clinical depression and pd: alan bonander speaks from the archives

[janet paterson <janet313@xxxxxxxxxxx>]

======================================================================
Post: 008396
Date: Sun, 28 Jan 1996
From: Alan Bonander
Subj: Depression in PD
--------------------------------------------------------------------

Please read this slowly and understand that I am learning how to put a "gut 
brain" together with a "normal" brain, finding pain in places where none 
exists.  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 d       epressioninParkinson'sdisease.Pleasereadslowly.

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 form 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, antidepressants 
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 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-convulsive therapy 
(ECT), antidepressants, exercise and stimulants.  Only two will be discussed -- 
antidepressants and ECT.  Drugs used are the following:

Antidepressants Used in Parkinson's Disease
   Tricyclic
        Elavil (amitriptyline)
        Tofranil (lmipramine)
        Pamelor (nortriptyline)
        Norpramiln (desipramine)
        Sinequan (doxepin)
   Monoamine oxidase inhibitors (A & B)
   Electroshock therapy (ECT)
   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 antidepressant that is not good for PD patients is 
Asenden (amoxapine) because of its dopamine receptor blockade function.

REMEMBER: Antidepressants take time to work

Antidepressants 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 antidepressant 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 antidepressants, 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 antidepressants or has a poor tolerance or compliance with 
antidepressant 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


Regards,
Alan Bonander
Age 55, Diag 12 yrs, liquid meds, pallidotomy
======================================================================


we lost alan bonander to asthma almost four years ago
he is missed


janet


janet paterson
53 now / 41 dx / 37 onset
613 256 8340 / PO Box 171 Almonte Ontario K0A 1A0 Canada
come visit my website "a new voice" at:


janet paterson
53 now / 41 dx / 37 onset
613 256 8340 / PO Box 171 Almonte Ontario K0A 1A0 Canada
come visit my website "a new voice" at: