxiety, depression and psychosis are common in Parkinson's disease (PD), and dementia occurs in about 90% of the patients. These symptoms can be more disabling than the motor dysfunction and they negatively impact quality of life, increase caregiver distress and are more frequently associated with nursing home placement. Depression can be treated with counselling and pharmacotherapy. Tricyclic antidepressants or selective serotonin reuptake inhibitors are widely used, but there is still need for controlled clinical trials. Management of psychosis in PD is complex and includes elimination of identifiable risk factors, reduction of polypharmacy and administration of atypical neuroleptics, which can alleviate psychotic symptoms without worsening motor functions. Clozapine is the best documented atypical neuroleptic shown to be effective against psychosis in PD patients. Cholinesterase inhibitors may prove additional benefit in psychotic PD patients. Recent evidence from small double-blind and open-label trials suggests that cholinesterase inhibitors may be effective in the treatment of dementia associated with PD.

A registry-based, case-control investigation of Parkinson's disease with and without cognitive impairment

In approximately 40% of the patients, Parkinson's disease (PD) is complicated by cognitive impairment. The objective of this study was to evaluate the impact of cognitive impairment on disease severity and motor function in idiopathic PD patients. Forty-one PD patients with cognitive impairment (PD-CI) (Mini-Mental State Examination < or =24) and 41 PD patients without cognitive impairment (PD-Control) matched for age at onset and duration of the disease were examined using the Unified Parkinson's Disease Rating Scale (UPDRS). PD patients with cognitive impairment had overall poorer motor function, worse rigidity (both axial and limb) and bradykinesia, as well as worse performance in activities of daily living compared with matched PD patients without cognitive impairment. This could either be attributed to a direct effect of cognitive impairment on parkinsonian symptoms or to decreased compliance of patients during clinical examination. PD patients should be routinely and carefully screened for dementia and caregivers should be aware of the effect of dementia on PD.

Does nefazodone improve both depression and Parkinson disease? A pilot randomized trial

Some of the selective serotonin reuptake inhibitors (SSRI)-induced motor side effects are mediated by stimulating 5-HT2 receptors in the basal ganglia, probably because serotonin inhibits the subsequent neuronal dopamine release. We hypothesized that nefazodone, a serotonin 2 antagonist/reuptake inhibitor (SARI) that selectively blocks 5-HT2 receptors, could disrupt the aforementioned inhibitory pathway. Therefore, increased dopamine levels in the postsynaptic milieu and an improvement in the motor symptoms in depressed patients with Parkinson disease (PD) should be observed. This study was designed to determine whether nefazodone has a dual activity as an antidepressant and as an agent capable of reducing the extrapyramidal symptoms in depressed parkinsonian patients. Depressed patients with PD were randomly assigned to 2 therapeutic groups: nefazodone or fluoxetine. Patients were evaluated by a psychiatrist and were blindly assessed by a neurologist with an array of scales. Patients on nefazodone (n = 9) showed a significant improvement over time in the total Unified Parkinson Disease Rating Scale score (UPDRS) (part II + part III) (P = 0.004) and in the UPDRS subscore part III (P = 0.003). None of these scores changed over time in the fluoxetine group (n = 7). Both, nefazodone and fluoxetine were equally effective as antidepressants: Beck Depression Inventory scores significantly improved (P < 0.001), with no significant differences between treatment groups (P = 0.97). If our results can be confirmed in a larger clinical trial, nefazodone ought to be considered over fluoxetine given its secondary beneficial effects regarding the reduction of extrapyramidal symptoms in depressed PD patients.

Prevalence, etiology, and treatment of depression in Parkinson's disease

Parkinson's disease (PD) is primarily a disease of elderly individuals with a peak age at onset of 55 to 66 years. It is characterized by bradykinesia, rigidity, tremor, and postural instability; and affects approximately 1 million individuals in the US and is the second most common neurodegenerative disease next to Alzheimer's disease. The motor symptoms of PD are the focus of pharmacotherapy, yet the nonmotor symptoms (e.g., dementia, psychosis, anxiety, insomnia, autonomic dysfunction, and mood disturbances) can be the most disturbing, disabling, and misunderstood aspects of the disease. Depressive symptoms occur in approximately half of PD patients and are a significant cause of functional impairment for PD patients. There is accumulating evidence suggesting that depression in PD is secondary to the underlying neuroanatomical degeneration, rather than simply a reaction to the psychosocial stress and disability. The incidence of depression is correlated with changes in central serotonergic function and neurodegeneration of specific cortical and subcortical pathways. Understanding comorbid depression in PD may therefore add to the understanding of the neuroanatomical basis of melancholia.

