hello all [including clan-members!]

there has been some discussion recently about 'tear attacks' and pd.

at the risk of destroying any illusions you all may have about my living in
paradise, i thought this little tale of mine might be relevant:

living here necessitates a certain tolerance for the local 'wild life' -
i.e. most new [human] arrivals are dismayed by the healthy size and
abundance of our cockroaches.

after my initial shock, i developed a strong hunting instinct, and would
stalk them with enthusiasm [and a large can of bugspray - a practice i have
since abandoned - but that's another tale]

however, one day i surprised myself by reacting completely differently.
bursting into tears at the sight of yet another interloper was so unlike my
normal reaction, that i had to take a closer look at it. [my reaction, not
the interloper]

since i had learned a bit about clinical depression from sharing a friend's
worries, i was able to recognise my response as a symptom of a larger
problem. some sessions with a therapist and a prescription for prozac
helped me regain my normal equilibrium.

i don't intend to suggest that anyone feeling a bit 'teary' is suffering
from clinical depression [cd], but offer this as another viewpoint.

i believe that we pd-ers are more vulnerable than the average population to
our emotions, both mentally and physically.

we are also more likely to suffer with cd, maybe partly due to our
emotional vulnerability as well as to our brain chemistry.

alan bonander posted this article about depression last january, and i
thought it might be valuable to re-post it. i'm sure he'd approve.


janet

---------------------------------------------------------------------
Date:    Sun, 28 Jan 1996 02:27:32 -0500
Subject: Depression in PD
---------------------------------------------------------------------

..... PD is like fighting a war on many fronts and thanks to this list
server, each day I learn more about the enemy.  Each time I look at my
generals researching the enemy as they see them, I realize the complexity
of the problem.  We really need additional funding -- pass the Udall Bill
and other bills so the war can really begin.

Here is depression in Parkinson's disease.  Please read slowly.

DEPRESSION IN PARKINSON'S DISEASE
(A Supplement to the Video)
by Alan Bonander

NOTE: This paper is a written supplement to the video of the presentation
called 'Depression in Parkinson's Disease' by Neal Slatkin, MD, a
presentation made at the state-wide meeting of YPSN of CA on June 10, 1995
in Duarte, CA.  Dr. Slatkin is a neurologist, parkinsonologist and director
of the Parkinson Center at the City of Hope Medical Center in Duarte,
California.

INTRODUCTION

Our sixteenth president, Abraham Lincoln, stated, "I am now the most
miserable man living. If what I feel were equally distributed to the whole
human family, there would not be one cheerful face on the earth. Whether I
shall ever be better, I cannot tell, I awfully forebode I shall not. To
remain as I am is impossible. I must die or be better, it appears to me."

This is one of the best statements on the problems of depression. An
eminent psychiatrist once said that more human suffering can be attributed
to depression than any other illness affecting mankind.

Approximately 6% of the US population will have a major depression sometime
during their life. A major depression is one which significantly limits
one's functionality.

In the older population, depression is a very significant problem. There
are about 45 million people over the age of 65. It is estimated that
between 10% and 20% of these people are having a major depression at any
point in time. That means somewhere between 4.5 million and 9 million older
people are having a major depression at any point in time.

If we look at a list of all causes of mortality in 1992, suicide is listed
between HIV(AIDS) and homicide. Surely if we have an epidemic of HIV(AIDS)
and an epidemic of crime in this country, we have an epidemic of suicide.
And suicide is only the tip of the iceberg when it comes to depression.

Costs are important in our society today. It is estimated that depression
costs $45.3 billion annually. That is composed of $14 billion for direct
costs (inpatient, outpatient, drugs), $7.5 billion for death from suicide,
$12.1 billion from decreased productivity and $11.7 billion from
absenteeism.

DEPRESSION IN PD

Depression is the most common neuro-psychiatric disturbance among PD
patients.  It is more common than psychosis, confusion and dementia.

The prevalence in PD, which is about 40%, is higher than for any other
chronic illness that is matched for similar degree of functional
impairment.

Of those with depression, about 50% are having a major depression.  The
other 50% are having a minor or mild depression which only sucks all the
joy out of their lives.

In a study performed at Columbia in New York, it was found that the annual
incidence, (number of new cases), of depression among Parkinson's patients
was 1.90% which was over 10 times the annual incidence of depression in the
general population of 0.17%.

Depression seems to appear at anytime.  It is often present at time of
diagnosis, after several years and with increasing physical impairments.

Depression can also appear during episodic periods.  About 70% of those
experiencing random "ON-OFF" cycles are more depressed when they are "OFF."
This change can happen almost instantaneously when they turn "OFF."

It appears that more females have depression (this is questionable) and
those with a past history of depression.  Also those experiencing rigidity,
bradykinesia and gait problems are more susceptible to depression.

