Parkinson's disease and anxiety: comorbidity with depression.

Parkinson's disease (PD) is frequently accompanied by symptoms of depression and anxiety. However, the relationship between anxiety and depression has not been rigorously defined in these patients. In this study, 42 patients with PD and 21 matched medical controls were evaluated using DSM-III-R criteria and a variety of psychiatric rating scales. Twelve (29%) PD patients but only one medical control had a formal anxiety disorder diagnosis. Of the 12 patients with PD who had an anxiety disorder diagnosis, 11 (92%) had a comorbid depressive disorder diagnosis. Of the 18 patients with a depressive disorder, 12 (67%) also had an anxiety disorder diagnosis. Furthermore, a stepwise regression analysis found that the depression measure explained 44% of the variance in anxiety measures whereas neither the severity of illness variables nor the levodopa dose contributed significantly to the variance. This study suggests that the excess anxiety found in PD patients is unlikely to be primarily a psychologic reaction to the illness or a side effect of levodopa treatment. Rather, we suggest that anxiety and depression are related manifestations of the underlying neurochemical changes of PD itself.

Smoking and movement disorders in psychiatric patients.

Previous studies have suggested that tardive dyskinesia may occur more frequently in patients who smoke. Further evidence of an interaction between smoking and movement disorders includes the low lifetime exposure to cigarettes found in Parkinson's disease patients. In this study 126 patients with chronic psychiatric illnesses were blindly evaluated for tardive dyskinesia, neuroleptic-induced parkinsonism, and akathisia. Patients who smoked received significantly higher doses of neuroleptics but did not have significantly more frequent or more severe tardive dyskinesia or parkinsonism. Female smokers did have significantly more akathisia. These results are discussed with regard to interactions between smoking, central dopaminergic tone, and the psychopathology of extrapyramidal syndromes. The effect of smoking on neuroleptic blood levels as well as clinical symptomatology is also discussed.

Treatment of erectile dysfunction in men with depressive symptoms: results of a placebo-controlled trial with sildenafil citrate.

OBJECTIVE: Depressed men commonly have erectile dysfunction, and men with erectile dysfunction are frequently depressed. Since the etiologic and modulatory relationships between depression and erectile dysfunction have been poorly characterized, a 12-week, randomized, double-blind, placebo-controlled trial was conducted at 20 urologic clinics to evaluate the effects of sildenafil treatment in men with erectile dysfunction and mild-to-moderate comorbid depressive illness. METHOD: Men (N=152, mean age=56 years) with erectile dysfunction for > or =6 months (mean=5.7 years), a DSM-IV diagnosis of depressive disorder not otherwise specified, and a Hamilton Depression Rating Scale score > or =12 (mean at baseline=16.9) were randomly assigned to flexible-dose treatment with sildenafil citrate or matching placebo. Interviewer-rated and self-report instruments were used to assess changes in sexual function, depressive symptoms, and quality of life. Conservative criteria were used to classify erectile dysfunction treatment response and nonresponse. RESULTS: Sildenafil was strongly associated with erectile dysfunction treatment response. Fifty-eight men met the conservative criteria for response (48 given sildenafil, 10 given placebo), and 78 men did not respond (18 given sildenafil, 60 given placebo). Mean decreases of 10.6 and 2.3 in Hamilton depression scale scores were seen in treatment responders and nonresponders, respectively; 76% of treatment responders showed a > or =50% decline in Hamilton depression scale score versus 14% of nonresponders. Quality of life was similarly improved in treatment responders. CONCLUSIONS: Sildenafil is efficacious for erectile dysfunction in men with mild-to-moderate depressive illness. Improvement of erectile dysfunction is associated with marked improvement in depressive symptoms and quality of life.

Dopamine-related personality traits in Parkinson's disease.

Studies suggest that Parkinson's disease (PD) is associated with a particular group of personality characteristics. With relative uniformity, PD patients are described as industrious, rigidly moral, stoic, serious, and nonimpulsive. In this controlled study, we used a recently developed personality questionnaire, Cloningers's Tridimensional Personality Questionnaire, to test the hypothesis that these personality traits are behavioural manifestations of damaged dopaminergic pleasure and reward systems. We found significantly less (p < 0.01) of a group of traits called "novelty seeking" in PD patients compared with matched medical controls. Patients with low novelty seeking are described as being reflective, rigid, stoic, slow-tempered, frugal, orderly, and persistent, characteristics similar to those in the clinical description of PD patients. We review evidence supporting the claim that novelty seeking is dopamine-dependent, and suggest that damage to the mesolimbic dopaminergic system causes the described personality profile of PD patients.

Modafinil augmentation of antidepressant treatment in depression.

BACKGROUND: Despite a relative lack of controlled data, stimulants are often used to augment antidepressant treatment in patients who have had only a partial response to first-line therapy. Modafinil is a novel psychostimulant that has shown efficacy in, and was recently marketed for, treating excessive daytime sleepiness associated with narcolepsy. The mechanism of action of modafinil is unknown, but, unlike other stimulants, the drug is highly selective for the central nervous system, has little effect on dopaminergic activity in the striatum, and appears to have a lower abuse potential. METHOD: In this retrospective case series, we describe 7 patients with DSM-IV depression (4 with major depression and 3 with bipolar depression) for whom we used modafinil to augment a partial or nonresponse to an antidepressant. The Hamilton Rating Scale for Depression was administered as part of routine clinical practice prior to treatment and at each subsequent visit. RESULTS: At doses of 100 to 200 mg/day, all 7 patients achieved full or partial remission, generally within 1 to 2 weeks. All patients had some residual tiredness or fatigue prior to starting modafinil, and this symptom was particularly responsive to augmentation. Side effects were minimal and did not lead to discontinuation of the drug in any of the patients. CONCLUSION: Modafinil appears to be a drug with promise as an augmenter of antidepressants, especially in patients with residual tiredness or fatigue. It is a particularly attractive alternative to other stimulants because of its low abuse potential and Schedule IV status.

Decreased extrapyramidal symptoms with intravenous haloperidol.

In a preliminary, prospective study, the intensity of extrapyramidal symptoms was rated in four patients receiving intravenous haloperidol and six patients receiving oral haloperidol. The raters were blind to the route of administration. In this pilot study, the first systematic evaluation of intravenous haloperidol and extrapyramidal symptoms, the patients receiving intravenous haloperidol experienced significantly (p less than .01) less intense extrapyramidal symptoms than did the patients receiving oral haloperidol. The literature on intravenous haloperidol is briefly reviewed, and possible explanations of the lower intensity of extrapyramidal symptoms with intravenous haloperidol in the patients studied are discussed.

Association of a serotonin transporter gene promoter polymorphism with harm avoidance behaviour in an elderly population.

A polymorphic 44-nucleotide insertion/deletion in the promoter region of the serotonin transporter gene (5-HTTLPR) has been shown to affect the level of expression of the serotonin transporter protein. An association between anxiety-related behavioural traits and the short form of the 5-HTTLPR has been reported. We determined the 5-HTTLPR genotype in genomic DNA samples from 84 subjects (47 Parkinson's disease patients and 37 controls) with a mean age of 67.4 years. The TPQ of Cloninger was used to obtain values for harm avoidance (HA), reward dependence and novelty seeking for all subjects. Analysis of variance showed a significant influence of the s-allele of the 5-HTTLPR on HA in both subject groups, with no significant interaction between diagnosis and genotype. Subjects with the l/l-genotype had significantly lower mean HA scores than the l/s subjects (P < 0.04) and s/s subjects (P < 0.003). A linear change in HA with genotype was observed, indicating a gene dose effect of the 5-HTTLPR s-allele on this personality dimension. Based on these findings it is suggested that there may be increased influence of the 5-HTTLPR short allele on anxiety-related traits during aging.

Quality of life, mood, and sexual function: a path analytic model of treatment effects in men with erectile dysfunction and depressive symptoms.

Erectile dysfunction (ED) is commonly associated with depressed mood and diminished quality of life (QoL), but few studies have investigated the causal associations involved. Therefore, we evaluated the correlation between several measures of mood, QoL, and sexual function in a retrospective analysis of a sample of depressed men (n=152), with ED enrolled in a clinical trial of sildenafil citrate (VIAGRA). Strong correlations were observed at baseline among measures of erectile function (EF), mood, and overall QoL. Significant treatment effects were observed on all three domains, with significant interactions between changes in mood and QoL. Based on multiple regression and path analysis, a model was developed in which EF changes were associated with improved mood and quality of sexual life, which resulted in improved partner satisfaction, family life, and overall life satisfaction. These data suggest that QoL changes associated with ED therapy may be mediated by changes in sexual function, mood, and family relationships.