Pramipexole and pergolide in the treatment of depression in Parkinson's disease: a national multicentre prospective randomized study

An 8-month multicentre prospective randomized study aimed at comparing the effects of dopamine receptor agonists pramipexole (PPX; Mirapexin) and pergolide (PRG; Permax) as add-on to L-dopa therapy on depression [Montgomery and Asberg Depression Rating Scale (MADRS)] in 41 non-demented patients (25 men, 16 women) suffering from both mild or moderate depression and advanced Parkinson's disease (PD). The assessment was performed by a blinded independent observer. Motor symptoms (UPDRS III), motor complications (UPDRS IV), activities of daily living (UPDRS II and VI) and depressive symptoms as measured by Self - Rating Depression Scale by Zung were evaluated in an open-label design. The average value of Zung scores decreased significantly in both groups with no statistical difference between both groups. A significant decrease in the average value of MADRS scores was present only in the PPX group. The average UPDRS scores decreased significantly with no statistical difference between both groups at the comparable average total daily dose of both preparations. In both cases, the total daily dose of L-dopa decreased significantly but the decrease was statistically more pronounced in the PRG group. Our results demonstrate the antidepressant effect of PPX in patients with PD while we can't make any conclusions with regard to antidepressant effect of PRG.

Depression and Parkinson's disease: a new look at an old problem

A National Institutes of Health (National Institute of Neurological Disorders and Stroke; National Institute of Mental Health; National Institute on Aging) working group meeting focused on the non-motor aspects of Parkinson's disease (PD). Below is the summary of the meeting presentations and recommendations for a research agenda on the epidemiology, assessment, circuitry, therapeutic approaches, and clinical trials of Parkinson's disease co-morbid with depression. A second summary will focus on PD and dementia.

Depression in Parkinson's disease

Depression in Parkinson's disease (PD) is a common complication, with a major impact on quality of life. Failure to recognize and treat depression can lead to premature and inappropriate discontinuation of antiparkinsonian therapies. Cited frequency for depression in PD varies between 2.7 and 70%. Methodological differences account for much of the disparity. The aetiology of depression in PD is complex, with 'tonic' (slowly changing and persistent) and 'phasic' (short-lived and fluctuating) components. Both depression and anxiety may predate the onset of the motor disorder by some years. Hedonistic homeostatic dysregulation is a cyclical mood disorder associated with excessive intake of dopaminergic therapies, inappropriate for the motor state. Negative affective symptoms occur on attempted reduction of medication, reinforcing the abnormal medication pattern. The Montgomery-Asberg Depression Rating Scale and the Hamilton Rating Scale for Depression have good diagnostic sensitivity and specificity for assessing depression in PD. There is a dearth of sizeable, placebo-controlled studies for evaluating drug treatment of depression in PD. Dopaminergic drugs have variable antidepressant properties. Selective serotonin reuptake inhibitors are currently the most commonly prescribed group of antidepressants in the depressed PD patient. Depression in the PD patient may be associated with a more rapid deterioration in cognitive and motor functions.

Comorbidity of depression with other medical diseases in the elderly

A major factor in the context of evaluating depression in the elderly is the role of medical problems. With aging there is a rapid increase in the prevalence of a number of medical disorders, including cancer, heart disease, Parkinson's disease, Alzheimer's disease, stroke, and arthritis. In this article, we hope to bring clarity to the definition of comorbidity and then discuss a number of medical disorders as they relate to depression. We evaluate medical comorbidity as a risk factor for depression as well as the converse, that is, depression as a risk factor for medical illness. Most of the disorders that we focus on occur in the elderly, with the exception of HIV infection. This review focuses exclusively on unipolar disorder. The review summarizes the current state of the art and also makes recommendations for future directions.

