depression and parkinson disease: an old drug still works (better) summary and comment by jonathan...

Depression and Parkinson Disease: An Old Drug Still Works (Better)

Summary and Comment by Jonathan Silver, MD

Published in Journal Watch PsychiatryFebruary 9, 2009

Tricyclics remain a good choice for depressed patients with neurologic disease.

Copyright © 2009. Massachusetts Medical Society. All rights reserved.

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Covering

• Menza M et al. A controlled trial of antidepressants in patients with Parkinson disease and depression. Neurology 2008 Dec 17; [e-pub ahead of print]. (http://dx.doi.org/10.1212/01.wnl.0000336340.89821.b3)

• Okun MS and Fernandez HH. Will tricyclic antidepressants make a comeback for depressed Parkinson disease patients? Neurology 2008 Dec 17; [e-pub ahead of print]. (http://dx.doi.org/10.1212/01.wnl.0000338145.24512.02)



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Background

• Few double-blind, placebo-controlled treatment trials exist regarding depression in patients with neurological disorders.

• Using a strong study design with both active and placebo controls, researchers compared outcomes after 8 weeks’ treatment with paroxetine CR, nortriptyline, and placebo in 52 cognitively intact patients with Parkinson disease and major depression (mean age, 63; 25 women).



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The Research

• Paroxetine was started at 12.5 mg/day (maximum dose, 37.5 mg/day; average dose, 28.4 mg/day).

• Nortriptyline was started at 25.0 mg/day (maximum dose, 75.0 mg/day; average dose, 48.5 mg/day).

• Completion rates were similar in the three groups.



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The Research

• At 8 weeks, nortriptyline was superior to placebo in the main outcome measure (change from baseline on a standardized depression scale) and to both placebo and paroxetine in response rates (53% vs. 24% and 11%, respectively).

• Remission rates were 41%, 17%, and 12%, respectively.

• Nortriptyline also had greater efficacy for symptoms of sleep, anxiety, and social functioning.

• The authors reported no evidence of drug effect on cognitive tests but did not present specific results.

• Paroxetine was associated with more side effects than placebo.

• The most common were constipation and dry mouth with nortriptyline and fatigue with paroxetine.



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Comment

• These results demonstrate the efficacy of an old drug and the importance of using active controls in research.

• Not all antidepressant classes have equal efficacy, and newer drugs are not necessarily better than older ones.

• Interestingly, a study of poststroke depression published several years ago showed that nortriptyline was more effective than fluoxetine, which was only as effective as placebo.

• Unfortunately, tricyclic antidepressants are infrequently used today, and psychiatric trainees seem to have little experience in prescribing this class of medication.



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Comment

• The anticholinergic properties of nortriptyline can be problematic to patients with cognitive problems.

• Paroxetine’s anticholinergic profile, however, is similar to nortriptyline’s and is greater than that of any other SSRI.

• Editorialists discuss issues related to design of this study and others on antidepressants in Parkinson disease.



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depression and parkinson disease: an old drug still works (better) summary and comment by jonathan...

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