Psychosocial interventions for depression and anxiety in Parkinson's disease

Cost-Effectiveness Analyses of Non-Pharmacological and Non-Surgical Interventions in Idiopathic Parkinson's Disease: A Systematic Review

Background

Interest in non-pharmacological/non-surgical interventions to treat Parkinson's disease (PD) has substantially increased. Although a few health-economic studies have been conducted, summary information on the cost-effectiveness is still scarce.

Objective

To give an overview of cost-effectiveness analyses (CEA) focusing on non-pharmacological/non-surgical interventions in PD patients.

Methods

A systematic literature search was conducted in five databases. Studies were included that provided cost-effectiveness analysis (CEA) or cost-utility analysis (CUA) of non-pharmacological/non-surgical interventions in PD patients. Study quality was assessed with the Drummond and CHEERS 2022 checklists respectively, for economic evaluation.

Results

N = 9 studies published between 2012-2023 were identified. Most studies undertook a CUA (n = 5); n = 3 reported a combination of CEA and CUA, and n = 1 a pure CEA. Most studies (n = 6) examined physical exercise. The CEA studies identified additional costs of 170€ -660€  for the improvement of one single unit of a clinical outcome and savings of 18.40€ -22.80€  per score gained as measured with established instruments. The four studies that found significant quality of life benefits show large variations in the incremental cost effectiveness ratio (ICER) of 3,220€ -214,226€  per quality-adjusted life year (QALY); notably interventions were heterogenous regarding content and intensity.

Conclusions

Despite increasing numbers of non-pharmacological/non-surgical intervention trials in PD patients, health-economic evaluations are rare. The examined intervention types and health-economic results vary greatly. Together with the heterogeneity of the health-economic studies these factors limit the conclusions that can be drawn. Further research and a standardization of methods is needed to allow decision makers to make meaningful interpretations, and to allocate scarce resources.

Psychosocial Aspects of Rehabilitation in Neurodegenerative Diseases and Fields of Approach

Psychosocial health is a concept included in definition of health by World Health Organization and corresponds to state of emotional and social well-being. In the context of neurological disorder, psychosocial health refers to social reintegration and psychological adjustment. Studies reporting that neurological diseases are associated with negative psychosocial health outcomes such as a decrease in the quality of life, a decrease in ability to establish and maintain social relationships, and an increase in high levels of depression, stress and anxiety have increased in recent years. Therefore, it is important to consider programs and interventions that can improve the psychosocial health of people with neurodegenerative diseases. Currently, it is not clear which psychosocial approaches can produce definitively positive results. The aim of this study is to examine how being an individual with Multiple Sclerosis and Parkinson's, which are the most common neurodegenerative diseases in the clinic, affects psychosocial health in the rehabilitation process and the existing evidence-based psychosocial approaches. For this purpose, a descriptive review was prepared by scanning English and Turkish articles with keywords on psychotherapeutic, psychosocial and mindfulness-based interventions and stress management, published in the determined databases in the last 10 years. Studies have shown that psychosocial approaches such as interventions for acquisition of social integration and adaptive coping strategies, cognitive and social behavioral therapy methods, concentration and movement-based mind-body exercises are effective in rehabilitation of neurodegenerative diseases. These approaches were reported to have benefits in reducing anxiety, depression and fatigue, improving sleep quality and quality of life, relationships, employment, level of participation, motivation and self-efficacy in exercise and physical activity, improving physical functions, facilitating difficult and personal experiences and adaptation to new life in rehabilitation processes and more evidence-based studies are needed.

Psychometrics and diagnostics of the Italian version of the Beck Depression Inventory-II (BDI-II) in Parkinson's disease

INTRODUCTION

Depression is one of the most disabling neuropsychiatric manifestations of Parkinson's disease (PD) and requires proper screening and diagnosis because it affects the overall prognosis and quality of life of patients. This study aimed to assess the psychometric and diagnostic properties of the Beck Depression Inventory-II (BDI-II) in an Italian PD cohort.

MATERIALS AND METHODS

Fifty consecutive outpatients with PD underwent the Italian version of the BDI-II and other questionnaires to evaluate anxiety and apathetic symptoms. Patients' caregivers completed the depression/dysphoria domain of the Neuropsychiatric Inventory (NPI-D). We evaluated the internal consistency, convergent and divergent validity, and factorial structure of BDI-II. Sensitivity, specificity, positive and negative predictive values, and likelihood ratios were computed using ROC analyses, and an optimal cutoff was defined using the Youden index.

RESULTS

The BDI-II proved to be internally consistent (Cronbach's α = 0.840) and substantially met the bi-factorial structure. Regarding construct validity, the BDI-II was substantially related to anxiety measures, but not to apathy. With the combination of the NPI-D and anxiety score used as the gold standard, the BDI-II overall showed good accuracy (AUC = 0.859) with adequate sensitivity (75%) and specificity (87%). The optimal cutoff point was defined at 14.50.

CONCLUSIONS

We provide evidence of the psychometric and diagnostic properties of the Italian version of the BDI-II as a screening tool for depression in patients with PD. The BDI-II was found to be reliable and valid for the measurement of depression in patients with PD; therefore, it is available for use in clinical research and practice.

Predictors of health-related quality of life in Parkinson's disease: the impact of overlap between health-related quality of life and clinical measures

PURPOSE

This study aimed to determine predictors of health-related quality of life (HRQoL) in Parkinson's disease (PD) and to explore their predictive value before and after controlling overlapping items between HRQoL and clinical variables.

METHODS

One hundred and eight PD patients underwent motor, anxiety, depression, apathy, fatigue, and neurocognition assessment. HRQoL was assessed by the Parkinson's Disease Questionnaire-39 (PDQ-39). In order to determine predictors of HRQoL in PD, stepwise multiple regression analyses were performed in two ways: before and after removing the emotional well-being dimension from PDQ-39 to control the overlap between depression and anxiety, and HRQoL.

RESULTS

HRQoL total index was predicted by anxiety, fatigue, motor symptoms, and depression, explaining 26.9%, 7.2%, 2.8%, and 1.9% of the variance. However, after removing overlapping items, HRQoL total index was predicted by fatigue (16.5%), anxiety (6.1%), motor symptoms (3.9%), and neurocognition (2.5%), but not depression. Regarding HRQoL dimensions, mobility and activities of daily living were predicted by fatigue (19.7% and 5%) and UPDRS-III (4% and 10.2%); emotional well-being by fatigue (7.9%); social support by anxiety (12.2%) and UPDRS-III (8.6%); communication by neurocognition (5.3%) and UPDRS-III (3.4%); cognition by anxiety (10.6%) and bodily discomfort by anxiety (23%) and fatigue (4.1%).

CONCLUSION

These findings showed the importance of identifying and controlling overlapping items of HRQoL and clinical measures to perform an accurate interpretation. HRQoL dimensions showed different predictors before and after controlling the overlap. Based on these results fatigue, anxiety, motor symptoms, and neurocognition, but not depression are the main predictors of HRQoL in PD patients.