Beyond the iron mask: towards better recognition and treatment of depression associated with Parkinson's disease

This review examines the frequency of depression complicating Parkinson's disease (PD), its aetiology and clinical features, and also how it may be recognised and treated. Studies investigating the frequency of depression in PD have yielded figures ranging between 2.7% and 70%. Methodological differences account for much of the disparity. The aetiology of depression in PD is complex, and probably relates to both biological and exogenous factors. Dysfunction of multiple neurotransmitter systems, including the serotonergic system, may be involved. Mood disturbances resulting from deep brain stimulation of the subthalamic nucleus may provide a fruitful area for future research, and assist our understanding of the neural networks involved in mediating depression. Several recent studies have confirmed that depression in the PD patient is a major determinant of quality of life and that this is closely related to dysfunction in other clinically important health areas. The validity for many existing scales in the screening, diagnosis, and monitoring of depression in the PD patient has not been established. The Montgomery-Asberg Depression Rating Scale and the Hamilton Rating Scale for Depression appear to have good diagnostic sensitivity and specificity when compared with DSM-IV criteria. Recommendations for the optimal drug treatment of depression in PD are difficult to give, due to an inexplicable dearth of sizeable, placebo-controlled studies. A majority of physicians would probably now opt for a selective serotonin reuptake inhibitor in the depressed PD patient. There is no good evidence that these drugs are associated with a worsening of motor features, but they should probably not be coprescribed with selegiline, because of the risk of causing a potentially serious serotonin syndrome. Several studies have suggested that depression in the PD patient is associated with a more rapid deterioration in cognitive and motor functions, perhaps as a surrogate marker for more extensive brainstem cell loss.

Depression in Parkinson's disease

Depression is common in Parkinson's disease (PD), and its identification and treatment are critically important in disease management. Despite depression's high prevalence and major impact on patient quality of life, questions remain regarding its epidemiology and preferred treatment. The authors of this paper summarize available information on the epidemiology of depression in PD, review treatment options, and discuss possible interactions between antidepressants and other agents. This information may help guide clinical treatment and define the need for further studies.

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

Selective serotonin reuptake inhibitors (SSRIs) have been reported to be useful in the treatment of depression in patients with Parkinson's disease (PD). However, a few reports have suggested that SSRIs may worsen parkinsonian motor symptomatology and extrapyramidal side effects have been reported in depressed patients treated with SSRIs. So far, no prospective trial comparing the effects of different SSRIs in depressed patients with PD has been performed. The aim of the present study was to assess the effects of four SSRIs (citalopram, fluoxetine, fluvoxamine, and sertraline) on motor performance and their efficacy on depression in a group of patients with PD. Sixty-two consecutive nondemented, nonfluctuating, depressed patients with PD were included in four treatment groups (15 patiens received citalopram, 16 fluoxetine, 16 fluvoxamine, and 15 sertraline). The evaluation of extrapyramidal and depressive symptomatology was performed with use of the Unified Parkinson's Disease Rating Scale (UPDRS), Beck Depression Inventory, and Hamilton Depression Rating Scale at baseline and after 1, 3, and 6 months. Fifty-two patients completed the study. UPDRS scores were not significantly modified by the add-on therapy with each of the SSRIs studied. A significant improvement in depressive symptoms from baseline to the end of the trial was obtained with all SSRIs (Beck and Hamilton scores improving; p < 0.05 according to an analysis of variance). Our findings suggest that SSRIs do not significantly worsen extrapyramidal symptomatology and may ameliorate depression in patients with PD.

Treatment of depression in comorbid medical illness

The rate of comorbid depression and medical illness varies from 10 to 40%. Over the years, there has been a paucity of studies completed despite the importance of knowing which antidepressants are the most effective and safest to use in comorbid states. In this review, focus is placed on disorders in these important areas: cardiovascular disease, neurological disorders, diabetes mellitus and cancer. Cardiovascular disease complications can be related in many cases to platelet clumping produced by medications; reductions in morbidity can be achieved by reducing platelet adhesiveness. Specific results have shown sertraline administration to be safe in the post myocardial infarction (MI) state. This is a time of depression-induced increases of 200-300% in mortality. Evidence for safe administration of bupropion, as well as the selective serotonin re-uptake inhibitors (SSRIs) fluoxetine and paroxetine, is also available. The appearance of major depression and diabetes mellitus has been successfully treated with fluoxetine, sertraline and nortriptyline (NTI), however, NTI may lead to a worsening of glucose indices due to its noradrenergic specificity. Regarding neurologic disorders, there is controlled data showing the safety and efficacy of citalopram, sertraline and fluoxetine in post stroke depression. Parkinson's disease has been associated frequently with depression, as might be expected from its characteristic dopamine deficient state. For perhaps the same reason, the agents that can block re-uptake of dopamine i.e., tricyclic antidepressants (TCAs), have been effective in comorborbid depression with Parkinson's disease. In dementia, there is a paucity of information on new agents. However, double-blind data seems to show efficacy for sertraline, paroxetine and citalopram. There are few studies of cancer-related depression treated in a controlled fashion with antidepressants; imipramine, amitriptyline, fluoxetine, paroxetine, mirtazapine and mianserin (not available in the USA) all have support from some published studies.

Depression in Parkinson's Disease

Depression is very common in Parkinson's disease (PD), but its severity and particular symptoms vary. It can often be difficult to diagnose because many of the symptoms typically associated with depression (eg, sleep difficulties, fatigue) can be seen in nondepressed patients with PD, and signs thought to represent depression (eg, lack of facial expression, slowness) can be produced by PD itself. Apathy, although a possible feature of depression, can exist apart from depression and is often associated with cognitive impairment. Therefore, when evaluating patients with PD for possible depression, one should concentrate on the psychological or ideational aspects of the illness. One must determine whether the patient feels sad or hopeless or has a marked inability to enjoy life. Once it has been determined that the patient has clinically significant depressive symptoms, it is important to let him or her know that depression is an aspect of PD requiring treatment, just like the motor manifestations of the disease. The idea of adding antidepressant medications and the possibility of psychotherapy should be introduced. A very reasonable first-choice antidepressant is either sertraline or paroxetine. Because of isolated case reports of worsening motor function associated with institution of a selective serotonin reuptake inhibitor (SSRI), one should keep track of when the medication was started so that the patient can be seen again within a month. It is important from a psychological perspective to have regular follow-up visits when treating depression. If the SSRIs are ineffective or not tolerated, nortriptyline is a good next choice. It has fewer anticholinergic effects and is less likely to cause or worsen orthostatic hypotension than other tricyclic antidepressants. Amitriptyline, although an old favorite of neurologists, is very sedating and has too much anticholinergic activity to be well tolerated in the higher doses needed to treat depression. If a patient could benefit from a dopamine agonist from a motor standpoint and his or her depressive symptoms are mild, consider using pramipexole, which may improve mood and motivation (although this has not yet been proven in a well-controlled trial). It is a good idea to keep patients on antidepressant therapy at least 6 months; many patients require long-term treatment. If a patient is severely depressed, he or she should be referred to a psychiatrist, who may consider admission to the hospital and possible electroconvulsive therapy.

Neuropsychiatric aspects of Parkinson's disease

Parkinson's disease (PD), a disorder characterized by movement abnormalities, is frequently complicated by psychiatric syndromes. Psychiatric assessment of the PD patient requires familiarity with the motor and cognitive aspects of PD, the various effects of antiparkinsonian medications, and how these relate to mental status changes and psychiatric phenomena. This review describes the various motor and nonmotor features of PD and focuses on the differential diagnosis of affective disorders in PD and their treatment.

Psychiatry in the geriatric neurology practice

This article provides a brief overview of the psychiatric syndromes most common in the elderly patient, as well as those most frequently accompanying neurologic disease. Diagnosis, work up, and treatment of depressive, psychotic, and anxiety disorders are also reviewed. This article is directed toward the practicing neurologist, with an emphasis on detection and treatment. Special attention is paid to psychiatric syndromes that accompany Parkinson's disease, stroke, and dementia. A brief review of the most common psychopharmacological agents is included as well.

Depression in Parkinson's disease. Pharmacological characteristics and treatment

Parkinson's disease (PD) is a common neurological illness and various degrees of depression frequently complicate its course. Risk factors for developing depression with PD include right-sided hemiparkinsonism, akinesia, increased severity of disability, anxiety and psychosis. Onset of parkinsonism at a younger age, female gender and the use of levodopa are arguable risk factors. Depression may be difficult to diagnose in patients with PD because the signs of the 2 disorders overlap. In addition, patients with atypical PD more commonly have depression than patients with classical PD presentations. Antidepressant response to antiparkinsonian treatment has been limited. Enhancement of catecholamine levels in the CNS by selegiline (deprenyl), a monoamine oxidase (MAO) type B inhibitor, has shown potential antidepressant as well as neuroprotective effects. Other MAO inhibitors have shown antidepressant efficacy in animal models but have not been well tolerated by patients with PD. A catechol-O-methyltransferase (COMT) inhibitor combined with an MAO inhibitor might synergistically maximise the levels of catecholamines in the CNS. Antidepressant medications used in patients without PD include tricyclic antidepressants (TCAs) and selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors (SSRIs), but only TCAs have been carefully studied for their antidepressant effects in PD. Electroconvulsive therapy has proven efficacy as antidepressant therapy in patients with PD, and transcranial magnetic stimulation has provided temporary relief of depression under experimental conditions. Adverse effects of polypharmacy in the attempted treatment of depression in patients with PD are common in the elderly. A 'serotonin syndrome' has occurred frequently enough to preclude the coadministration of selegiline with SSRIs or TCAs, and multiple interactions between antiparkinsonian and antidepressant medications further complicate treatment strategies in patients with PD. An algorithmic approach to the pharmacological treatment of depression is described in this article.

