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Dale, the algorithm for the management of PD supplement 10 to Neurology journal issue fr December 1994 volume 44 number 12 page S41 has the following: Electroconvulsive therapy (ECT) is another treatment modality available for the therapy of depression in PD.[136] Typically, ECT is considered either for severe depression that is unresponsive to medical therapy or for temporary amelioration of severe depressive symptoms during the 1- to 3-week latency before antidepressant drugs take effect. A fringe benefit of this approach is that transient improvement might occur in the motor signs of PD, as well.[137] Anxiety and panic reactions. Like depression, anxiety or panic might appear predominantly during "off" periods in some patients but in others can be present throughout the day, irrespective of control of parkinsonian symptoms. Using DSM-III-R criteria, a recent study found that 38% of PD patients manifested clinically significant anxiety.[138] When anxiety occurs predominantly during "off" periods, its intensity tends to parallel the difference in motoric function between the "on" and "off" states.[139] In patients who experience anxiety largely while "off," therapeutic attention first should be directed to improving fluctuations in motor performance before considering pharmacologic intervention. In patients who suffer persistent anxiety or whose fluctuations cannot be sufficiently controlled to improve their "off"-period anxiety, anxiolytic drugs are indicated. The most useful agents for this purpose are the benzodiazepines, such as diazepam, alprazolam, and lorazepam. Typical dosages for this purpose are 0.5 to 1 mg three times daily for alprazolam or 2.5 to 5 mg four times daily for diazepam. Still lower dosages are often required at the initiation of therapy in the elderly. For patients who do not benefit from the benzodiazepines, imipramine or buspirone can be considered, but it must be recognized that the former agent can have undesirable side effects, such as confusion or hypotension, and that the latter has mild dopamine-blocking properties. Panic disorder consists of a severe state of anxiety that occurs episodically and is characterized by a variety of psychologic, autonomic, and somatic symptoms. These include, among others, breathlessness, nausea and vomiting, diaphoresis, dizziness, choking, and the fear of dying or going insane. In occasional patients, such symptoms coincide with their levodopa "off" states. For these individuals, dosage adjustment of their antiparkinsonian drugs, as described in the section, "Motor problems," is the appropriate treatment. In other patients, treatment directed at panic disorder, per se, is necessary. Benzodiazepines also may be useful in these cases, but higher dosages may be required to achieve the desired result. A specific benzodiazepine, clonazepam, may be especially useful in panic disorder. Should these agents be ineffective, the serotonin reuptake inhibitors can also be used to good advantage. For refractory cases, ECT may be effective. hope this helps. -- Ron Vetter 1936, 1984 PD dz ... "money is coined liberty" ... Dostoevsky e-mail: [log in to unmask] http://www.ridgecrest.ca.us/~rfvetter