Efficacy of Acupuncture for Parkinson's Disease Anxiety: Two-Stage Protocol for a Randomized Controlled Clinical Trial

Parkinson's disease anxiety (PDA) is a nonmotor symptom of Parkinson's disease (PD) that is often neglected. PDA poses a far-reaching challenge to the treatment of PD. Acupuncture could be successful in the treatment of PDA. However, the evidence for this is still limited. We propose a two-stage clinical trial. In stage 1, a total of 70 volunteers with PDA will be randomly assigned to either acupuncture (manual acupuncture) or control group (sham acupuncture) in a 1 : 1 ratio. Treatments will be performed for four weeks. The change in the Hamilton Rating Scale for Anxiety (HAMA) score from baseline to week 4 and week 12 will be the primary outcome. The levels of adrenocorticotropic hormone (ACTH), cortisol (CORT), serotonin (5-HT), and corticotropin-releasing factor (CRH) in the patients' serum and the scores on the Hoehn–Yahr Rating Scale and the Unified Parkinson's Disease Rating Scale (UPDRS) will all be considered among the secondary outcomes. Participants will be followed up until week 12. In stage 2, a total of 82 volunteers with PDA will be randomly assigned to either an acupuncture (manual acupuncture) or a control group (anti-Parkinson drugs only) in a 1 : 1 ratio. HAMA score will be the primary outcome. Universality, feasibility and cost effectiveness, Hoehn–Yahr Rating Scale, UPDRS, and serological indicators will be secondary outcomes. Participants will be followed up until week 4. The statistical analysis will include all the allocated individuals. The First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine's Research Ethical Committee authorized this procedure, and the trial is registered with ChiCTR2100047253.

Neuropsychiatric Treatments for Parkinson's Disease: Nonpharmacological Approaches

Although diagnosed by characteristic motor features, Parkinson's disease and other movement disorders are frequently accompanied by a wide range of neuropsychiatric symptoms that require a multidisciplinary approach for treatment. Neuropsychiatric symptoms such as depression, anxiety and cognitive symptoms strongly influence quality of life, motor symptoms, and non-motor bodily symptoms. This review summarizes our current understanding of the neuropsychiatric symptoms in movement disorders and discusses the evidence base for treatments focusing on rehabilitation and nonpharmacological approaches. A practical approach is then proposed for patient selection for specific treatments based on disease stage. The article focuses mostly on Parkinson's disease as a prototypical movement disorder with the largest evidence base but the principles discussed herein are applicable to a range of other movement disorders.

Parkinson and depression: review and outlook

Depression in Parkinson's Disorder (DPD) has been estimated to appear in up to 40% of people with PD and negatively impacts quality of life, motor and cognitive deficits and functional disability. Knowledge of the pathophysiology of DPD is unclear, DPD may be related to dysfunction in subcortical nuclei and the prefrontal cortex, striatal-thalamic-prefrontal and basotemporal limbic circuits, brainstem monoamine, and indolamine (i.e. dopamine, serotonin, and norepinephrine) systems. DPD is characterized by sadness, loss of interest, increased exhaustibility, feelings of helplessness, reduced drive, dysphoria, irritability, and pessimism about future. The diagnosis is complicated by overlap with PD symptoms, Detection of depression in PD should be made by psychometric depression scales. DPD is underrecognized and undertreated in clinical practice. Treatment mainly includes antidepressive medications and behavioral interventions as psychotherapy. Dopamine agonists showed some antidepressant effects, there are no sufficient numbers of RCTs. Important randomized clinical trials (RCTs) are summarized. SSRIs and SNRIs have a satisfying efficacy in DPD. TCAs are also good for improving depression. Side effects of different antidepressants (e.g. TCAs, SSRIs, SNRIs, bupropion, MAOIs) and potential interactions should be considered. In existing guidelines so far no statements, algorithms and recommendations are given for diagnosis and treatment of DPD. Methodologically adequate designed RCTs and comparative studies (NIS) which offer evidence-based results are urgently needed having the impact of DPD in mind.

Acceptability and Feasibility of a Mindfulness Intervention Delivered via Videoconferencing for People With Parkinson's

Mindfulness-based group therapy is a rapidly growing psychological approach that can potentially help people adjust to chronic illness and manage unpleasant symptoms. Emerging evidence suggests that mindfulness-based interventions may benefit people with Parkinson's. The objective of the paper is to examine the appropriateness, feasibility, and potential cost-effectiveness of an online mindfulness intervention, designed to reduce anxiety and depression for people with Parkinson's. We conducted a feasibility randomized control trial and qualitative interviews. Anxiety, depression, pain, insomnia, fatigue, impact on daily activities and health-related quality of life were measured at baseline, 4, 8, and 20 weeks. Semi-structured interviews were conducted at the end of the intervention. Participants were randomized to the Skype delivered mindfulness group (n = 30) or wait-list (n = 30). Participants in the mindfulness group were also given a mindfulness manual and a CD with mindfulness meditations. The intervention did not show any significant effects in the primary or secondary outcome measures. However, there was a significant increase in the quality of life measure. The incremental cost-effectiveness ratio was estimated to be £27,107 per Quality-Adjusted Life Year gained. Also, the qualitative study showed that mindfulness is a suitable and acceptable intervention. It appears feasible to run a trial delivering mindfulness through Skype, and people with Parkinson's found the sessions acceptable and helpful.

Non-motor complications in late stage Parkinson's disease: recognition, management and unmet needs

Introduction: The burden of non-motor symptoms (NMS) is a major determinant of health-related quality of life in Parkinson's disease (PD), particularly at its late stage.Areas covered: The late stage is usually defined as the period from unstable advanced to the palliative stage, characterized by a combination of emerging treatment-resistant axial motor symptoms (freezing of gait, postural instability, falls and dysphagia), as well as both non-dopaminergic and dopaminergic NMS: cognitive decline, neuropsychiatric symptoms, aspects of dysautonomia, pain and sleep disturbances (insomnia and excessive day-time sleepiness). Here, the authors summarize the current knowledge on NMS dominating the late stage of PD and propose a pragmatic and clinically focused approach for their recognition and treatment.Expert opinion: The NMS progression pattern is complex and remains under-researched. While dopamine-dependent NMS may improve with dopamine replacement therapy, non-dopamine dependent NMS worsen progressively and culminate at the late stages of PD. Furthermore, some PD specific features could interact negatively with other comorbidities, multiple medication use and frailty - the evaluation of these aspects is important in the creation of personalized management plans in the late stage of PD.