Sertraline for the treatment of depression in Parkinson's disease

Although antidepressant medications are commonly used to treat depression in Parkinson's disease (PD), little information is available regarding their safety and efficacy in this condition. Sertraline is a relatively selective serotonin reuptake inhibitor with some dopamine reuptake inhibitor activity. It has a favorable tolerability profile, especially in the elderly. We undertook an open-label pilot evaluation of the safety and efficacy of sertraline to treat depression in PD. A total of 15 patients with PD and depression participated in the study. Sertraline was introduced at a daily dose of 25 mg for 1 week and then increased to 50 mg/day. Patients underwent evaluation at baseline and at a final visit approximately 7 weeks later. Sertraline was generally well tolerated, but five patients experienced side effects, and two discontinued medication. Patients taking selegiline experienced more adverse effects. Beck Depression Inventory scores improved significantly (mean +/- SE = 16.0 +/- 2.0 vs 11.7 +/- 1.9, p = 0.03), and Unified Parkinson's Disease Rating Scale and energy-level scores were unchanged. These results suggest that sertraline may be a useful treatment for depression in PD. As substantial placebo effects can occur in studies of PD and depression, placebo-controlled, double-blind studies are warranted.

A review of continuation and maintenance electroconvulsive therapy

BACKGROUND

Many patients with major psychiatric disorders who are severely ill, medication-resistant, or medication-intolerant respond more reliably and quickly to a course of electroconvulsive therapy (ECT). The management of such patients after successful treatment with ECT is of significant importance given the high rate of relapse and recurrence of these disorders. The unmet clinical need to maintain the mental health of these seriously ill patients at an optimal level has revived the interest in ECT as an alternative prophylactic treatment.

METHOD

We review the historical background of ECT and the literature that supports its use as a prophylactic treatment in various disorders and special populations. A clinical summary outlining its efficacy, acceptability, risks, cost-effectiveness, and medicolegal aspects is followed by a guide for prescribing ECT for prophylactic reasons.

RESULTS

Continuation and maintenance ECT (C/MECT) has been found to be efficacious, safe, well tolerated, and cost-effective. Its greatest impact has been in reducing relapse, recurrence, and rehospitalization, particularly in the management of recurrent mood disorders in the elderly. The elderly are usually refractory or intolerant to pharmacotherapy but have a good response to ECT during the index episode. Parkinson's disease (PD), schizophrenia, and obsessive-compulsive disorder (OCD), as well as affective disorders coexisting with dementia, neurological disorder, or mental retardation, have also been reported to respond to C/MECT. The outcome depends greatly on rate of compliance. Cognitive risk of C/MECT need to be further studied because the literature to date consists mostly of case reports and anecdotal evidence. Controlled studies with well-defined outcome measurements are needed.

CONCLUSIONS

When planning a rational approach to the care of patients with major psychiatric disorders, clinicians should carefully consider ECT along with other alternatives.