Depression and anxiety in Parkinson's disease: possible effect of genetic variation in the serotonin transporter.

Recently, a functional polymorphism in the promoter region of the serotonin transporter gene has been linked to anxiety. In cell culture, the short allele of this polymorphism synthesizes less serotonin transporter, resulting in a reduction of the removal of serotonin from the synaptic cleft. This pilot study examines depression and anxiety in Parkinson's disease patients as a function of the variation in this polymorphism. Thirty-two patients were genotyped and then blindly administered the Hamilton Depression and Anxiety Scales. Clinical data on the neurologic features of the disease were also gathered. Patients with the short allele of the serotonin transporter promotor scored significantly higher on both the depression and anxiety measures. There were no differences between groups for any neurologic variable. Patients with the short allele were more likely to have scores for anxiety and depression that indicated "caseness." This study suggests that the short allele of the serotonin transporter gene may represent a significant risk factor for the development of anxiety and depression in Parkinson's disease patients.

Psychiatry in the geriatric neurology practice.

This article provides a brief overview of the psychiatric syndromes most common in the elderly patient, as well as those most frequently accompanying neurologic disease. Diagnosis, work up, and treatment of depressive, psychotic, and anxiety disorders are also reviewed. This article is directed toward the practicing neurologist, with an emphasis on detection and treatment. Special attention is paid to psychiatric syndromes that accompany Parkinson's disease, stroke, and dementia. A brief review of the most common psychopharmacological agents is included as well.

Treatment of anxiety associated with electrophysiologic studies.

Programmed electrical stimulation, also known as electrophysiologic studies (EPS), is a cardiologic technique used to help guide physicians in their management of selected patients with cardiac arrhythmias. Data are presented for 14 consecutive patients undergoing EPS seen in psychiatric consultation who had a diagnosis related to anxious mood. Successful management strategies, which evolved from work with these patients, included psychologic approaches (supportive psychotherapy and education) and psychopharmacologic agents (most commonly alprazolam). EPS and related physiologic aspects of anxiety and stress are briefly reviewed.

Controlled study of extrapyramidal reactions in the management of delirious, medically ill patients: intravenous haloperidol versus intravenous haloperidol plus benzodiazepines.

In a prospective study, the intensity of extrapyramidal symptoms (EPS) was rated in two groups of delirious, medically ill patients. Fourteen patients received intravenous (IV) haloperidol and benzodiazepines for control of severe agitation and four received IV haloperidol alone. Patients were rated daily by a standardized scale for EPS by raters blind to the dose of haloperidol and benzodiazepines. Patients receiving haloperidol and benzodiazepines had significantly (p less than 0.001) less EPS than patients receiving IV haloperidol alone. In the haloperidol and benzodiazepine group there were only one case of very mild parkinsonian-like EPS and no cases of akathisia or dystonia. No adverse respiratory or cardiac reactions were seen in any patients. The literature on the use of IV haloperidol alone and in combination with benzodiazepines is briefly reviewed and possible explanations of the lower intensity of EPS with IV haloperidol in combination with benzodiazepines are discussed.

Somatoform disorders: diagnosis and treatment.

Somatoform disorders are a group of syndromes in which patients focus on and complain of physical symptoms when there is no demonstrable underlying organic pathology or when complaints are in excess of what is expected. Medical and psychiatric physicians must seek better treatment and diagnosis.

Parkinson's disease and depression: the relationship to disability and personality.

In a study of 104 patients with Parkinson's disease (PD) and 61 control subjects with equal disability scores, PD patients had higher depression scores (P < 0.001) than control subjects. Functional disability was correlated with depression in PD and, in a regression analysis, explained 9% of the variance in depression (P < 0.001). Depression was not correlated with novelty seeking, a personality trait related to dopaminergic pleasure and reward systems. Harm avoidance, a trait related to central serotonergic systems, was, however, correlated with depression (P < 0.001) and explained 31% of the variance in depression scores. Results support the hypotheses that both physiologic and psychologic factors contribute to depression seen in these patients and that serotonergic function plays a more critical role than dopaminergic function.