Case Studies of Mental Health in General Practice(22)
——Parkinson′s Disease and Depression

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With China′s aging population,it was found high prevalence of Parkinson′s disease in the community. According to Zhang and his colleagues,prevalence for Chinese people aged 65 or above was 1.7%[1]. Parkinson′s disease is a problem that that most GPs come across in their clinical practice and depression is highly prevalent affecting approximately 40%-50% of these patients[2].When compared to equivalently disabled patients,the rate of severe depression is doubled[3].There is significant overlap between the symptoms of Parkinson′s disease and depression and therefore distinguishing between the two can be difficult. We recommend screening patients at least once a year for depression as it is commonly under diagnosed and under treated. Without treatment,depression can exacerbate the decline in motor and cognitive function requiring earlier commencement of anti-parkinsonian medications and reduce the patient′s quality of life[4].

1 History

Mrs. Lee comes into your practice concerned that her husband of 40 years has become increasingly withdrawn and irritable. He doesn′t want to go to visit the children or grandchildren,which is very uncharacteristic for him,and hardly leaves the house.In his younger years,Mr. Lee was a school principal and lived a very active life.Ten years ago when he was aged 57 he developed some Parkinsonian symptoms. Initially he noticed a tremor and some stiffness in his left hand and came to see you. In conjunction with the care of a neurologist over the years he was commenced on a range of anti-parkinsonian medications and is currently taking Madopar,which is a combination of Levadopa and Carbidopa,in addition to Selegiline,a dopamine agonist.

Over the last two years his condition has progressed and as a result his motor symptoms fluctuate and the Levadopa does not last as long between doses as it use to. He has particular difficulty with walking and often has trouble getting going. He also has difficulty getting out of the chair and overthe last 12 months he has needed help when getting dressed. This has caused a lot of stress for him and for the family and in particular Mrs. Lee who has been looking after him. A carer comes to help twice a week but Mrs. Lee is feeling the strain of looking after him 24 hours a day.

2 Further history

On further history,Mr. Lee,he tells you that he has trouble sleeping and that he often feels that life is no longer worth living. He denies any suicidal plan per se but says that he feels like he is a big burden on his wife and his family and that he cannot do any of the things that he used to enjoy. As a former school principal he has always loved reading and writing and now he finds that his concentration is so poor he can only get through a few pages of a book and he gets tired and puts it down. He says that he has trouble writing. He also tells you that he finds it very embarrassing that he needs so much help from his wife with the most basic tasks.

3 Examination

On examination Mr. Lee has many of the typical symptoms of Parkinson′s disease. He has the classic mask like face,and his speech is quiet and monotonous and flat. He has difficulty getting out of the chair and walks over to the examination couch with a shuffling gait. He has an obvious tremor in the left-hand and on neurological examination he has the typical cogwheel rigidity associated with Parkinson′s disease. The rest of his physical examination is unremarkable apart from evidence of constipation on abdominal examination.

On mental status examination he is quiet and reserved,sitting in the chair looking down and rarely engages in eye contact. His mood is described as sad,his affect is flat and not reactive. He acknowledges that he has felt life is not worth living but denies any current thoughts about self-harm or suicide. There is no evidence of delusional thinking or hallucinations. He is orientated in time,place and person.

4 Questions

4.1 Question 1:What are the common day to day difficulties that someone with Parkinson′s disease may experience as the disease progresses?

4.2 Question 2:What are key symptoms to look for that may suggest depression in a patient with Parkinson′s Disease?

4.3 Question 3:How are depression and Parkinson′s disease linked?

4.4 Question 4:What treatments are available for depression in Parkinson′s Diseaseand what are key considerations in starting an antidepressant.

4.5 Question 5:What are some important issues surrounding the family and carers in looking after a person with Parkinson′s disease?

5 Answers

5.1 Answer 1:The common day to day difficulties that someone with Parkinson′s disease may experience as the disease progresses The progression of symptoms and disease severity varies from person to person. A unilateral resting tremor is the most common initial symptom noticed,however it does not have to be present for the diagnosis of Parkinson′s disease to be made. This symptom is not particularly disabling,as it does not impair functional use of the hand. As the disease progresses,bradykinesia (slowness of movement),rigidity (stiffness) and gait disturbance occur. Truncal bradykinesia causes walking to be slow and difficulty initiating movements such as rising from a chair,turning in bed and turning around. The impact on mobility is often one of the key frustrations for people experiencing Parkinson′s disease.

Levadopa may result in noticeable improvements in motor symptoms due to increased dopamine levels in the brain. Additionally non-pharmacological measures can be instigated such as using a high chair with armrests. An unfortunate outcome of Levadopa use is the ′wearing off′ effect,as the disease progresses and the availability of dopamine in the brain reduces the doses of levadopa are effective for a shorter period of time. Symptoms therefore fluctuate and are often worsen before next dose. The worsening of motor symptoms includes freezing,which is the transient inability to walk,and unsteadiness,both of which increases the patient′s falls risk.

