Depression

Depression is a relatively common neurological condition. It may occur on its own (as an episode of major depressive disorder or MDD) or it may occur during the course of another chronic neurological illness such as stroke. It is important that depression be recognized and treated since studies have shown that it increases the morbidity and mortality associated with these conditions.

Sometimes it is difficult to weed out which symptoms are due to depression and which due to the organic brain (neurological) condition. Patients who have fronto-temporal dementia (Pick’s disease), Parkinson’s disease, frontal lobe strokes may look depressed. They are akinetic (do not move spontaneously), have mask like emotionless faces and do not talk readily (abulia). On the first glance it may seem they have depression and not an organic neurological condition.

The point I am making is that depression may mask an underlying neurological condition like dementia or a frontal lobe tumor. The reverse is also true, people who have neurodegenerative conditions may have superimposed depression. Upon treating the depression they feel much better and may improve in caregivers rating scales.

The diagnosis of depression is essentially a clinical one. There are certain clinical features which if present for a sufficient length of time usually 2 weeks suffice to make a clinical diagnosis of major depressive disorder (MDD). These features include what is called anhedonia (loss of pleasure in day to day activities), depressed mood ( in children it may present as irritability), weight loss or weight gain, insomnia or hypersomnia (sleeping more than usual), changes in behavior and personality, feeling tired and fatigued, feeling of hopelessness and worthlessness and thoughts of death or sucide.

In a clear cut case no other investigations are warranted but like I stated earlier, at times some organic neurological conditions can present as depression. So to rule out secondary causes of depression, your doctor may order a MRI brain and tests like thyroid function tests (to check if your thyroid hormones are within the normal range–this is usually a simple blood test).

Treatment of depression: Treatment of depresion when it presents along or during the course of a neurodegenerative condition like dementia and Parkinson’s disease is essentially the same as treatment of idiopathic depression (depression which occurs without any organic cause). It involves using drugs. The most commonly prescribed drugs are those which belong to two classes:

1) Tricyclic antidepressants–drugs which belong to this class include medications like Elavil (amitriptyline) and  nortriptyline.

2) Selective Serotonin Reuptake Inhibitors (SSRIs)–drugs include Prozac (fluoxetine) and Paxil (paroxetine) among numerous others.

If a neurological condition is responsible for the depressive symptomatology. example a frontal lobe tumor then removal of that tumor or treatment of the underlying neurological condition is needed. Other treatments that may be attempted include CBT (cognitive behavioral therapy).

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Parkinson’s disease

Parkinson’s disease is a relatively common neurodegenerative disease. It was first described by James Parkinson in his now classical essay titled ” The Shaking Palsy”. James Parkinson was an astute observer and his longitudinal description of the disease which now bears his name was on the basis of just a single patient.

Like other neurodegenerative diseases, Parkinson’s disease starts in the later age groups (60’s and onwards). Sometimes it may start in the younger age groups especially if there is a family history of the disease. This is referred to as Familial Parkinson’s Disease.

Typical Parkinson’s disease has a clinical triad consisting of:

a) rigidity (patient’s are rigid–when you passively move their limbs you experience increased resistance. Rigidity is a condition in which the tone of the body is increased. Tone refers to the resistance offered to passive movement of a limb across the joint)

b) bradykinesia or akinesia: as the name suggests, this means that the patient’s are bradykinetic. They have paucity of spontaneous movements, when they walk they do not have the characteristic arm swing which describes the human walk.

c) resting tremor: Parkinson’s disease (PD) patient’s have a characteristic tremor in their hands and feet. The tremor is a resting tremor meaning that it is most prominent when they are relaxed and their arms are at complete rest (when you walk, your arms are at rest by the side of your body and the tremor can be clearly seen).

 

Other features of Parkinson’s disease (PD):

d) PD patient’s have a typical disturbance of gait and posture. They seem off balance and are prone to falls. They walk bend forward in short quick steps (as if chasing something). This characteristic gait of PD patient’s has been referred to as festinating gait. If you accidently push a PD patient to the side or backward or forward, they are unable to compensate and may fall down. Falls and the disturbance in gait and posture is an important cause of morbidity in PD patient’s. When PD patient’s turn they do not turn in one smooth motion rather thay turn with small steps.

e) PD patient’s have a mask like face. They do not have the characteristic facial expressions which so define when humans talk. They may not blink while speaking ( sort of staring look), do not smile or frown.

f) PD patient’s may notice a change in their writing. Typically the hand writing becomes smaller and smaller and more illegible. This is referred to as micrographia.

g) The voice of PD patient’s is monotonous and lacks the variations in the pitch and tone which defines human speech.

 

A point to note here is that unlike Alzheimer’s disease, PD patient’s usually have no impairment in memory at least in the early to middle stages of the disease. Later on in the disease course, they may develop cognitive impairments, this condition is referred to as Parkinson’s disease dementia (PDD) or dementia associated with Parkinson’s disease.