Report from a multidisciplinary meeting on anxiety as a non-motor manifestation of Parkinson's disease

Anxiety is a severe problem for at least one-third of people living with Parkinson's disease (PD). Anxiety appears to have a greater adverse impact on quality of life than motor impairment. Despite its high prevalence and impact on daily life, anxiety is often undiagnosed and untreated. To better address anxiety in PD, future research must improve knowledge about the mechanism of anxiety in PD and address the lack of empirical evidence from clinical trials. In response to these challenges, the Parkinson's Foundation sponsored an expert meeting on anxiety on June 13th and 14th 2018. This paper summarizes the findings from that meeting informed by a review of the existing literature and discussions among patients, caregivers, and an international, clinician-scientist, expert panel working group. The goal is to provide recommendations to improve our understanding and treatment of anxiety in PD.

Treatment of psychiatric disturbances in hypokinetic movement disorders

Introduction: We reviewed studies that assessed the treatment of psychiatric disturbances in Parkinson's disease and atypical parkinsonisms. Neuropsychiatric disturbances in these conditions are frequent and have a profound impact on quality of life of patients and of their caregivers. It is therefore important to be familiar with the appropriate pharmacological and non-pharmacological interventions for treating these disorders. Areas covered: The authors searched for papers in English in Pubmed using the following keywords: Parkinson's disease, multiple system atrophy, progressive supranuclear palsy, corticobasal degeneration, Lewy body dementia, depression, apathy, anxiety, fatigue, sleep disorders, obsessive compulsive disorders, psychosis, hallucinations, delusions, impulse control disorders. Expert opinion: In Parkinson's disease, depression may benefit from the optimization of dopaminergic therapy, from the use of antidepressants acting on both the serotoninergic and noradrenergic pathways and from cognitive behavioral therapy. Psychosis in Parkinson's disease may improve with the use of clozapine; the serotonin inverse agonist pimavanserin has been shown to be effective. Treatment of impulse control disorders is primarily based on the removal of dopamine agonists. No controlled studies have investigated the treatment of neuropsychiatric disorders in multiple system atrophy, progressive supranuclear palsy or corticobasal degeneration. Acethylcholinesterase inhibitors may be used to treat hallucinations in Lewy body dementia.

The role of dispositional mindfulness in a stress-health pathway among Parkinson's disease patients and caregiving partners

PURPOSE

Parkinson's disease (PD) patients and their caregivers experience significant distress that impacts physical, emotional and social functioning in the patient, and in turn, has a significant impact on the caregiver. Lower levels of stress have been associated with a better prognosis in PD. The quality of dispositional mindfulness-innate present moment, non-judgmental awareness-has consistently been associated with less perceived stress, greater well-being, and better physical health in both clinical and healthy populations. To date, associations of mindfulness with distress, depression, sleep problems, and other variables that define health-related quality of life have not been examined in the context of PD patient/caregiver dyads.

METHODS

We investigated the impact of dispositional mindfulness in a stress-health model among eighteen dyads consisting of PD patients and their caregivers.

RESULTS

Multilevel linear modeling (actor-partner interdependence models) revealed significant associations between dispositional mindfulness and stress appraisal, interpersonal support, depressive symptoms, sleep, and health-related quality of life (HRQOL) within both dyadic partners. As expected, results demonstrated significant associations of distress with interpersonal support, depressive symptoms, sleep and HRQOL for both PD patients and caregivers.

CONCLUSIONS

Dispositional mindfulness was associated with reduced distress and its downstream clinical consequences. These results support an ameliorative role for dispositional mindfulness among PD patients and caregivers, as a protective factor against psychosocial burdens imposed on couples related to disease and caregiving. Findings suggest future studies should explore mindfulness training as a therapeutic option.

Cognitive-Behavioral Therapy for Anxiety in Parkinson's Disease

Parkinson's disease (PD) is characterized by motor symptoms, but nonmotor symptoms also significantly impair daily functioning and reduce quality of life. Anxiety is prevalent and debilitating in PD, but remains understudied and undertreated. Much affective research in PD focuses on depression rather than anxiety, and as such, there are no evidence-based treatments for anxiety in this population. Cognitive-behavioral therapy (CBT) has shown promise for treating depression in PD and may be efficacious for anxiety. This exploratory study implemented a multiple-baseline single-case experimental design to evaluate the utility and feasibility of CBT for individuals with PD who also met criteria for a DSM-5 anxiety disorder (n = 9). Participants were randomized to a 2-, 4-, or 6-week baseline phase, followed by 12 CBT sessions, and two post treatment assessments (immediately post treatment and 6-week follow-up). Multiple outcome measures of anxiety and depression were administered weekly during baseline and intervention. Weekly CBT sessions were conducted in-person (n = 5) or via secure videoconferencing (n = 4). At post treatment, seven of the nine participants showed significant reductions in anxiety and/or depression, with changes functionally related to treatment and most improvements maintained at 6-week follow-up. Effects of CBT on secondary outcomes varied across participants, with preliminary evidence for reduction in fear of falling. Adherence and retention were high, as were treatment satisfaction and acceptability. The findings of this pilot study provide preliminary evidence for the utility of CBT as a feasible treatment for anxiety and comorbid depressive symptoms in PD and highlight the potential of telehealth interventions for mood in this population.

Enhanced motivation of cognitive control in Parkinson's disease

Motor and cognitive deficits in Parkinson's disease (PD) have been argued to reflect motivational deficits. In prior work, however, we have shown that motivation of cognitive control is paradoxically potentiated rather than impaired in Parkinson's disease. This is particularly surprising given the fact that Parkinson's disease is often accompanied by depression, a prototypical disorder of motivation. To replicate our previous finding and assess the effects of depression, we investigated performance of PD patients with (n = 22) and without depression (history) (n = 23) and age‐matched healthy controls (n = 23) on a task specifically designed to measure the effect of reward motivation on task‐switching. We replicated previous findings by showing contrasting effects of reward motivation on task‐switching in PD patients and age‐matched healthy controls. While the promise of high versus low reward improved task‐switching in PD, it tended to impair task‐switching in age‐matched healthy controls. There were no effects of a depression (history) diagnosis in PD patients. These findings reinforce prior observations that Parkinson's disease is accompanied by enhanced incentive motivation of cognitive control and highlight the potential of incentive motivational strategies for overcoming cognitive deficits in Parkinson's disease.

Assessment and Management of Neuropsychiatric Symptoms in Parkinson's Disease

Neuropsychiatric symptoms are highly prevalent in Parkinson's disease and associated with decreased quality of life and adverse health outcomes. In this review, the assessment and management of common neuropsychiatric symptoms are discussed: depression, anxiety, psychosis, cognitive impairment, dementia and apathy. Validated assessment scales are now available for the majority of symptoms. Balancing dopaminergic therapy plays an important role in their management as increasing doses of dopaminergic agents might address depression and anxiety related to 'off' phases, non-motor fluctuations and apathy, while dose reduction might alleviate psychotic symptoms. More targeted treatment is possible through medications utilising different pathways. Although efficacy profiles of individual agents require further exploration, antidepressants as a drug class have shown utility in depression and anxiety in Parkinson's disease. Psychological therapies, especially cognitive behavioural approaches, are effective. Pimavanserin allows the treatment of psychosis in Parkinson's disease without directly affecting the dopaminergic and cholinergic system. The cholinergic system is currently the only target in Parkinson's disease dementia, and antagonists of this system, as are many psychotropic drugs, need to be used with caution. Management of apathy largely relies on non-pharmacological strategies adapted from dementia care, with antidepressants being ineffective and the role of stimulant therapy needing further evaluation.

