Treatment of psychiatric disturbances in hypokinetic movement disorders

ABSTRACT

Introduction: We reviewed studies that assessed the treatment of psychiatric disturbances in Parkinson’s disease and atypical parkinsonisms. Neuropsychiatric disturbances in these conditions are frequent and have a profound impact on quality of life of patients and of their caregivers. It is therefore important to be familiar with the appropriate pharmacological and non-pharmacological interventions for treating these disorders.

Areas covered: The authors searched for papers in English in Pubmed using the following keywords: Parkinson’s disease, multiple system atrophy, progressive supranuclear palsy, corticobasal degeneration, Lewy body dementia, depression, apathy, anxiety, fatigue, sleep disorders, obsessive compulsive disorders, psychosis, hallucinations, delusions, impulse control disorders.

Expert opinion: In Parkinson’s disease, depression may benefit from the optimization of dopaminergic therapy, from the use of antidepressants acting on both the serotoninergic and noradrenergic pathways and from cognitive behavioral therapy. Psychosis in Parkinson’s disease may improve with the use of clozapine; the serotonin inverse agonist pimavanserin has been shown to be effective. Treatment of impulse control disorders is primarily based on the removal of dopamine agonists. No controlled studies have investigated the treatment of neuropsychiatric disorders in multiple system atrophy, progressive supranuclear palsy or corticobasal degeneration. Acethylcholinesterase inhibitors may be used to treat hallucinations in Lewy body dementia.

KEYWORDS:

• Parkinson disease
• multiple system atrophy
• progressive supranuclear palsy
• corticobasal degeneration
• Lewy body dementia
• depression
• impulse control disorders
• hallucinations
• psychosis
• anxiety

Article highlights

• Psychiatric disturbances are frequent in patients with hypokinetic movement disorders and worsen the quality of life and overall disability in such patients

• In Parkinson’s disease, the optimization of dopaminergic medication should be considered as a means of treating depression.

• Studies reviewed show that there are no clear differences in efficacy between the various antidepressants in the treatment of depression in PD. The first approach to the treatment of hallucinations and psychosis in PD should be based on simplifying the dopaminergic treatment; clozapine and quetiapine may then be used as long as any side effects or worsening in motor symptoms are carefully monitored. Olanzapine and aripiprazole must not be used for the treatment of psychosis in PD.

• DBS may be beneficial in the treatment of depression and ICD in some PD patients, but may be associated with a worsening of these psychiatric disturbances in other patients.

• A careful evaluation of risk factors associated with ICD should be part of each clinical assessment in PD patients and guide the choice of treatment.

• If ICDs are present, dopaminergic drug should be reduced and the patient should be carefully monitored for any worsening in the motor symptoms or the development of dopamine agonist withdrawal syndrome.

• No RCT studies exist to guide physicians in the choice of the correct treatment for psychiatric disorders in MSA, PSP, CBD and DLB.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Supplementary material

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Additional information

Funding

This paper was not funded.