Despite the archetypal patient being an elderly person with obvious motor symptoms,the frequency of non-motor symptoms is extremely high and can be equally debilitating in patients with newly diagnosed Parkinson′s disease[5-6]. Constipation,nausea and abdominal bloating occur due to the altered autonomic nervous system slowing down the intestinal tract and delaying stomach emptying. Fatigue,sleep disturbance,excessive salivation,hyposmia,urinary urgency and frequency are also early common non-motor symptoms. Mild cognitive impairment can occur as early as the time of diagnosis however,being such subtle changes,such as forgetfulness,it frequently goes unnoticed. The non-motor symptoms demonstrated in later disease include apathy,dementia or serious cognitive disturbance impairing the patients′ capacity to care for themselves.

5.2 Answer 2:Key symptoms to look for that may suggest depression in a patient with Parkinson′s disease The common symptoms of depression such as lowered mood,poor motivation,insomnia,poor concentration and slowing are often present,and should be looked for,however most are also symptoms of Parkinson′s disease. Other symptoms which are usually seen in persons with depression such as fatigue,weight loss,anhedonia and difficulty concentrating may also be seen as part of Parkinson′s disease. An important area requiring special consideration is the symptom of apathy. At the final stages of the disease,in the bradykinetic patients who are unresponsive to Levadopa,apathy is common and often mistaken as depression.

There are,however,some differentiating features. It can be helpful to distinguish between a pervasive depressed mood and fluctuating mood associate with motor fluctuations. Guilt,self blame and suicidal ideations are more frequently associated with depression. Further,looking for other ′depressive cognitions′; such as feelings of worthlessness,hopelessness,and negative view of the future can also help differentiate a depressive disorder.

5.3 Answer 3:How are depression and Parkinson′s disease linked? Depression is quite common in Parkinson′s disease with up to 50% of people experiencing mild to moderate depressive symptoms. Depression as a separate entity is more common in the in the early stages of Parkinson′s disease (first 5 years). The cause of depression early in PD is likely to be a reaction to the psychosocial stressors associated with the physical illness and grief associated with being diagnosed with a chronic progressive disease. Depression may also be linked to Parkinson′s disease through biological mechanisms,particularly deficiency of neurotransmitters,such as serotonin,which is one postulated cause of depression. Another likely contributing factor is the frontal lobe′s role in mood regulation,an area of the brain that is underactive in Parkinson′s disease. Prolonged used of levadopa and disease progression sees the onset off luctuating motor symptoms and dyskinesias. The associated anxiety becomes a driver for anhedonia and consequential depression frequently becomes apparent.

5.4 Answer 4:Treatments available for depression in Parkinson′s diseaseand key considerations in starting an antidepressant The typical grief related depression in early disease can be treated with psychotherapy,which will often negate the need for medications. Cognitive Behaviour Therapy is tremendously effective in changing negative thinking patterns. Interpersonal Therapy and counselling are also useful. The more biological depression affecting the patient′s later on in the disease may require treatment with an antidepressant. Given the frequent co-morbid anxiety,medications with an anxiolytic component or the addition of a mood stabilizer can be useful.

Apathetic patient′s do not respond to antidepressant agents and are better off without the potential risk for adverse effects and drug interactions.

Selective Serotonin Reuptake Inhibitors (SSRIs) are first line antidepressant medications and in clinical practice are the most commonly prescribed antidepressants used to treat depressed patients with Parkinson′s disease. GPs managing depression in patients with Parkinson′s Disease should have a low threshold for referring the patient for specialist assessment and management,especially as some of the anti-parkinsonian medications can have beneficial or detrimental effects on the patient′s mental state.

5.5 Answer 5:Important issues surrounding the family and carers in looking after a person with Parkinson′s disease The GP often is looking after the carer as well as the patient affected by Parkinson′s disease. Being a carer can often disrupt relationships with friends and family due to increased fatigue,psychosocial stressors and often the stigma associated with patient′s suffering from a chronic illness. The carer needs a lot of support to help maintain their own mental and physical health,and there is a risk that they can become isolated form their usual work and social activities without sufficient support. Having access to accurate and comprehensible information about Parkinson′s Disease can be very helpful for carers too. A number of websites provide good quality information about Parkinson′s disease:

http://www.pdf.org；

http://www.parkinsons.org.au；

http://www.parkinson.org；

http://www.mayoclinic.com/health/parkinsons-disease/DS00295；

http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Parkinson′s_disease_explained.

1 Zhang ZX,Roman GC,Hong Z,et al.Parkinson′s disease in China:Prevalence in Beijing,Xi′an,and Shanghai[J].The Lancet,2005,365(9459):595-597.

2 Allain H,Schuck S,Maudui N.Depression in Parkinson′s disease[J].BMJ,2000,320(7245):1287-1288.

3 Remy P,Doder M,Lees A,et al.Depression in Parkinson′s disease:Loss of dopamine and noradrenaline innervation in the limbic system[J].Brain,2005,128(6):1314-1322.

4 Parkinson′s Disease Foundation.Understanding Parkinson′s disease[EB/OL]. http://www.pdf.org.

5 Hauser A.Parkinson disease[EB/OL].http://emedicine.medscape.com/article/1831191-overview.

6 Fernandez HH.Updates in the medical management of Parkinson disease[J].Cleve Clin J Med,2012,79(1):28-35.