The management of treatment-resistant depression in the medically ill

There are a few well-designed studies to systematically assess treatment-resistant depression in the medically ill patient. Psychiatrists, however, do have extensive clinical experience in treating depression in the medical patient. This experience can be useful in helping to determine treatment resistance and in selecting consequent treatment choices. A decision tree is offered in Table 1 to clarify the questions the clinician must answer. The first step is to evaluate the role of the medical illness and to decide whether or not treating that effectively will also clear the depression. Physicians may find it helpful to use a decision tree in initiating treatment of patients with depression and physical illness. Once it has been clarified that the diagnosis of depression is a correct one and that an antidepressant medication is in order, consideration of safety, side effects, and other current prescriptions used by the patient must occur. Drug-drug interactions as well as changes in the clearance of medications are critical to the effectiveness of the choice and tolerability for the patient. An antidepressant agent needs to be given for an adequate time with optimization of dosing. Augmenting a medication to increase its therapeutic action could be tried if one agent alone is not effective. An alternative approach is that the second drug selected might affect different neurotransmitters, and the combination of mechanisms would result in resolution of symptoms. Adding psychotherapy, especially when social supports are lacking, can be particularly helpful. ECT is an important consideration for severe depression when suicidal concerns are imminent or the patient has not responded to pharmacotherapy trials. While we await further studies of treatment-resistant depression in large enough numbers of patients with particular illnesses, we can use these guidelines to direct our decisions to switch or augment our initial choices to provide the safest, most effective care possible.

Freezing of gait in Parkinson's disease is improved by treatment with weak electromagnetic fields

Freezing, a symptom characterized by difficulty in the initiation and smooth pursuit of repetitive movements, is a unique and well known clinical feature of Parkinson's disease (PD). It usually occurs in patients with long duration and advanced stage of the disease and is a major cause of disability often resulting in falling. In PD patients freezing manifests most commonly as a sudden attack of immobility usually experienced during walking, attempts to turn while walking, or while approaching a destination. Less commonly it is expressed as arrest of speech or handwriting. The pathophysiology of Parkinsonian freezing, which is considered a distinct clinical feature independent of akinesia, is poorly understood and is believed to involve abnormalities in dopamine and norepinephrine neurotransmission in critical motor control areas including the frontal lobe, basal ganglia, locus coeruleus and spinal cord. In general, freezing is resistant to pharmacological therapy although in some patients reduction or increase in levodopa dose may improve this symptom. Three medicated PD patients exhibiting disabling episodes of freezing of gait are presented in whom brief, extracerebral applications of pulsed electromagnetic fields (EMFs) in the picotesla range improved freezing. Two patients had freezing both during "on" and "off" periods while the third patient experienced random episodes of freezing throughout the course of the day. The effect of each EMFs treatment lasted several days after which time freezing gradually reappeared, initially in association with "off" periods. These findings suggest that the neurochemical mechanisms underlying the development of freezing are sensitive to the effects of EMFs, which are believed to improve freezing primarily through the facilitation of serotonin (5-HT) neurotransmission at both junctional (synaptic) and nonjunctional neuronal target sites.

Methodology of Treatment Studies in Geriatric Depression

Treatment studies of geriatric depression should focus not only on recovery and remission but also on relapse, recurrence, disability, quality of life, cognitive impairment, and exacerbation of medical morbidity. Each of these outcomes appears to have different predictors. Medical burden may influence geriatric depression, response to antidepressants, and overall disability, as well as specific conditions underlying geriatric depression (e.g., Alzheimer's disease, stroke, or parkinsonism). Measures of medical morbidity, cognitive impairment, and perhaps structural brain abnormalities should be considered as possible influences on treatment response. Studies of geriatric depression associated with specific disease entities are necessary, using instruments that avoid rating symptoms and signs that are part of a concurrent dementia syndrome or result from a medical illness. However, there should also be ratings with an "all-inclusive" approach that disregards the origin of depressive symptoms-whether from depression, dementia, or the medical illness. This strategy will reduce the risk of underdiagnosing depression.

Concentrations of serotonin and its related substances in the cerebrospinal fluid of parkinsonian patients and their relations to the severity of symptoms

We evaluated the concentrations of free and total serotonin (5-hydroxytryptamine, 5-HT) and its related substances in the cerebrospinal fluid from patients with Parkinson's disease (PD). The concentrations of total 5-HT, 5-hydroxytryptophan, kynurenine and 3-hydroxykynurenine decreased significantly in PD patients compared with controls. The concentration of total 5-HT had significant negative correlations with Hoehn and Yahr's stages, the severity of rigidity, akinesia and gait freezing; the correlation with gait freezing was most conspicuous.