Cognitive behavioral group therapy versus psychoeducational intervention in Parkinson's disease

OBJECTIVE

The aim of the current study was to evaluate whether cognitive behavioral group therapy has a positive impact on psychiatric, and motor and non-motor symptoms in Parkinson's disease (PD).

METHODS

We assigned 20 PD patients with a diagnosis of psychiatric disorder to either a 12-week cognitive behavioral therapy (CBT) group or a psychoeducational protocol. For the neurological examination, we administered the Unified Parkinson's Disease Rating Scale and the non-motor symptoms scale. The severity of psychiatric symptoms was assessed by means of the Hamilton Depression Rating Scale, the Hamilton Anxiety Rating Scale, the Brief Psychiatric Rating Scale, and the Clinical Global Impressions.

RESULTS

Cognitive behavioral group therapy was effective in treating depression and anxiety symptoms as well as reducing the severity of non-motor symptoms in PD patients; whereas, no changes were observed in PD patients treated with the psychoeducational protocol.

CONCLUSION

CBT offered in a group format should be considered in addition to standard drug therapy in PD patients.

The effects of yoga versus stretching and resistance training exercises on psychological distress for people with mild-to-moderate Parkinson's disease: study prxotocol for a randomized controlled trial

Background

Psychological distress is prevalent among people with Parkinson’s disease (PD) and aggravates their motor symptoms, thereby leading to increased disability, high healthcare costs, and poor health-related quality of life (HRQoL). The under-recognition and adverse effects of the pharmacological management of anxiety and depression among the PD population are considerable. Thus, adopting a Complementary and Alternative Management (CAM) approach to address this problem is important. Yoga, one of the most common “mind-body” CAM therapies, can improve the psychological wellbeing of people with chronic illnesses. However, limited research on the effects of yoga in people with PD has been conducted. This study will determine the effects of yoga on the psychological wellbeing of people with mild-to-moderate PD and will compare these effects with those of stretching and resistance training exercises.

Methods

A community-based, single-blind, randomized trial will be conducted. A total of 126 subjects will be recruited and randomly divided into yoga (n = 63) or stretching and resistance exercise (n = 63) groups. For 8 weeks, the yoga group will receive a weekly 90-min session of yoga, and the control group will receive a weekly 60-min session of stretching and resistance exercises. The primary outcome will be the level of psychological distress measured using the Hospital Anxiety and Depression Scale. The secondary outcomes will include the severity of motor symptoms measured by the Movement Disorders Society – Unified Parkinson’s Disease Scale − Part III Motor Examination; mobility, balance, and fall risk measured by the Timed Up and Go test; spiritual wellbeing measured by the Holistic Wellbeing Scale; and HRQoL measured by the Parkinson’s Disease Questionnaire-8. Assessment will be conducted at baseline, 8th, and 20th weeks of follow-ups.

Discussion

This study will be the first randomized trial to compare the effect of yoga versus stretching and resistance training exercises in a PD population. Results will contribute to the value of yoga as a therapeutic option for managing psychological distress in PD patients. Multiple outcomes including psychological, physiological, and spiritual and HRQoL will also be measured to elucidate the potential mechanisms of yoga. The effect of yoga on people with chronic illnesses will further be elucidated. This information should contribute to future research, practice, and policy related to PD management.

Trial registration

WHO Primary Registry – Chinese Clinical Trials Registry (ChiCTR): CUHK_CCRB00522 Registered on 8 October 2016; date of approval 19 August 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2223-x) contains supplementary material, which is available to authorized users.

Treatment of Nonmotor Symptoms in Parkinson's Disease

Nonmotor symptoms (NMS) are integral to Parkinson's disease (PD) and the management can often be challenging. In spite of the growing evidence that NMS have a key impact on the quality of life of patients and caregivers, most clinical trials still focus on motor symptoms as primary outcomes. As a consequence strong evidence-based treatment recommendations for NMS occurring in PD are spare. In this chapter, the current data addressing the treatment of major NMS such as sleep, cognitive and autonomic dysfunction, and depression and anxiety are described.

Responsiveness of the short-form health survey and the Parkinson's disease questionnaire in patients with Parkinson's disease

Background

The responsiveness of a measurement instrument is important for understanding its ability to detect changes in the progression of a disease. We examined and compared the internal and external responsiveness of the 36-item Short-Form Health Survey (SF-36) and the 39-item Parkinson’s Disease Questionnaire (PDQ-39) in patients with Parkinson’s Disease (PD).

Methods

Seventy-four patients with PD were evaluated using the SF-36 and PDQ-39 at baseline and again after one year. In addition, their motor signs, motor difficulties of daily living, and depressive symptoms were assessed as external criteria. The internal responsiveness was examined using effect size, standardized response mean, and the Wilcoxon signed rank test. The external responsiveness was examined using receiver operating characteristic curves, correlation analyses, and regression models.

Results

Both instruments were partially sensitive to changes during the 1-year follow-up and able to discriminate between patients with improved versus deteriorated motor signs. In addition, both were similarly responsive to changes in the motor difficulties of daily living; the SF-36 appeared to be more sensitive than the PDQ-39 to changes in depressive symptoms.

Conclusions

The SF-36 and the PDQ-39 were acceptably internally and externally responsive during the 1-year follow-up.

Electronic supplementary material

The online version of this article (doi:10.1186/s12955-017-0642-8) contains supplementary material, which is available to authorized users.

A practical approach to detection and treatment of depression in Parkinson disease and dementia

PURPOSE OF REVIEW

To review the available evidence for the detection and management of depression in Parkinson disease (PD) and dementia.

RECENT FINDINGS

Depression is a common comorbidity in those with PD or dementia, and leads to increased morbidity. There are several available and accurate tools for the detection of depression in PD (e.g., Geriatric Depression Scale) and dementia (e.g., Cornell Scale for Depression in Dementia). Treatment of depression depends on patient preference, severity of depression, comorbidities, and available resources. Despite variable evidence, the use of nonpharmacologic strategies to manage depression is suggested. Pharmacologic management is guided by modest evidence in PD and dementia, but also informed by the management of late-life depression (LLD).

SUMMARY

There is evidence to guide the diagnosis and management of depression in PD or dementia. However, more research is required in this field to better inform clinical decision-making.

