Depression: impact and management by the patient and family.

Prodromal personality features possibly presaging PD include excessive introversion, punctuality, and inflexibility. Neurobehavioral symptoms of PD that might complicate recognition and treatment of depression include loss of initiative, social withdrawal, excessive dependency indecisiveness, fatigue, apprehension about new challenges, and agoraphobia. In connection with this last feature, PD patients should be encouraged to venture out of the house because the extrapyramidal motor system, which is compromised in PD, takes over in a relaxed, familiar setting. Thus, Parkinson patients tend to have more symptoms at home than away from home. The deteriorating cognitive function which may occur in some PD patients may exacerbate social withdrawal and certain fears. Features of major depression in parkinsonian depression parallel those of the uncomplicated variety, but loss of appetite/weight and sleep disturbances may be more severe in parkinsonian depression. Serotonin depletion probably underlies the pathophysiology of this condition, in that cerebrospinal-fluid levels of serotonin's terminal metabolite decline to a greater extent in parkinsonian depression than in uncomplicated PD. After establishing the severity of depression, the clinician can contemplate several management approaches: in addition to group psychotherapy, antidepressants (after discontinuation of selegiline to avoid adverse events), particularly tricyclic antidepressants with low anticholinergic action (i.e., low potential for confusion) or selective serotonin reuptake inhibitors may be administered. Depressive symptoms during "off" periods (i.e., at nadirs of drug levels) may be relatively intractable and warrant patient and family education. Finally, electroconvulsive and light therapy represent appropriate therapeutic modalities for selected patients.