With regard to emotional reactions in degenerative brain diseases, Parkinson disease is complicated by a depressive reaction in approximately one-quarter of cases. Weakness and fatigability, already aspects of the motor syndrome, are added to the principal psychologic manifestations and the resulting therapeutic problem becomes formidable. Another hazard in Parkinson and in Lewy-body disease is the tendency for l-dopa itself to provoke a depression in a limited number of patients, sometimes with suicidal tendencies, paranoid ideation, and psychotic episodes. Huntington chorea is quite often associated with depression, even before the movement disorder and dementia become conspicuous. In one series, 10 of 101 patients with Huntington disease either committed suicide or attempted it, and this outcome is commented on in almost all large series of that disease. Alzheimer disease may be accompanied by depressive symptoms, in which instance it is difficult or impossible early in the illness to evaluate the relative contributions of the mood disorder and the dementia. In later stages, the overt signs of depression usually abate.
Depression during and after pregnancy The main risk for depression during pregnancy is a history of previous depressions. Certain epidemiologic factors also come into play including a family history of depression, single motherhood, cigarette smoking, low income, youth, and domestic violence. The implications, however, of depression during and after pregnancy are great in that the fetus and neonate are at risk of suffering due to inadequate prenatal and postnatal care and there is an increased rate of miscarriage. Several pieces of controversial evidence suggest that maternal depression may affect fetal growth and infant temperament. Furthermore, postpartum depression is also more common in women with prenatal depression and may lead to similar difficulties with infant care.
The treatment of depression during pregnancy has attracted considerable attention because of the potential risks to the fetus of the class of serotonin reuptake inhibitors. This is discussed in a later section. The clinical aspects of depression during pregnancy have been summarized by Stewart.
Clinical Presentation of Depression
Fully developed endogenous depression may evolve within a few days, or more often, it emerges gradually, on a background of vague prodromal symptoms that had been present for months. Chapter 23 provides a detailed description of the symptoms and signs of depression. Here it need only be repeated that the patient expresses feelings of sadness, unhappiness, discouragement, hopelessness, and despondency, with loss of self-esteem. Reduced energy and activity, typically expressed as mental and physical exhaustion, is almost always present, to the point of catatonia in the most severe cases. Indeed, as emphasized in Chap. 23, the most common cause in general practice of symptoms relating to reduced psychic and physical energy and drive (conation) is depression. There is usually heightened irritability, most often reported by a spouse or friends, as well as a lack of interest in activities that formerly were pleasurable.