Different effects of serotonin (5-HT) uptake blockers in caudate nucleus and hippocampus of the rabbit: role of monoamine oxidase in dopaminergic terminals

Slices of rabbit hippocampus or caudate nucleus were incubated with [3H]-5-HT (0.1 microM, 60 min) or with [3H]-DA. In hippocampal tissue, the 5-HT uptake blockers chlorimipramine, fluvoxamine, and 6-nitroquipazine (0.1, 1, 10 microM) reduced the percentage content of [3H]-5-HT in a concentration dependent manner. The degree of inhibition of [3H]-5-HT content produced by the 5-HT uptake inhibitors was not affected by the MAO inhibitors pargyline or amezinium (which by themselves enhanced [3H] loading) or the catecholamine uptake inhibitor nomifensine (which by itself did not affect [3H] loading). In caudate nucleus tissue, however, the [3H]-5-HT accumulation was reduced only at the highest concentration of the 5-HT uptake blockers (10 microM). In the additional presence of the MAO inhibitors or nomifensine (which by themselves increased or diminished, respectively, the [3H] labelling) the 5-HT uptake inhibitors became more potent in reducing the percentage [3H]-5-HT accumulation of caudate nucleus slices. These results indicate (1) that a false labelling of [3H]-5-HT into dopaminergic terminals in the caudate nucleus can be prevented by nomifensine, (2) that the 5-HT uptake blockers seem to accumulate within the dopaminergic terminals, where they may display a MAO inhibitory property. The 5-HT uptake blockers were ineffective on the percentage tritium accumulation of caudate nucleus slices incubated with [3H]-DA, regardless of the presence of pargyline or nomifensine. Tritiated DA and deaminated [3H]-metabolites were separated in the superfusate of [3H]-DA-release experiments in caudate nucleus tissue.(ABSTRACT TRUNCATED AT 250 WORDS)

Parkinson's disease complicated by anxiety

In a 39-year-old man with Parkinson's disease and a history of anxiety disorders, anxiety-provoking situations such as group psychotherapy precipitated panic attacks and caused pronounced worsening of the parkinsonian symptoms. Extra doses of carbidopa-levodopa failed to control the intensified symptoms. During a 1-month hospitalization period, the anxiety disorders diminished when a combination of psychotherapy, behavioral therapy, and desipramine was used; however, the relationship between increased anxiety and worsened parkinsonian symptoms persisted. In patients with refractory Parkinson's disease, clinicians should consider the possibility of the presence of an anxiety disorder that may be affecting the neurologic condition.

Bradyphrenia in parkinsonism: a historical review

The development over the last 60 years of the concept of bradyphrenia, a syndrome including slowing of cognitive processing in parkinsonism, is described. Psychic akinesia and subcortical dementia are seen as more recent synonyms for this syndrome. Its relations to akinesia and the psychomotor retardation of depression are considered in a historical context, as are its implications for the relation of neurological and psychiatric disorder.

Anti-depressive treatment in Parkinson's disease. A controlled trial of the effect of nortriptyline in patients with Parkinson's disease treated with L-DOPA

Nineteen patients with L-DOPA treated parkinsonism involving depressive symptoms, the therapeutic effect of nortriptyline was compared to placebo in a controlled trial. The depressive and neurological symptoms were evaluated by rating scales. Nortriptyline had a clinical significant effect with regard to the depressive symptoms, whereas the neurological parameters were unchanged. The authors suggest the depression in Parkinson's disease to be of both reactive and endogenous origins.

Effects of desipramine on neuronal responses to dopamine, noradrenaline, 5-hydroxytryptamine and acetylcholine in the caudate nucleus of the rat

1 The sensitivity of single neurones to microelectrophoretically applied dopamine, noradrenaline (NA), 5-hydroxytryptamine (5-HT) and acetylcholing (ACh) was investigated in the caudate nucleus of the rat, anaesthetized with halothane. Both excitatory and depressant responses could be observed to each of the agonists. There was a high correlation between the direction of responses to dopamine and noradrenaline, whereas there was no significant correlation between the direction of responses to dopamine and ACh. 2 The effect of desipramine was studied on both excitatory and depressant responses to dopamine, NA and 5-HT, and on excitatory responses to ACh. Both potentiation and antagonism of neuronal responses to monoamines and ACh could be observed after a brief application of desipramine. 3 Excitatory responses to glutamate were not affected by desipramine. 4 The observation that responses to dopamine and NA can be potentiated by desipramine in the caudate nucleus suggests that uptake blockade is not a prerequisite for potentiation. 5 It is suggested that the potentiation of neuronal responses to dopamine by desipramine may be responsible for the therapeutic efficacy of desipramine in Parkinson's disease.