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Question. I have an 80-year-old relative with Parkinson’s disease and depression who was started on Prozac with good initial effects on mood and energy levels. Unfortunately, he complained of worsening tremor. A pharmaceutical representative for Zoloft has suggested that this antidepressant would be a better choice for use in patients with parkinsonian symptoms because it has some dopaminergic effects. Have there been any studies of patients with Parkinson’s disease suggesting which antidepressants, and presumably which neurotransmitter modulation, are most efficacious in treatment?

Answer. You are raising a very important question, which, unfortunately, has not been settled by any good, controlled studies. The pharmaceutical representative is correct that Zoloft has greater dopaminergic activity than Prozac. In theory, this ought to be of some benefit in Parkinson’s disease, but I have seen no comparative studies (e.g., Zoloft vs. Prozac). All agents of this type, called SSRIs, have the potential of worsening tremor and other parkinsonian symptoms; that includes Zoloft, Prozac, Paxil and Luvox.

The problem is, there are few alternatives that have a comparable safety factor in elderly patients. The old tricyclic antidepressants (amitriptyline, nortriptyline) have a beneficial effect in Parkinsonism, because they reduce a brain chemical called acetylcholine. Unfortunately, this same effect can cause dry mouth, blurry vision and often memory impairment. Furthermore, the tricyclics can cause various cardiac problems. Wellbutrin is a nontricyclic, non-SSRI that has had mixed results in Parkinsonism, but is generally quite safe in the elderly. There are still insufficient data on very new agents, such as Effexor or Remeron.

Frankly, if your relative did well on Prozac initially, I would consider a retrial at a lower dose (e.g., 5-10 mg/day or even every other day). Some patients can get an antidepressant effect from Prozac even taking it 3 times per week, since it is so long-lasting. Another option that could be considered is L-deprenyl (if he is not already taking this). This is an agent used for both Parkinson’s and depression. I would suggest a good consultation with an experienced geriatric psychiatrist, working in concert with a neurologist.