Laura Marsh

Anxiety disorders are common in Parkinson's disease (PD), but are not well characterized. This study determined the prevalence and clinical correlates of all DSM‐IV‐TR anxiety disorder diagnoses in a sample of 127 subjects with idiopathic PD who underwent comprehensive assessments administered by a psychiatrist and neurologist. A panel of six psychiatrists with expertise in geriatric psychiatry and/or movement disorders established by consensus all psychiatric diagnoses. Current and lifetime prevalence of at least one anxiety disorder diagnosis was 43% (n = 55) and 49% (n = 63), respectively. Anxiety disorder not otherwise specified, a DSM diagnosis used for anxiety disturbances not meeting criteria for defined subtypes, was the most common diagnosis (30% lifetime prevalence, n = 38). Compared with nonanxious subjects, panic disorder (n = 13) was associated with earlier age of PD onset [50.3 (12.2) vs. 61.0 (13.7) years, P < 0.01], higher rates of motor fluctuations [77% (10/13) vs. 39% (25/64), P = 0.01] and morning dystonia [38% (5/13) vs. 13% (8/62), P < 0.03]. This high prevalence of anxiety disorders, including disturbances often not meeting conventional diagnostic criteria, suggests that anxiety in PD is likely underdiagnosed and undertreated and refined characterization of anxiety disorders in PD is needed. In addition, certain anxiety subtypes may be clinically useful markers associated with disease impact in PD. © 2009 Movement Disorder Society

Valid tools are needed to assess depression across the spectrum of cognitive impairment in Parkinson's disease (PD). The validity of the Cornell scale for depression in dementia (CSDD) was tested in a PD sample with a range of cognitive impairment. Psychiatric diagnoses were established according to DSM‐IV‐TR. Receiver operating characteristic curves tested the discriminant validity of the CSDD compared to the clinical diagnoses of major and minor depression. The curve for symptomatic depression had an area under the curve of 0.82. For the cut‐off score ≥ 6, sensitivity was 0.83 and specificity was 0.73; for the cut‐off score ≥ 8, sensitivity was 0.75 and specificity was 0.82. There was no evidence for differential measurement with respect to cognitive impairment or any other demographic or clinical variables. This study suggests that the CSDD is a valid tool for identifying depressive disorders in patients with PD across a spectrum of cognitive impairment. © 2008 Movement Disorders Society

Executive dysfunction (ED) is a prominent and often disabling feature of cognitive impairment in Parkinson's disease (PD). Few studies have examined treatments. Given the role of noradrenergic pathology in ED, atomoxetine, a norepinephrine reuptake inhibitor indicated for attention deficit hyperactivity disorder (ADHD), may be a potential treatment for PD‐related ED. Twelve patients with PD and disabling ED completed an 8‐week pilot open‐label, flexible dose (25–100 mg/day) trial of atomoxetine. On primary outcome measures, atomoxetine was associated with improved ED based on the Clinical Global Impression‐Change Scale (75% positive response rate; 95% CI: 43–95%, P < 05) and behavioral measures of ED [Frontal Systems Behavior Scale (FrSBE) Executive Dysfunction and Connors Adult ADHD Rating Scale (CAARS) inattention/memory subscales]. Adverse effects included sleep and gastrointestinal disturbances and hypomania. Atomoxetine is tolerable in PD and may benefit clinical manifestations of ED, warranting further study in controlled trials. © 2008 Movement Disorder Society

Mood disorders are the most common psychiatric problem associated with Parkinson's disease (PD), and have a negative impact on disability and quality of life. Accurate diagnosis of depressive disturbances in PD is critical and will facilitate the testing and use of new interventions; however, there are no clear diagnostic criteria for depressive disorders in PD. In their current form, strict Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria are difficult to use in PD and require attribution of specific symptoms to PD itself or the depressive syndrome. Additionally, DSM criteria for major depression and dysthymia exclude perhaps half of PD patients with comorbid clinically significant depression. This review summarizes an NIH‐sponsored workshop and describes recommended changes to DSM diagnostic criteria for depression for use in PD. Participants also recommended: (1) an inclusive approach to symptom assessment to enhance reliability of ratings in PD and avoid the need to attribute symptoms to a particular cause; (2) the inclusion of subsyndromal depression in clinical research studies of depression of PD; (3) the specification of timing of assessments for PD patients with motor fluctuations; and (4) the use of informants for cognitively impaired patients. The proposed diagnostic criteria are provisional and intended to be defined further and validated but provide a common starting point for clinical research in PD‐associated depression. © 2005 Movement Disorder Society

Objective: To determine the prevalence and impact of comorbid psychiatric disturbances in Parkinson disease (PD) patients with psychosis. Methods: Subject data were derived from a research database of 116 PD patients participating in standardized motor, cognitive, psychiatric, and caregiver assessments. Results: There were 25 patients (22%) with psychosis manifest as hallucinations (n = 9), delusions (n = 1), or hallucinations and delusions (n = 15) and 25 patients (22%) who had no current or past psychiatric comorbidities (PDN). In the psychotic group, 44% had psychosis only (PSY), and 56% had psychosis plus at least one other comorbid psychiatric disturbance (PSY+), including depressive disorders (71%), anxiety disorders (21%), apathetic syndromes (14%), and delirium (14%). There were no differences in age, sex, education, or age onset or duration of PD among the PSY, PSY+, and PDN groups. Both psychotic groups had greater motor, functional, and frontal cognitive deficits and increased caregiver burden scores relative to PDN. PSY+ showed greater global and selective cognitive deficits compared to PDN. Psychosis was a primary predictor of caregiver burden, whereas depressive symptoms indirectly enhanced motor impairments. Conclusions: Nonpsychotic psychiatric disturbances, especially affective disturbances, are common comorbidities in PD patients with psychosis and warrant clinical attention to reduce morbidity and caregiver distress.

Psychotic symptoms are common and can be a major therapeutic challenge in patients with Parkinson’s disease (PD). PD-related psychosis is usually characterized by visual hallucinations or delusions and is most often induced by antiparkinsonian medications. However, other medical conditions, psychoactive medications, sleep disturbances, mood disorders, and cognitive impairments are relevant risk factors. Patients with PD should be continually monitored for factors that can trigger the development of psychotic symptoms, including minor symptoms. This includes ongoing critical re-evaluation of the therapeutic regimen, with adjustments as indicated to optimize function across motor, cognitive, and psychiatric domains. Treatment strategies to reduce psychotic symptoms are determined by the clinical picture. “Benign” symptoms may require only education and reassurance. Antipsychotic medications are required for disabling symptoms and emergency hospitalization may be required for agitation that affects the safety of the patient or others. Medication management is often complex and includes elimination or reduction of antiparkinsonian agents (although this can compromise motor function), management of medical comorbidities, and use of atypical antipsychotics. Clozapine and quetiapine are regarded as the most safe and effective atypical neuroleptics in PD patients. Cholinesterase inhibitors can enhance cognition and may reduce psychotic symptoms.

Psychiatric disturbances are a common feature of Parkinson’s disease (PD), which is a degenerative disorder defined by its characteristic movement abnormalities. Its management is optimal when PD is viewed as a neuropsychiatric disorder, because this encourages consideration of the motor deficits along with its psychiatric and cognitive aspects. This review addresses the diagnosis and treatment of the most common psychiatric disorders in PD, and provides an update of related clinical research, including studies on neurosurgical treatments.