A randomized trial of individual versus group-format exercise and self-management in individuals with Parkinson's disease and comorbid depression

BACKGROUND

Depression is common in people with Parkinson's disease (PD), and exercise is known to improve depression and PD. However, lack of motivation and low self-efficacy can make exercise difficult for people with PD and comorbid depression (PD-Dep). A combined group exercise and chronic disease self-management (CDSM) program may improve the likeli-hood that individuals will engage in exercise and will show a reduction in depression symptoms. The purpose of this study was to compare changes in depression in PD-Dep between individual versus group exercise plus CDSM and to examine participant adherence and perception of the interventions.

METHODS

Participants (N=30) were randomized to either Enhanced EXerCisE thErapy for PD (EXCEED; group CDSM and exercise) or self-guided CDSM plus exercise. Outcomes were change in depression assessed with the Montgomery-Asberg Depression Rating Scale (MADRS), cognition, apathy, anxiety, sleep, quality of life, motor function, self-efficacy, and patient satisfaction.

RESULTS

Both groups showed significant improvement in MADRS (P<0.001) with no significant group difference. Individuals in EXCEED group enjoyed the group dynamics but noted difficulty with the fixed-time sessions.

CONCLUSION

Both group CDSM plus exercise and self-guided CDSM plus exercise can improve depression in PD-Dep. These findings suggest that development of a remotely delivered group-based CDSM format plus manualized exercise program could be useful for this population.

AIDE-Acute Illness and Depression in Elderly Patients. Cognitive Behavioral Group Psychotherapy in Geriatric Patients With Comorbid Depression: A Randomized, Controlled Trial

BACKGROUND

Comorbid depression is highly prevalent in geriatric patients and associated with functional loss, frequent hospital re-admissions, and a higher mortality rate. Cognitive behavioral psychotherapy (CBT) has shown to be effective in older depressive patients living in the community. To date, CBT has not been applied to older patients with acute physical illness and comorbid depression.

OBJECTIVES

To evaluate the effectiveness of CBT in depressed geriatric patients, hospitalized for acute somatic illness.

DESIGN

Randomized controlled trial with waiting list control group.

SETTING

Postdischarge intervention in a geriatric day clinic; follow-up evaluations at the patients' homes.

PARTICIPANTS

A total of 155 randomized patients, hospitalized for acute somatic illness, aged 82 ± 6 years and suffering from depression [Hospital Anxiety and Depression Scale (HADS) scores >7]. Exclusion criteria were dementia, delirium, and terminal state of medical illness.

INTERVENTION

Fifteen, weekly group sessions based on a CBT manual. Commencement of psychotherapy immediately after discharge in the intervention group and a 4-month waiting list interval with usual care in the control group.

MEASUREMENTS

HADS depression total score after 4 months. Secondary endpoints were functional, cognitive, psychosocial and physical status, resource utilization, caregiver burden, and amount of contact with physician.

RESULTS

The intervention group improved significantly in depression scores (HADS baseline 18.8; after 4 months 11.4), whereas the control group deteriorated (HADS baseline 18.1; after 4 months 21.6). Significant improvement in the intervention group, but not in the control group, was observed for most secondary outcome parameters such as the Barthel and Karnofsky indexes. Intervention effects were less pronounced in patients with cognitive impairment or acute fractures.

CONCLUSIONS

CBT is feasible and highly effective in geriatric patients. The benefits extend beyond effective recovery and include improvement in physical and functional parameters. Early diagnosis, good access to psychotherapy, and early intervention could improve care for depressive older patients.

CLINICAL TRIAL REGISTRATION

www.germanctr.de German Trial Register DRKS 00004728.

Human behavioral assessments in current research of Parkinson's disease

Parkinson's disease (PD) is traditionally classified as a movement disorder because patients mainly complain about motor symptoms. Recently, non-motor symptoms of PD have been recognized by clinicians and scientists as early signs of PD, and they are detrimental factors in the quality of life in advanced PD patients. It is crucial to comprehensively understand the essence of behavioral assessments, from the simplest measurement of certain symptoms to complex neuropsychological tasks. We have recently reviewed behavioral assessments in PD research with animal models (Asakawa et al., 2016). As a companion volume, this article will systematically review the behavioral assessments of motor and non-motor PD symptoms of human patients in current research. The major aims of this article are: (1) promoting a comparative understanding of various behavioral assessments in terms of the principle and measuring indexes; (2) addressing the major strengths and weaknesses of these behavioral assessments for a better selection of tasks/tests in order to avoid biased conclusions due to inappropriate assessments; and (3) presenting new concepts regarding the development of wearable devices and mobile internet in future assessments. In conclusion we emphasize the importance of improving the assessments for non-motor symptoms because of their complex and unique mechanisms in human PD brains.

A Meta-Analysis of Nonpharmacological Interventions for People With Parkinson’s Disease

Nonpharmacological interventions are important in providing care for Parkinson’s disease (PD) patients. However, there is limited evidence related to their impacts on health-related quality of life (HRQOL). We aimed to examine the effectiveness of nonpharmacological interventions for improving the HRQOL of PD patients. Articles published in peer-reviewed journals from 2000 to 2015 were searched through electronic searching, computerized author searching, and footnote chasing. A meta-analysis was performed using the RevMan 5.3 program. Overall, effect size for the studies ( n = 18) was −4.17 with 95% confidence interval (CI) from −7.63 to −0.70 ( Z = 2.36, p = .02), indicating positive effects of nonpharmacological interventions on HRQOL. In subgroup analysis regarding the intervention types, the effect size of exercise programs was −5.73 with 95% CI of −11.36 to −0.10 ( Z = 2.00, p = .05). Thus, nonpharmacological interventions, and particularly exercise programs, were effective in improving the HRQOL of PD patients.

Relationships among Depression, Anxiety, Sleep, and Quality of Life in Patients with Parkinson's Disease in Taiwan

The aim of this study was to examine the relationships among depression, anxiety, sleep disturbances, Parkinson's disease (PD) symptoms, PD medications, and health-related quality of life (QOL) and to identify the predictors of health-related QOL in PD patients. To do this, we administered a battery of questionnaires and rating scales (validated Chinese versions), including the Unified Parkinson's Disease Rating Scale, 39-item Parkinson's Disease Questionnaire, Parkinson's Disease Sleep Scale-2, Beck Depression Inventory, and Beck Anxiety Inventory, to 134 patients with PD whose Minimental State Examination scores were ≥24. We found that patients who reported having poorer QOL had longer disease durations, more severe PD symptoms, higher Hoehn and Yahr stages, and higher levodopa dosages, as well as higher levels of anxiety and depression, more sleep disturbances, and poorer overall cognitive statuses. Among these variables, the cognitive status, dependency of activities of daily living, depression, and anxiety were identified as predictors of QOL in PD patients and were all significant and independent factors of poor QOL in PD patients. The clinicians should be aware of the effects of these factors on QOL and attempt to treat comorbid psychiatric conditions to improve the PD patients' QOL.

The Network Model of Depression as a Basis for New Therapeutic Strategies for Treating Major Depressive Disorder in Parkinson's Disease

The high prevalence of major depressive disorder in people with Parkinson’s disease (PD), its negative impact on health-related quality of life and the low response rate to conventional pharmacological therapies call to seek innovative treatments. Here, we review the new approaches for treating major depressive disorder in patients with PD within the framework of the network model of depression. According to this model, major depressive disorder reflects maladaptive neuronal plasticity. Non-invasive brain stimulation (NIBS) using high frequency repetitive transcranial magnetic stimulation (rTMS) over the prefrontal cortex has been proposed as a feasible and effective strategy with minimal risk. The neurobiological basis of its therapeutic effect may involve neuroplastic modifications in limbic and cognitive networks. However, the way this networks reorganize might be strongly influenced by the environment. To address this issue, we propose a combined strategy that includes NIBS together with cognitive and behavioral interventions.

Rumination and behavioural factors in Parkinson's disease depression

OBJECTIVE

Parkinson's disease is associated with high rates of depression. There is growing interest in non-pharmacological management including psychological approaches such as Cognitive Behaviour Therapy. To date, little research has investigated whether processes that underpin cognitive models of depression, on which such treatment is based, apply in patients with Parkinson's disease. The study aimed to investigate the contribution of core psychological factors to the presence and degree of depressive symptoms.

METHODS

104 participants completed questionnaires measuring mood, motor disability and core psychological variables, including maladaptive assumptions, rumination, cognitive-behavioural avoidance, illness representations and cognitive-behavioural responses to symptoms.

RESULTS

Regression analyses revealed that a small number of psychological factors accounted for the majority of depression variance, over and above that explained by overall disability. Participants reporting high levels of rumination, avoidance and symptom focusing experienced more severe depressive symptoms. In contrast, pervasive negative dysfunctional beliefs did not independently contribute to depression variance.

CONCLUSION

Specific cognitive (rumination and symptom focusing) and behavioural (avoidance) processes may be key psychological markers of depression in Parkinson's disease and therefore offer important targets for tailored psychological interventions.

The Therapeutic Potential of Exercise to Improve Mood, Cognition, and Sleep in Parkinson's Disease

In addition to the classic motor symptoms, Parkinson's disease (PD) is associated with a variety of nonmotor symptoms that significantly reduce quality of life, even in the early stages of the disease. There is an urgent need to develop evidence-based treatments for these symptoms, which include mood disturbances, cognitive dysfunction, and sleep disruption. We focus here on exercise interventions, which have been used to improve mood, cognition, and sleep in healthy older adults and clinical populations, but to date have primarily targeted motor symptoms in PD. We synthesize the existing literature on the benefits of aerobic exercise and strength training on mood, sleep, and cognition as demonstrated in healthy older adults and adults with PD, and suggest that these types of exercise offer a feasible and promising adjunct treatment for mood, cognition, and sleep difficulties in PD. Across stages of the disease, exercise interventions represent a treatment strategy with the unique ability to improve a range of nonmotor symptoms while also alleviating the classic motor symptoms of the disease. Future research in PD should include nonmotor outcomes in exercise trials with the goal of developing evidence-based exercise interventions as a safe, broad-spectrum treatment approach to improve mood, cognition, and sleep for individuals with PD.

Paraquat and psychological stressor interactions as pertains to Parkinsonian co-morbidity

A number of epidemiological and experimental studies have implicated the non-selective herbicide, paraquat, in the development of sporadic Parkinson's disease (PD). While preclinical research has focused mainly on elucidating the nigrostriatal effects of paraquat, relatively little data are available concerning non-motor brain systems and inflammatory immune processes (which have been implicated in PD). Hence, in the present study, we sought to take a multi-system approach to characterize the influence of paraquat upon extra-nigrostriatal brain regions, as well ascertain whether the impact of the pesticide might be enhanced in the context of chronic intermittent stressor exposure. Our findings support the contention that paraquat itself acted as a systemic stressor, with the pesticide increasing plasma corticosterone, as well as altering neurochemical activity in the locus coeruleus, paraventricular nucleus of the hypothalamus, nucleus accumbens, dorsal striatum, and central amygdala. However, with the important exception striatal dopamine turnover, the stressor treatment did not further augment these effects. Additionally, paraquat altered inter-cytokine correlations and, to a lesser extent, circulating cytokine levels, and concomitant stress exposure modulated some of these effects. Finally, paraquat provoked significant (albeit modest) reductions of sucrose preference and weight gain, hinting at possible anhendonic-like or sickness responses. These data suggest that, in addition to being a well known oxidative stress generator, paraquat can act as a systemic stressor affecting hormonal and neurochemical activity, but largely not interacting with a concomitant stressor regimen.

Antidepressive treatments for Parkinson's disease: A systematic review and meta-analysis

CONTEXT

Depression affects 50-70% of patients with Parkinson's disease resulting in significant comorbidity, executive dysfunction, and poorer quality of life. Divergent results from studies of different treatments preclude definite treatment recommendations.

OBJECTIVE

To perform a systematic review and meta-analysis of published randomized controlled trials (RCTS) evaluating the efficacy of pharmacologic and behavioral interventions, and repetitive transcranial magnetic stimulation (rTMS) for depression among patients with idiopathic Parkinson's disease.

DATA SOURCES

Trial registers and the following databases were searched: PubMed, CINAHL, EMBASE, and PsycInfo. Bibliographies of relevant articles were cross-referenced.

STUDY SELECTION AND DATA EXTRACTION

RCTs comparing pharmacologic, behavioral, or rTMS with a placebo/other drugs or methods with no restrictions on participant age, gender, and duration or setting of treatment were included. Eligibility assessment was performed independently. Identified records were sequentially screened according to eligibility criteria. Differences in mean depression score and 95% confidence intervals were calculated.

RESULTS

A total of 893 idiopathic Parkinson's disease patients with clinical depression across 20 RCTs were included. The overall standard mean difference for all pharmacologic interventions was 0.30 (95% CI -0.00, 0.61, p = 0.054). On stratification, there was a distinct difference in effect between antidepressants (SMD of 0.54, 95%CI 0.24, 0.83, p = 0.000) and non-antidepressants (SMD of -0.29, 95% CI -0.86, 0.29, p = 0.328). Behavioral interventions demonstrated significant efficacy with an effect size of 0.87 (95% CI 0.41, 1.33, p = 0.000).

CONCLUSIONS

This meta-analysis demonstrates that pharmacologic treatment with antidepressant medications, specifically the selective serotonin reuptake inhibitors (SSRIs), and behavioral interventions (CBT) significantly improved depression among Parkinson's disease patients.

