Depressive symptomatology may occur at any stage of PD and is a major factor related to poor quality of life for both patients and caregivers, with caregiver distress highly correlated with the patient's severity of depression (8,12,63,64). Depressive disorders are common in PD. In a community-based study, the prevalence of depressive symptomatology in PD patients was six times that of healthy age- and sex-matched controls (2). In a registry-based study of 211,245 patients, Nilsson et al. (65) compared the incidence of depression in PD patients (n = 11,698) with non-PD patients with diabetes (n = 91,318) and non-PD patients with osteoarthritis (n = 10,822) who were matched for degree of disability. An increased probability of developing a depressive episode was found for patients with PD when compared with the diabetes and osteoarthritis groups. Nilsson et al. (66) also showed that patients with an affective disorder (depression or mania) had an increased risk of being diagnosed with PD (odds ratio 2.2) when compared to patients with osteoarthritis or diabetes.
In an analysis of 10 studies that used DSM-III criteria to define depression, an aggregate prevalence of 42% was reported for depressive disorders in PD (67). The prevalence rates of dysthymia, minor depression, and major depression in PD patients were 22.5%, 36.6%, and 24.8%, respectively. Studies using DSM-IV criteria and a structured clinical interview reported similar results, with the prevalence of major depression ranging from 20% to 25% in PD (11,68-70). Additionally, depression appears to occur more frequently in the presence of advanced disease, anxiety, cognitive impairment, and psychosis (2,71-74).
In an international survey of over 1000 PD patients, more than 50% of patients displayed clinically significant depressive symptomatology (8). In a clinic-based study of over 350 patients with PD, clinically significant depressive symptomatology was present in 57% of patients, with 40.2% considered mildly to moderately depressed and 16.7% classified as moderately to severely depressed (71).
Patients with PD may also suffer from depressive symptoms that do not meet criteria for major depression, minor depression, or dysthymic disorder, but nonetheless seem to have clinical relevance. Subsyndromal depression is defined as the presence of two or more depressive symptoms at subthreshold levels (i.e., short duration or not present most of the day or nearly every day) (75). Patients with depressive symptoms only during "off " states may be classified as having subsyndromal depression. With the inclusion of clinically important subsyndromal depressive disorders, the prevalence of clinically significant depressive symptomatology is present in 40% to 64% of patients with PD (2,8,11,12,15,71).
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