On another page on this website, we discussed why depression in Parkinson’s disease is an important topic, noted that depression commonly goes undiagnosed and untreated in these patients, and shared some tips on diagnosing depression in persons with Parkinson’s disease. Please see the following article on this website:
On this page, we’ll discuss how to treat major depression in these patients.
What’s special about this situation?
As in other persons, major depression in persons with Parkinson’s disease may be treated with an antidepressant medication, cognitive-behavior therapy, or a combination of both. So, why do we need to discuss the treatment of depression in these patients as a special topic?
1. MAO-B inhibitors (selegiline, rasagiline, safinamide) and dopamine agonists (pramipexole, ropinirole, rotigotine), which are used as treatments for Parkinson’s disease, can be sufficient as treatments for the depression as well.
2. These patients can have more side effects from some antidepressants compared to most other patients with major depression.
3. Though SSRIs are the most commonly used antidepressants in these patients, bupropion and SNRIs may have advantages over SSRIs in these patients,
For most patients, the first-line antidepressant can be bupropion, an SNRI, an SSRI, or mirtazapine. There isn’t just one “antidepressant of choice” for depression in Parkinson’s disease.
To help decide which specific medication to recommend, we’ll discuss some factors that may be considered.
As of March 2021, bupropion has not been specifically studied in a randomized clinical trial for the treatment of depression in patients with Parkinson’s disease. It can have pros and cons as an antidepressant in persons with Parkinson’s disease;
– Due to its dopaminergic activity, it may improve the symptoms of Parkinson’s disease (Goetz et al., 1984).
– It is believed to be less likely than other antidepressants to cause or worsen restless legs syndrome or REM sleep behavior disorder in these patients.
– But, it may worsen psychotic symptoms.
In general, in these patients, bupropion may be a better choice than SSRIs, unless psychotic symptoms are present.
SSRIs and SNRIs
SSRIs are the most commonly used antidepressants in patients with Parkinson’s disease (Lattoo et al., 2012), but this doesn’t mean that they are necessarily the best choice.
Possible worsening of motor symptoms
SSRIs and SNRIs can sometimes worsen motor symptoms in persons with Parkinson’s disease (Agüera-Ortiz et al., 2021), but this is not common and, so, we don’t have to avoid SSRIs in these patients.
It is thought that sertraline may be least likely to worsen motor symptoms in these patients, though this has not been specifically shown in a controlled clinical trial (as of March 2021). Still, in a systematic consensus study, experts agreed that, in general, sertraline is the best-tolerated SSRI in patients with Parkinson’s disease (Agüera-Ortiz et al., 2021). Note: This does not mean that we can’t use other SSRIs in these patients.
Possible drug interactions
Since patients with Parkinson’s disease are likely to be on other medication (which may change over time) and drug interactions can occur, the effects of particular antidepressants on P450 enzymes is another factor that can help choose between antidepressants. For example, among the SSRIs, fluoxetine, paroxetine, and fluvoxamine are potent inhibitors of certain P450 enzymes.
Tricyclic antidepressants (TCAs)
TCAs can be considered as a second-line treatment option for the treatment of major depression in persons with Parkinson’s disease.
Note: Person’s with Parkinson’s disease may be more likely than others to have certain side effects of TCAs:
– Orthostatic hypotension
– Cognitive impairment due to anticholinergic effects.
In a systematic consensus study, experts agreed that, in general, nortriptyline is the best-tolerated TCA in patients with Parkinson’s disease (Agüera-Ortiz et al., 2021).
Also, in a placebo-controlled clinical trial in about 50 patients (which, in this population, is considered to be a big study), nortriptyline was more effective than paroxetine (Menza et al., 2009).
Electroconvulsive therapy (ECT)
As in other patients with difficult-to-treat major depression, ECT may be used in persons with Parkinson’s disease. The motor symptoms of Parkinson’s disease may also improve with ECT but this improvement is usually temporary.
Major depression is common in persons with Parkinson’s disease and had a huge impact on these patients.
But, as of March 2021, research has not clearly established the efficacy of antidepressants for treating major depression in persons with Parkinson’s disease. Also, if an antidepressant is prescribed, it is not clear which ones should be used first-line.
MAO-B inhibitors (selegiline, rasagiline, safinamide) and dopamine agonists (pramipexole, ropinirole, rotigotine), which are used as treatments for Parkinson’s disease, can be sufficient as treatments for the depression as well.
Among the antidepressants, in clinical practice, SSRIs, SNRIs, bupropion, and mirtazapine are commonly used.
Lastly, let’s not forget psychotherapy for these patients, especially when the depression is not severe. The research evidence for psychotherapy as a treatment for depression in people with Parkinson’s disease is uncertain. But, a study that interviewed many physicians and a small number of patients with Parkinson’s disease noted the following (Goodarzi et al., 2018):
“Both the movement disorder neurologists and patients with [Parkinson’s disease] discussed dramatic improvement with psychotherapy, in some cases more so than with medications, which resulted in physicians being surprised that the recommendation for non-pharmacologic therapy in PD was uncertain.”
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