Electroconvulsive therapy for depression in Parkinson's disease: systematic review of evidence and recommendations

This report describes the participants and compares the acute and longer-term treatment outcomes associated with each of four successive steps in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial. A broadly representative adult outpatient sample with nonpsychotic major depressive disorder received one (N=3,671) to four (N=123) successive acute treatment steps. Those not achieving remission with or unable to tolerate a treatment step were encouraged to move to the next step. Those with an acceptable benefit, preferably symptom remission, from any particular step could enter a 12-month naturalistic follow-up phase. A score of or=11 (HRSD(17)>or=14) defined relapse. The QIDS-SR(16) remission rates were 36.8%, 30.6%, 13.7%, and 13.0% for the first, second, third, and fourth acute treatment steps, respectively. The overall cumulative remission rate was 67%. Overall, those who required more treatment steps had higher relapse rates during the naturalistic follow-up phase. In addition, lower relapse rates were found among participants who were in remission at follow-up entry than for those who were not after the first three treatment steps. When more treatment steps are required, lower acute remission rates (especially in the third and fourth treatment steps) and higher relapse rates during the follow-up phase are to be expected. Studies to identify the best multistep treatment sequences for individual patients and the development of more broadly effective treatments are needed.

Substantial variation in the prevalence of dementia in Parkinson's disease (PDD) has been reported. The aim of this study was to review systematically and critically previous studies of the prevalence of PDD using PubMed to search the literature. Studies focusing on PD and PDD, as well as those examining on the epidemiology of dementia subtypes, were included. Predefined inclusion and exclusion criteria were used and the quality of the studies included was rated. Articles were included if: (1) the proportion of PDD among patients with either PD or dementia was reported in an original study; (2) patients had been subjected to prospective clinical examination; and (3) strategies to include all subjects with either PD or dementia within the community or hospital clinics within a geographical area were employed. Twelve studies of the prevalence of PD or PDD (1,767 patients included) and 24 prevalence studies of dementia subtypes (4,711 patients included) met the inclusion criteria. In the PD/PDD studies, the proportion (mean and 95% confidence interval) with PDD in PD was 24.5% (17.4-31.5). There were significant methodological variations between studies and in the four studies that matched the quality criteria most closely, the rate of PDD was 31.1% (20.1-42.1). The prevalence of PDD was estimated as 0.5% in subjects 65 years or older. The percentage of PDD among those with dementia was 3.6% (3.1-4.1), with an estimated prevalence of PDD of 0.2% in subjects aged 65 years or older. Despite methodological variation, this systematic review suggests that 24 to 31% of PD patients have dementia, and that 3 to 4% of the dementia in the population would be due to PDD. The estimated prevalence of PDD in the general population aged 65 years and over is 0.2 to 0.5%. Copyright (c) 2005 Movement Disorder Society.

Depression is a common comorbid condition in Parkinson's disease (PD) and a major contributor to poor quality of life and disability. However, depression can be difficult to assess in patients with PD due to overlapping symptoms and difficulties in the assessment of depression in cognitively impaired patients. As several rating scales have been used to assess depression in PD (dPD), the Movement Disorder Society commissioned a task force to assess their clinimetric properties and make clinical recommendations regarding their use. A systematic literature review was conducted to explore the use of depression scales in PD and determine which scales should be selected for this review. The scales reviewed were the Beck Depression Inventory (BDI), Hamilton Depression Scale (Ham-D), Hospital Anxiety and Depression Scale (HADS), Zung Self-Rating Depression Scale (SDS), Geriatric Depression Scale (GDS), Montgomery-Asberg Depression Rating Scale (MADRS), Unified Parkinson's Disease Rating Scale (UPDRS) Part I, Cornell Scale for the Assessment of Depression in Dementia (CSDD), and the Center for Epidemiologic Studies Depression Scale (CES-D). Seven clinical researchers with clinical and research experience in the assessment of dPD were assigned to review the scales using a structured format. The most appropriate scale is dependent on the clinical or research goal. However, observer-rated scales are preferred if the study or clinical situation permits. For screening purposes, the HAM-D, BDI, HADS, MADRS, and GDS are valid in dPD. The CES-D and CSDD are alternative instruments that need validation in dPD. For measurement of severity of depressive symptoms, the Ham-D, MADRS, BDI, and SDS scales are recommended. Further studies are needed to validate the CSDD, which could be particularly useful for the assessment of severity of dPD in patients with comorbid dementia. To account for overlapping motor and nonmotor symptoms of depression, adjusted instrument cutoff scores may be needed for dPD, and scales to assess severity of motor symptoms (e.g., UPDRS) should also be included to help adjust for confounding factors. The HADS and the GDS include limited motor symptom assessment and may, therefore, be most useful in rating depression severity across a range of PD severity; however, these scales appear insensitive in severe depression. The complex and time-consuming task of developing a new scale to measure depression specifically for patients with PD is currently not warranted.