Interestingly, those with PD more on their right side are more likely to
have depression.  The patient current age, family history of PD, dementia
and tremor seem to not influence depression.

Young onset patients (those getting PD before age 50) are 3 times more
likely to have a major depression than those with normal onset (36% vs.
11%).  Mild or minor depression is about the same for any age of onset (16%
vs. 14%). Together, Young onset patients are about twice as likely to
experience depression than those with normal onset PD (52% vs. 25%).

WHAT IS DEPRESSION

Question:  Is depression merely the exaggeration of a normal mood state
(sadness) or is it a qualitatively different mood state?

Temperature and mood can be viewed on a continuous scale.  A temperature of
104 degrees is qualitatively very different than a temperature of 100
degrees.  Similarly, sadness and depression are qualitatively very
different.

Question:  Is depression primarily caused by psychological stress and
conflict or is it related primarily to a biological abnormality?

There are two different types of depression:  Endogenous which is
biological such as neurochemical, and exogenous which is situational coming
from the environment.  Normally a depression is composed of some
combination of both endogenous and exogenous causes.

Studies have been done on the neurochemical component of depression.  It
has been found that the neurochemicals of serotonin and norepinephrine are
involved in depression.

Everyone knows that there is a deficiency of dopamine in PD. It turns out
that norepinephrine is manufactured from dopamine.

Dopamine is manufactured from tyrosine and levodopa with the help of an
enzyme called ENZ.  Thus if there is a deficiency of dopamine there is
reason to believe there could be a deficiency of norepinephrine.

Serotonin is manufactured form a substance called tryptophan.  This process
uses the same enzyme called ENZ.  As fewer and fewer neurons are available
to produce dopamine, there is a cannibalistic effect on the neurons
producing serotonin.

The process to create dopamine from levodopa enters the serotonin cells and
takes the ENZ, leaving little for the manufacture of serotonin. Thus
serotonin levels could fall for that reason.

SYMPTOMS OF DEPRESSION

   Sadness
   Depressed mood (especially in the morning)
   Hopelessness, helplessness and self-blame
   Loss of interest & pleasure in activities
   Loss of energy - fatigue - leading to inactivity
   Decreased concentration - indecisiveness which has led some doctors to
      diagnosis dementia incorrectly
   Sleep disturbance
   Preoccupation with negative thoughts - seeing the world through maroon
      colored glasses rather than rose colored.
   Poor appetite and weight loss
   Thoughts of death and suicide and in some cases actually doing it

DIAGNOSING DEPRESSION IN PD

DEPRESSION -->> MOTOR IMPAIRMENTS -->> DEPRESSION

Most people can understand that motor impairments can cause depression.  It
is more difficult to understand that depression can cause motor
impairments.

We have no difficulty believing that the mind can heal the body.  It is
more difficult to grasp that the mind can cause physical impairments.

Dr. Slatkin states that when he tells a patient that the mind is causing
physical impairment, they do not believe him. He says they are going to be
offended and angry with him.

"They think I am telling them that their symptoms are not 'real' and that I
feel in some way they are faking it.  This is truly not the case."

Mood state and physical state are interrelated.  Solving only one side of
the problem does little.  Both mood state and physical state must be
evaluated together.

When there is an rapid deterioration in the physical state of a PD patient
keep in mind that adding the Parkinson's medications alone may not help.
Dr. Slatkin is convinced, from his many years of working with PD patients,
that when a patient is depressed, the medications for PD do not work.

Thus both sides of the equation must be addressed.  Ways of improving mood
state are exercise, increased activity, anti-depressants and counseling.

Ways of improving the physical state are with Parkinson's medications.

Clinical Features of Depression
   Sad faces
   Fatigability
   Sleep disturbance
   Speech: slow, ... ,
   Stooped posture
   Constipation
   Diurnal variation
   Low mood
   Motivation loss
   Hopelessness
   Loss of interest
   Feel inadequate
   Suicidal wishes
   Indecisiveness
   Conscious guilt
   Loss of appetite
   Cry in interview

Looking at the clinical features of depression, there is an overlap of
clinical features with PD.  The first seven symptoms are common to both
depression and PD.

This means that if a PD patient goes in to his/her physician with one or
more of the common symptoms, what are the chances that the physician will
recognize these as depression and not PD?

There is no objective test of depression.  What doctors rely on are tests
such as the Beck Depression Inventory, Geriatric Depression Scale, SCL-90,
MMPI and Hamilton Rating Scale.  These combined with time spent with the
patient, good patient history and a proper physical examination help the
physician diagnosis depression.

The "Mask of Depression" is there to remind us that depression is often
masked by physical symptoms.  The symptoms are chronic and recurrent pain,
fatigue, memory loss, problems with sleep and sexual dysfunction.

