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EDITORIAL
Depression is a common psychiatric non-motor symp- SSRIs sertraline is characterized by a low selectivity
tom occurring in ParkinsonÕs disease (PD) and nega- for serotonin relative to dopamine reuptake, suggesting
tively affecting patientsÕ quality of life and disability [1]. a favorable efficacy profile. One recent randomized
There is large variability in depression prevalence rates study showed that sertraline treatment in PD is safe
and this is related to overlap with motor features, dif- and unlike the tricyclic antidepressant amitriptyline
ficulties in the evaluation of cognitively impaired pa- improves quality of life, particularly activities of daily
tients and lack of scales specifically designed and living, mobility, and stigma [11].
validated for PD. In a prospective study, Hughes et al. In the current issue of the journal, Kulisevsky
[2] reported that presence of depression and dementia et al.[12] report the results of 6-month prospective
were important predictors of mortality in PD subjects evaluation of serterline therapy in a large cohort of 310
followed for over 11 years. In a cohort of 114 PD depressed PD patients at various disease stages and
patients, Weintraub et al. [3] found that depression and recruited from over 50 Spanish movement disorder
cognitive impairment were associated with altered centers. Interestingly, the authors found that sertraline
functional ability, in addition to psychosis, age, PD treatment not only improved depression but also
duration, apathy, sleepiness, and motor impairment. resulted in motor benefit as expressed by changes in
Nuti et al. [4] reported in a population of 90 PD sub- both total Unified Parkinson’s disease Rating Scale
jects that depression and dysthymia (diagnosed (UPDRS) and sub-scores including motor. Only a few
according to DSM-IV criteria) were present in 40% of patients noticed increase of tremor amplitude. The
cases with associated generalized anxiety (11%) and study is important given the large number of included
panic disorder (30%). Finally, Chaudhuri et al. [5] used subjects. However, patients were not randomized and
a specific questionnaire (NMS Quest) to assess non- neurologists were allowed changes in dopaminergic
motor symptoms and reported that sadness was present therapy during the observation period making inter-
in 44.7% of PD versus 26% controls. pretation of the results somehow controversial.
Despite the relevance of depression in PD, there is Nonetheless, these findings are complementary to
little evidence for efficacy and safety of antidepressant those of a randomized study showing that pramipexole,
therapies and trials assessing effectiveness of individual a dopamine agonist with high affinity for D3 receptors,
drugs are mostly open-label, non-randomized, and improved both mood and mobility in a cohort of PD
limited to small patient cohorts [6]. A Cochrane review patients on stable levodopa monotherapy [13].
published in 2003 on the treatment of depression in PD Some considerations should now be drawn: first,
found only three randomized controlled trials on anti- depression has gained clinical relevance in PD and
depressant medications for a total of 106 patients [7]. application of a revised version of UPDRS along with
The authors concluded that available data on the specific questionnaires and scales will help recognition
effectiveness of antidepressant therapies in PD were of affected patients. Secondly, depression affects quality
insufficient and no recommendation was possible for of life and patient self-perception of motor function and
their use. this further emphasizes the need for treatment. Thirdly,
This may explain why depression in PD is under- SSRIs and in particular sertraline have now demon-
treated, at least according to some recent large surveys. strated good safety and tolerability for clinical use and
The Parkinson Study Group collected data on 23 000 they may be considered first line in treating PD
PD patients in the USA and found that 26% was on depression. Dopamine agonists are also likely to be
treatment with antidepressant drugs [8]. A recent reg- beneficial and pramipexole is currently evaluated in a
ister-based study in Denmark showed that among double-blind multicentre study. Finally, effectiveness
22 827 patients on anti-Parkinson medications, 19.9% and safety should be confirmed in placebo-controlled
were taking antidepressants [9]. Similarly, a cross-sec- trials. Placebo effect is large in depression and partic-
tional epidemiologic study on non-motor symptoms ularly in PD. A recent study of rotigotine patch in ad-
conducted in selected movement disorder centers in vanced PD reported a 35% responder rate to placebo
Italy (PRIAMO) revealed that only 169 of 1072 PD (vs. 67% to pramipexole and 59.7% to rotigotine) [14].
patients (15.8%) were treated for depression [10]. Therefore, further studies are warranted to fill this
Moreover, serotonin reuptake inhibitors (SSRIs) important gap, ensure best medical therapy to patients
that are frequently used to treat depression have been and provide class I evidence of efficacy for anti-
reported to occasionally worsen parkinsonism. Among depressants in PD.