Review
Psychosis, apathy, depression and anxiety in Parkinson's disease

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Abstract

Psychiatric symptoms are important non-motor features in PD, which occur at high frequency and have significant impact on health related quality of life. This review concentrates on the prevalence, pathophysiology, diagnosis and treatment of depression, anxiety, apathy and psychosis. The pathophysiology of these disorders is complex, reflecting the widespread brainstem and cortical pathology in PD, with involvement of several neurotransmitters, including dopaminergic, serotonergic, noradrenergic and cholinergic systems. The diagnosis of psychiatric conditions, in particular affective disorders, is challenging because of the overlap of somatic features of psychiatric disorders and underlying movement disorder. The pathogenesis is likely to differ considerably from non-PD patients, and treatments used in general psychiatry services may not be as effective in PD and will require clearer clarification in well-designed clinical studies. Management strategies include adjustment of dopaminergic medication, use of psychotropic treatments and behavioural and psychological approaches. However, the future challenge will be to develop treatments developed specifically for the pathogenesis of these disorders in PD.

Introduction

Psychiatric symptoms are common in Parkinson's disease, occur at higher prevalence than in age-matched controls and have significant impact on quality of life (Barone et al., 2009, Chaudhuri et al., 2006, Gallagher and Schrag, 2008, Gallagher et al., 2010). They include depressive disorders, anxiety, apathy, psychosis and impulse control disorders (ICD) and dopamine dysregulation syndrome (DDS). We here review the prevalence, pathophysiology, diagnosis and treatment of the affective disturbances, apathy and psychosis.

Section snippets

Prevalence

Establishing the prevalence of disorders of mood, motivation and anxiety in PD is complicated by the symptomatic overlap between the somatic features of the neuropsychiatric and underlying movement disorder, differences in the phenomenology of these disorders in PD (dPD) and the general population, frequently coexisting cognitive problems, psychiatric side effects of dopaminergic medication, the presence of motor and non-motor fluctuations and the different diagnostic frameworks available

Depression, anxiety and apathy

Clinically, a number of factors have been associated with depression in PD. These include younger age of symptom onset, longer disease duration, increased motor severity, motor complications (fluctuations and dyskinesias), disease stage (Hoehn and Yahr), disability (Schwab and England), dopaminergic medication (higher Levodopa equivalent dose), and motor subtype (particularly postural instability gait difficulty, PIGD) (Dissanayaka et al., 2011). Other associations include co-existing

Depression

Diagnostic frameworks for depression include DSM criteria for major, minor or subsyndromal depression and the International Statistical Classification of Diseases and Related Health Problems (criteria for a mild, moderate or severe depressive episode. DSM-IV-R diagnosis of major depression requires one or more of the two core criteria (depressed mood, loss of interest or pleasure), and a total of five or more symptoms including significant weight change, insomnia or hypersomnia, psychomotor

Depression

Pharmacological agents used for depression in general psychiatry practice, including tricyclic antidepressants (TCA), the tricyclic-related drugs (e.g. trazodone), the selective serotonin reuptake inhibitors (SSRIs), the serotonin and noradrenaline reuptake inhibitor venlafaxine, the selective noradrenaline reuptake inhibitor reboxetine, the presynaptic alpha-2 adrenoreceptor antagonist mirtazapine and the noradrenaline–dopamine reuptake inhibitor (NDRI) bupropion may all have a role in

Conclusion

Depression, anxiety, apathy and psychosis are important non motor symptoms in PD. The pathophysiology of these disorders is likely to relate to widespread brainstem and cortical neuronal loss and LB deposition, with involvement of different neurotransmitter systems, including dopaminergic, serotonergic, cholinergic and adrenergic transmission. The pathology of affective disorders in PD may be distinct from depression, anxiety and apathy in non-PD subjects, and there are particular challenges in

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