Often no physical cause of these symptoms can be found. What is found is
that these are physical symptoms of the underlying depression.

A study was performed that found that 58% of PD patients said, "Fatigue is
among my three most disabling symptoms."  Fatigue was highly correlated
with depression.

It as also found that 67% were found to have "fatigue with PD was different
in quality or severity" than that experienced before the diagnosis. Fatigue
was not correlated with disease severity.

TREATMENT OF DEPRESSION

Treatment of depression uses counseling, education, electro-convolsive
therapy (ECT), anti-depressants, exercise and stimulants.  Only two will be
discussed -- anti-depressants and ECT.  Drugs used are the following:

Anti-depressants Used in Parkinson's Disease
   Tricyclic
        Elavil (amitriptyline)
        Tofranil (lmipramine)
        Pamelor (nortriptyline)
        Norpramiln (desipramine)
        Sinequan (doxepin)
   Selective Serotonin Reuptake Inhibitors (SSRI)
        Prozac (fluoxetine)
        Zoloft (sertraline)
        Paxil (paroxetine)
   Miscellaneous
        Desyrel (treazdone)
        Wellbutrin (buproprion)
        Effexor (ventafaxine)
        Serzone (nofazodone)

The SSRI drugs inhibit the reuptake of serotonin. This allows more
serotonin to hang around in the synapse with hope more will cross the
synapse to the receptors of the receiving neuron.

One thing that we do not want is dopamine receptor blockade.  The one
anti-depressant that is not good for PD patients is Asenden (amoxapine)
because of its dopamine receptor blockade function.

REMEMBER: Anti-depressants take time to work

Anti-depressants have both a quick effect and a longer therapeutic effect.
Often the synoptic effect and the adverse side effects can show in hours or
days.  The therapeutic effect usually takes from three to six weeks.

Thus it is important to stay on these drugs for a few weeks to determine if
they can help.  If nothing happens in the first few days, this is correct.

Many of the tricyclic antidepressants are also good pain relievers --
especially for nerve pain syndrome.

There is about a 70% response rate regardless of agent used.  A drug is
often selected by looking at the side effects to be avoided.  There are no
good biological response markers.

Melancholic and persistent, recurrent depression seem to respond best. The
side effects of SSRI drugs are:

Side Effects of SSRI Drugs (Partial listing)
   Nausea
   Diarrhea
   Sexual dysfunction  (delayed ejaculation in men, lower libido in both
       sexes)
   Sleep or near sleep
   General fatigue
   Dry mouth
   Constipation
   Difficulty with urination
   Memory loss (amnesia)
   Dizziness from drop in blood pressure
   Akathisia (need to move)
   Worsening of PD symptoms
   Serotonin Syndrome

Serotonin syndrome arises when an anti-depressant that inhibits reuptake
reacts with a monoamine oxidase inhibitor.

Drugs that increase serotonin activity in the brain are: SSRI (Prozac,
Zoloft, Paxil), TCAD (Elavil, Pamelor, Desyrel), Lithium, Tryptophan.  The
Monoamine oxidase inhibitor is Eldepryl (selegine, deprenyl).

Pharmacists, if they know you are using both Eldepryl and one of the
anti-depressants, are required to call your physician to let them know they
are prescribing drugs that may be contraindicated. Always discuss the
possible interaction with your physician.

Serotonin Syndrome Symptoms
   Motor symptoms
        Jerking of arms and legs
        Increased stiffness and rigidity
        Incoordination
   Mental behavioral symptoms
        Agitation
        Confusion
        Disorientation
        Restlessness
   Miscellaneous
        Fever
        Nausea, Diarrhea
        Shriving, flushing
        Sweating
   Exceptional problems
        High fever
        Seizures
        Coma, Death

ELECTRO-CONVULSIVE THERAPY

Electro-convulsive therapy has a long history of use.  It was observed that
when a patient would have a seizure  they would get better.  Various
methods were used to cause seizures.  In 1941 the first tests of ECT in the
US were done in New York.  Looking in a book on the use of ECT, one finds
Parkinson's disease on the list.

ECT can be a very valuable therapy if the patient has had a poor response
to anti-depressants or has a poor tolerance or compliance with
anti-depressant medications or patients having problems due to manic
depressive disorder.

OTHER THERAPIES FOR DEPRESSION

EDITORAL COMMENT: Please note that this paper has discussed therapies
involving medications for depression in Parkinson's disease.

These therapies are important; however, the therapies of exercise,
increased activity and counseling should also be considered.  Remember to
be open with your physician when discussing both mood state and physical
state problems.

To be depressed is not unusual; but to stay depressed is unnecessary.

END
---------------------------------------------------------------------

[log in to unmask]