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Depression and Parkinson's Disease
Question
Which antidepressants generally work best in advanced Parkinson's disease?
Is off-time depression helped by antidepressants or only by anti-Parkinson
agents?
Response from *Gary Kennedy, MD, 08/24/00
Depressive symptoms are common in Parkinson's disease and may precede
the appearance of movement disorder. However, the choice of
antidepressants is limited by the autonomic instability and
susceptibility to
drug-induced dyskinesia that some patients experience. Nortriptyline,
sertraline, or citalopram may benefit the patient with a major depressive
episode. Drug interactions are less frequent with these agents. However,
cardiovascular and autonomic effects limit the safety of nortriptyline, and
dyskinesia is an infrequent but well-recognized complication of SSRI
treatment. As a result, there is a credible argument for bupropion or
methylphenidate, particularly in cases of advanced Parkinson's disease
complicated by depression. Both agents are thought to have
dopamine-enhancing properties, freedom from drug interactions, and are not
sedating. Ritalin is prescribed at 5 mg after breakfast and 5 mg after lunch
with the maximum dose being 15 mg twice daily. Start bupropion at 75 mg and
build to 150 mg twice daily. The on/off phenomenon associated with
dopaminergic medications is poorly understood. Antidepressants may be
beneficial in general, but there is little evidence that they will
ameliorate the
on/off episodes.
Suggested Reading
Kennedy GJ. Geriatric Mental Health Care; A Treatment Guide for Health
Professionals. Guilford Press; 2000.
[*Gary Kennedy, MD Professor of Psychiatry, Director, Division of Geriatric
Psychiatry, Montefiore Medical Center, Albert Einstein College of Medicine,
Bronx, N.Y.]
Comments
5/15/01
Treating depression in Parkinson's disease patients is not an easy task.
At the
53rd Scientific Meeting of the American Academy of Neurology this week, Paul
Gordon and colleagues at Columbia-Presbyterian Medical Center in New York
reported that mirtazapine 15-30 mg/day may be useful in relieving
Parkinsonian tremors. Since it is an antidepressant as well, it is worth
trying to
use it in depressed Parkinsonian patients.
Abdelhamid Hashem, MD
Psychiatrist
Egypt
=========
3/23/01
Electroconvulsive therapy is also an effective antidepressant in the treatment
of Parkinson's disease -- actually, it is effective in treating
Parkinson's even
without depression.[1]
Reference:
1.Abrams R. Electroconvulsive Therapy. 3rd ed. Oxford Univ Press;
1997.
N. Vaidya, MD
===================
11/17/00
In Parkinson's disease there is a lack of dopamine, but if you give
ritalin, the
affective symptoms do not improve, and you could provoke euphoria, as the
dopamine available (with ritalin) increases delusions, and paranoia and
hallucinations may appear.
Tricyclic agents are very useful for depression in Parkinson's disease. The
anticholinergic effect helps patients with tremors. In fact,
neurologists use
imipramine 25mgs per day to diminish tremors. But you have to be careful,
because if the patient is using anticholinergics, you can provoke delirium.
The ISRS such as paroxetine are the most likely to cause tremors. Roboxetine
offers a new approach to depression in Parkinson's disease. As we know, a
lack of dopamine produces a lack of norepinephrine, and if you give
roboxetine you improve affective symptoms without the risk of delusions and
hallucinations that the increases of dopamine give you, and without the
risk of
cardiovascular effects of TCA.
Dr. Sergio Galvan
Psychiatrist
Mexico
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