Effects of music and music therapy on mood in neurological patients

Mood disorder and depressive syndromes represent a common comorbid condition in neurological disorders with a prevalence rate that ranges between 20% and 50% of patients with stroke, epilepsy, multiple sclerosis, and Parkinson’s disease. Notwithstanding, these conditions are often under-diagnosed and under-treated in the clinical practice and negatively affect the functional recovery, the adherence to treatment, the quality of life, and even the mortality risk. In addition, a bidirectional association between depression and neurological disorders may be possible being that depressive syndromes may be considered as a risk factor for certain neurological diseases. Despite the large amount of evidence regarding the effects of music therapy (MT) and other musical interventions on different aspects of neurological disorders, no updated article reviewing outcomes such as mood, emotions, depression, activity of daily living and so on is actually available; for this reason, little is known about the effectiveness of music and MT on these important outcomes in neurological patients. The aim of this article is to provide a narrative review of the current literature on musical interventions and their effects on mood and depression in patients with neurological disorders. Searching on PubMed and PsycInfo databases, 25 studies corresponding to the inclusion criteria have been selected; 11 of them assess the effects of music or MT in Dementia, 9 explore the efficacy on patients with Stroke, and 5 regard other neurological diseases like Multiple Sclerosis, Amyotrophic Lateral Sclerosis/motor neuron disease, Chronic quadriplegia, Parkinson’s Disease, and Acquired Brain dysfunctions. Selected studies are based on relational and rehabilitative music therapy approaches or concern music listening interventions. Most of the studies support the efficacy of MT and other musical interventions on mood, depressive syndromes, and quality of life on neurological patients.

Enhanced Exercise Therapy in Parkinson's disease: A comparative effectiveness trial

Objectives

Exercise can improve motor function in people with Parkinson’s disease but depression reduces the motivation to participate in regular exercise. The aim of this study was to develop a novel Enhanced Exercise Therapy program that uses manual-driven guided exercise and peer-facilitated psychoeducation for individuals with Parkinson’s disease and depression.

Design

24 week randomized controlled design.

Methods

Thirty individuals were randomized to Enhanced Exercise Therapy or self-guided therapy, and evaluated at baseline, 12-weeks and at 24-weeks. Enhanced Exercise Therapy included group exercise and group psychoeducation for 12 weeks. Between 13–24 weeks, individuals had access to the fitness facility but group sessions were not held. Self-guided therapy included written guidelines for a self-paced exercise program and psychoeducation. Primary outcome measures included the number of exercise sessions and International Physical Activity Questionnaire score. Secondary measures included resting heart rate, supine blood pressure, estimated VO₂max and incidence of orthostatic hypotension.

Results

Twenty four individuals completed the study (80% retention) and both groups attended similar number of exercise sessions. There were no significant changes in cardiovascular fitness measures but there was a significant increase in the amount of physical activity in the Enhanced Exercise Therapy group and a decrease in the self-guided therapy group during the post-intervention period.

Conclusions

Enhanced exercise therapy appears to promote engagement in an exercise program and more physical activity, even after group sessions were concluded in individuals with Parkinson’s disease and depression.

Disexecutive functions and depression in patients with Parkinson disease: the impact on rehabilitation outcome

BACKGROUND

Studies relating to patients with Parkinson disease that assess neuropsychologic, psychologic, and clinical aspects are very uncommon.

OBJECTIVE

The aim of this study was to analyze the impact of executive functioning (impaired vs. not impaired) or depression (depressed vs. nondepressed) on the outcome of rehabilitation treatment in patients with Parkinson disease without dementia at the medium stage of disease.

METHODS

Forty consecutive inpatients affected by Parkinson disease were psychologically and neuropsychologically assessed by means of standardized tests during the first week of admission and at discharge after undergoing an intensive rehabilitation training.

RESULTS

At baseline, the patients (mean [SD] age, 70.1 [8.0]; Mini-Mental State Examination [MMSE], ≥24) showed impairment in the following executive functions: frontal functions (32.5%), selective and divided attention (55.0% and 41.9%, respectively), and word fluency (17.5%). Depressive symptoms reported using the Geriatric Depression Scale were distributed as follows: mild (n = 13), 32.5%; moderate (n = 4), 10.0%; and severe (n = 5), 12.5%. As for the outcome of the intensive rehabilitation treatment, a general improvement in the Unified Parkinson's Disease Rating Scale, the Berg's scale, the 6-min walking test, and the Timed Up and Go test was observed (P < 0.0001). The improvement was homogeneous for all groupings of the patients for all of the considered variables, indicating that the changes in performance as a result of treatment were unaffected by the presence of executive function deficits or moderate-to-severe depression.

CONCLUSIONS

The patients' executive function impairment or moderate-to-severe depressive symptoms did not seem to interfere with the outcome of the intensive physical and occupational rehabilitation. Therefore, these aspects in patients without dementia should not be considered a contraindication to an intensive rehabilitation program. Furthermore, despite the presence of impaired executive functions and/or of depressive symptoms, the 4-wk multidisciplinary rehabilitation program resulted to be highly effective.

Managing depression in Parkinson’s patients: risk factors and clinical pearls

SUMMARY 

Parkinson’s disease (PD) is a neurodegenerative condition that is on the rise as the world’s population ages. As our understanding of the disease increases, depression has emerged as a common syndrome in this population that significantly reduces quality of life, making its understanding, recognition and treatment an important area of focus for clinicians and researchers alike. It is hypothesized that depression is a consequence of the disease process itself, sometimes developing prior to the onset of motor symptoms. Many of the diagnostic tools and treatments for depression have not been fully evaluated in the PD population. However, several traditional diagnostic interviews and depression rating scales have been used in recent clinical trials. These study results suggest that some of the currently available antidepressant medications may be effective and well tolerated in this population. This paper reviews our understanding of depression in PD as well as the current recommendations for its diagnosis and treatment.

The potential of dental stem cells differentiating into neurogenic cell lineage after cultivation in different modes in vitro

Trauma or degenerative diseases of the central nervous system (CNS) cause the loss of neurons or glial cells. Stem cell transplantation has become a vital strategy for CNS regeneration. It is necessary to effectively induce nonneurogenic stem cells to differentiate into neurogenic cell lineages because of the limited source of neurogenic stem cells, relatively difficult cultivation, and ethical issues. Previous studies have found that dental stem cells can be used for transplantation therapy. The aim of this study was to explore a better inductive mode and time point for dental stem cells to differentiate into neural-like cells and evaluate a better candidate cell. In this study, dental follicle stem cells (DFSCs), dental papilla stem cells (DPSCs), and stem cells from apical papilla (SCAPs) were cultivated in five different modes. The proliferation ability, morphology, and expression of neural marker genes were analyzed. Results showed that DFSCs showed a higher proliferation potential. The proliferation was decreased after cultivation in chemical inductive medium as cultivation modes 3 and 5. The cells could present neural-like cell morphology after cultivation with human epidermal growth factor (EGF) and fibroblast growth factor-basic (bFGF) as cultivation modes 4 and 5. The vast majority of DFSCs gene expression levels in mode 4 on the third day was upregulated significantly. In conclusion, our data suggested that different dental stem cells exhibited different neural differentiation potentials. DFSCs might be the better candidate cell type. Furthermore, cultivation mode 4 and timing of the third day may promote differentiation into neurogenic cell lineages more effectively before transplantation to treat neurological diseases.

Anxiety in Parkinson's disease: identification and management

Anxiety disturbances are recognized as common psychiatric comorbidities in Parkinson's disease (PD) and contribute to significant impairments in areas of cognitive, functional, motor and social performance. Anxiety in PD results in reduced quality of life, higher levels of care dependency and increased caregiver burden. Surprisingly, there is a paucity of treatment data. In one randomized, controlled study, bromazepam was found to be effective for anxiety in PD. However, usage of benzodiazepines in the PD population is limited by potential risk of confusion and falls. There are no controlled studies of selective serotonin reuptake inhibitors (SSRIs) for anxiety in PD. However, results from uncontrolled studies suggest that SSRIs are effective for anxiety in PD, although in these studies anxiety outcomes were secondary. This review underscores that, given the high prevalence of anxiety disturbances in PD, there is a significant paucity of treatment data for this population. Additional studies are warranted. In the meantime, clinicians should rely on empiric assessments of known risks and putative benefits to guide treatment decisions. Cognitive and behavioral therapies (with or without pharmacotherapy) have demonstrated efficacy and warrant consideration. When feasible, a targeted and individualized multimodal approach utilizing psychotherapeutic interventions along with pharmacologic therapies should be considered.

[Coexistent depressive and anxiety disorders in neurological diseases: from a perspective of multimorbidity]

The high rate of coexistent emotional disorders in neurological diseases is challenging. As a rule this coexistence comprises a more dramatic subjective suffering, reduced psychological coping, possible negative interferences with somatic treatments and rehabilitation, an impaired quality of life and higher grades of psychosocial disability. It may also lead to an overall increased risk of somatic morbidity and even mortality in the further course of illness. The complex interrelations may be favorably integrated within a biopsychosocial model. Psychological and psychosocial stressors can be appreciated on their own discrete levels but have to be reflected in their neurobiological correlates. Both neurological and emotional disorders frequently share decisive pathogenetic mechanisms, i.e. the underlying process of neurological disease may contribute to major affective problems also in a somatopsychic direction. From a perspective of multimorbidity the prevalence and clinical relevance of coexistent depressive and anxiety disorders, common pathogenetic mechanisms and implications for treatment will be described for stroke and Parkinson's disease, as selected neurological disorders.

Anxiety and depression in Parkinson's disease

OPINION STATEMENT

Anxiety and depression, while very common problems in Parkinson's disease (PD), have not been subject to adequate treatment trials. While a handful of double blind placebo-controlled trials of depression have been published, only a small number of subjects have been enrolled in most of these. There have been no adequate treatment trials of anxiety. Thus, most practitioners base their treatments on what has been published in the general population and their own personal experience. The data suggest that depression is probably treatable in some cases, but there are no data to support any drug treatment of anxiety. Much of the rationale for treating these disorders is based primarily on side effect profiles rather than efficacy and is almost entirely based on anecdotal experience. Although we lack convincing data, we do believe in the pharmacologic treatment of depression and anxiety and choose medications based on side effect profiles, some of which may be useful. We favor the selective serotonin reuptake inhibitors (SSRIs) in general for both depression and anxiety because of their relative freedom from side effects but will often choose mirtazapine if insomnia or weight loss is a problem, clonazepam for anxiety without depression if an SSRI is insufficient or if REM sleep behavior disorder is a problem, or a tricyclic antidepressant if drooling is troubling and the patient is not demented. Alternatively, we use the serotonin and noradrenaline reuptake inhibitor venlafaxine in those who do not tolerate an SSRI. SSRIs cannot be used for anxiety on an as needed basis, whereas short-acting benzodiazepines may be useful for this purpose. Psychosocial treatments of both depression and anxiety have also been under-studied, with probable benefits and a benign adverse effect profile.

Comparative efficacy and acceptability of antidepressants in Parkinson's disease: a network meta-analysis

Background

Depression is a common non-motor symptom in patients with Parkinson's disease (PD). There are many kinds of antidepressants being used, such as tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), and Dopamine agonists which are suggested as alternative antidepressants for the treatment of depression in PD. Which one should we choose first? Literatures have shown inconsistent results.

Methods

We conducted a network meta-analysis of randomized controlled trials to compare the efficacy and acceptability of therapeutic methods for the treatment of depression in Parkinson's disease.

Results

We used the odds ratios (OR) as effect size firstly and the results indicated no statistical significance between each compared intervention. Then we used the logarithm of the individual odds ratios as effect size. With efficacy of TCAs as the standard of comparison, the degree of incoherence (a measure of how closely the entire network fits together) was small (ω =  4.824827e-05). The logor were: SSRIs −0.69 (95% CI −1.28– −0.10); Pramipexole −0.73 (−1.71– −0.26); Pergolide −1.97 (−3.67– 0.27); SNRIs −0.86 (−1.86– 0.15); Placebo −1.24 (−1.99– −0.50). With Placebo as the standard of comparison, the logor were: TCAs 1.24 (0.50– 1.99); SSRIs 0.55 (−0.03– 1.13); Pramipexole 0.51 (−0.12– 1.15); Pergolide −0.73 (−2.25– 0.80); SNRIs 0.38 (−0.42– 1.19); TCAs, pramipexole, pergolide and SNRIs showed better profile of acceptability, leading to significant fewer discontinuations than that of SSRIs.

Conclusions

There is insufficient evidence to support antidepressant efficacy for SSRIs, pramipexole, pergolide and SNRIs. TCAs might be the best choice when starting antidepressant treatment in patients of Parkinson's disease because it has the most favorable balance between benefits and acceptability, followed by pramipexole and SNRIs, SSRIs might be the last choice.

[Depression in Parkinson's disease]

The frequency of depression in patients with Parkinson's disease is approximately 30-40%. Depression has a significantly negative impact on the QOL in Parkinson's disease patients. It leads to the worsening of tremors and frozen gait without disease progression and decreases the patient's motivation to participate in rehabilitation. The distinguishing feature of depression in patients with Parkinson's disease is that guilt, self-blame and suicidal ideation are rarely seen compared to that observed in patients with major depression. Depression can occur in the pre-motor, diagnostic and advanced stages of Parkinson's disease. In particular, patients with wearing-off symptoms are apt to develop anxiety. As for treatment, it is very important to optimize dopamine replacement therapy. Antiparkinsonian drugs may have beneficial effects not only on the motor symptoms of the disease, but also the patient's mood. Cognitive behavioral therapy (CBT) and peer counseling may also be beneficial.