Elsevier

Biological Psychiatry

Volume 54, Issue 3, 1 August 2003, Pages 363-375
Biological Psychiatry

Mood disorders and medical illness
Prevalence, etiology, and treatment of depression in Parkinson’s disease

https://doi.org/10.1016/S0006-3223(03)00530-4Get rights and content

Abstract

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.

Introduction

James Parkinson described melancholia in his original report of the disorder that bears his name. Depression is one of the most common nonmotor symptoms of Parkinson disease (PD) occurring in approximately half of patients (Dooneief et al 1992).

Section snippets

Incidence of depression

Estimates of the incidence of comorbid depression vary widely, from 4% to 75% Allain et al 2000, Ranoux 2000, and there are few prospective epidemiologic studies. The surveys that are available suffer from a number of methodological flaws, including inaccurate sampling methods and imprecise tools to quantify depressive symptoms. One source of variation is the survey site. Surveys in research centers diagnose depression in 40% to 50% of patients compared to community-based studies which have

Assessment of depression

The diagnosis of depression in PD is particularly difficult because, perhaps more than any other medical disorder, the symptoms of PD overlap with the symptoms of depression. Patients with advanced PD often have significant sleep disturbance, fatigue, psychomotor slowing, difficulty concentrating, and diminished sexual function. PD patients can appear withdrawn from social activities, because they are unable to participate due to disabling dyskinesias and are socially uncomfortable with their

Impact of major depression and subsyndromal depression

Depression can impair both fine motor skills (Kuhn et al 1996) and cognitive function Kuzis et al 1997, Troster et al 1995, Mayeux et al 1981, Starkstein et al 1990a, Starkstein and Robinson 1991, Stern et al 1993b and is a primary factor negatively affecting quality of life in PD Kuopio et al 2000, Phillips 1999. In a cross-sectional, randomized, multicenter survey of patients with PD, caregivers, and clinicians in six countries, depressive symptoms were the single most important factor in

Etiology of depression in Parkinson’s disease

Theories related to the etiology of depressive symptoms in PD argue that depression 1) is “reactive” and secondary to the psychosocial stress of a chronic disease and the associated disability or 2) results from neuroanatomical changes that occur in PD and is a symptom of the underlying neurodegeneration. These theories are not mutually exclusive and are discussed below.

Relationship of comorbid disorders to depression

Dementia, hypothyroidism, testosterone deficiency, and elevated plasma homocysteine levels have all been associated with depression in PD. These disorders may be overlooked because the clinical symptoms overlap with PD, particularly PD complicated by comorbid depression. Cognitive impairment is a common nonmotor complication of PD that is made worse by major depression Mayeux et al 1981, Starkstein et al 1990b, Starkstein and Robinson 1991, Starkstein et al 1992, Troster et al 1995.

Effect of medication used to treat motor symptoms

Dopamine agonists (e.g., levodopa and amantadine) are only weak antidepressants Maricle et al 1995, Menza et al 1990, but they can cause other psychiatric symptoms, including delirium, agitation, restlessness, and hallucinations. The monoamine oxidase type B (MAO-B) inhibitor selegiline has weak antidepressant properties (Cummings 1992) but is much less effective than the nonspecific MAO inhibitors (e.g., phenelzine). The D2 dopamine receptor agonist pramipexole is effective in treating non-PD

Somatic treatment of depression in PD

As with many medical disorders, the treatment of comorbid depression in PD is complicated by the difficulty in diagnosing depression, the potential increased sensitivity to the side effects of the medications, and the willingness of the patient to accept the diagnosis and treatment. The tricyclic antidepressants (TCAs) can be difficult for PD patients to tolerate because of the autonomic dysfunction that is an integral part of the neurologic disease. The TCAs can aggravate PD-associated

Large-scale clinical trial of depression in PD

Depression is one of the most common and debilitating disorders associated with PD, yet the diagnostic criteria for comorbid depression in PD have not been clarified. The studies to date have been relatively small and have failed to answer important clinical questions related to the management of comorbid depression. Essential to treatment is the accurate diagnosis of depression. Developing diagnostic criteria for the phenotypes of depression in PD and structured clinical interviews and rating

Discussion

Depression occurs in approximately half of PD patients, increases both motor and cognitive disability, and is a primary source of both patient and caregiver distress. The etiology of depression is not simply a reaction to psychosocial stress but the result of the neurodegenerative process which affects both monoamines and indolamines and the basal ganglia-frontal circuits integral to mood disorders. Preliminary studies suggest that SSRIs may be effective and are well tolerated; however, given

Acknowledgements

Aspects of this work were presented at the conference, “The Diagnosis and Treatment of Mood Disorders in the Medically Ill,” November 12-13, 2003, in Washington, DC. The conference was sponsored by the Depression and Bipolar Support Alliance through unrestricted educational grants provided by Abbott Laboratories, Bristol-Meyers Squibb Company, Cyberonics, Inc., Eli Lilly and Company, Forest Laboratories, Inc., GlaxoSmithKline, Janssen Pharmaceutica Products, Organon Inc., Pfizer Inc, and Wyeth

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