Anxiety & Depression
words by barbara hurley / photograph by john emerson
efore he came to UMDNJ 22 years ago, and well before he became involved in clinical trials, Matthew Menza, MD, had a basic question to answer. Would he choose neurology or psychiatry? He found his answer in neuropsychiatry, the middle ground between the two, where the behavioral aspects of neurology are explored.
That answer ultimately led him to a host of other questions about Parkinson’s disease, depression and anxiety. Menza came to research in Parkinson’s disease through his clinical work. He found many of the questions abouttthe psychiatric and behavioral manifestations of the disease were unanswered in the literature, and it was clear that someone needed to try to find some answers. How much of the depression associated with Parkinson’s came from a psychological reaction to having the illness, and how much from the chemical changes in the brain that are part of the disease? Since the neurological changes in Parkinson’s disease are much clearer than in other similar conditions, he reasoned, there was also an opportunity to learn about behavioral issues that related to other psychiatric disorders.
In the past 10 years, Menza has done more than 50 clinical trials. His most recent trial, the first NIH-funded study of antidepressants in Parkinson’s disease patients, was completed after 31/2 years, and the results were highlighted in the journal Neurology. The study concluded that depression in patients with Parkinson’s is responsive to treatment, and that an older antidepressant, nortriptyline, was more effective than the newer paroxetine CR. For this and other studies, Menza stresses the importance of safety and informed consent, which he takes very seriously. “A clinical trial is a collaboration between the patient and the clinician-scientist,” he says. One patient that he remembers well is Jane Low.
Low had a year of unanswered questions before she finally learned in 2004 that she had Parkinson’s disease. Was foot surgery in 2003 the cause of her feelings of unbalance? Why was her sense of space so distorted that she suffered from severe anxiety as a passenger in a car? Why did bright lights affect her so adversely even though three ophthalmologists told her that nothing was wrong with her eyes? In her search for answers, her visits to physicians included a psychiatrist – did she have some sort of phobia? — and a neurologist. Both noted her “masked face,” usually an indicator of Parkinson’s. But she lacked the tremor ordinarily associated with Parkinson’s disease. Besides, her Internet search gave some reassurance: Asians, and Low is of Chinese background, have a lower incidence of the disease. But tests ruled out other diagnoses and her immediate response to the drug Sinemet confirmed Parkinson’s.
Low continued to suffer from the anxiety and depression that are often a part of Parkinson’s disease, and these symptoms brought her to Menza’s office. When she saw him in July 2005, he explained the goals of the clinical trial that would compare the effectiveness of two antidepressants. “It seemed safe enough,” she says, “and I was curious.” She reports that Menza put no pressure on her and clearly outlined what her choices were. For Low, the nortriptyline treatment was amazingly successful. A licensed clinical social worker specializing in psychotherapy, she observes that the trial helped her appreciate in new ways the value of medications.
Low, who turned 53 in January, is still working, although she has cut back on her hours. Her Parkinson’s is not always obvious, but she has found that telling her co-workers and clients about her condition has made her more comfortable. “I feel more authentic,” she explains. “I don’t have to use energy to hide things.” She is glad that she participated in the clinical trial — which she characterizes as “an important learning experience” — and could make a contribution to science. And she would do another.
Menza in fact has other Parkinson’s trials looking at the use of non-pharmacologic treatments for depression and sleep disorders, as well as anxiety, psychosis and impulse control problems. He is now heading a two to three-year study of sleep disorders that involves four centers around the country.
Many of Menza’s studies focus on how care is delivered. “Most doctors don’t think to ask Parkinson’s patients about depression,” he notes. “It’s treatable and has a tremendous impact on quality of life. Antidepressants do work.”
Until five years ago, he explains, the clinical trials for Parkinson’s disease concentrated on motor issues. “Now, patients have started to ask about how they live with this illness,” he reports. “With the support of strong advocacy groups and spokespeople like Michael J. Fox, they want to explore behavioral and quality of life concerns.”
Parkinson’s disease patients are a “remarkable group of people,” according to Menza. “Clinical trials can be inconvenient, but they are willing. They want to find the answers,” he adds. “And when the trials are over, most say ‘thank you for allowing me to participate.’”