Management of hallucinations and psychosis in Parkinson's disease.
BACKGROUND
Hallucinations and psychosis are common in patients with Parkinson's disease (PD), with reported prevalences of up to 48% and 80%, respectively. However, few randomized, double-blind, placebo-controlled trials evaluating the treatment options have appeared in the literature. The studies that have been published were complicated by lack of agreement on the diagnosis of psychosis in PD, poor completion rates, mixed populations that included dementia, and other issues. Several reviews, guidelines, and consensus statements have sought to establish standards for treating these symptoms of PD. In 2006, the American Academy of Neurology (AAN) published a practice guideline (based on articles published up to 2004) for management of depression, psychosis, and dementia in patients with PD. Since then, a number of relevant studies have been published.


OBJECTIVE
The purpose of this article was to review data that have appeared in the literature since publication of the AAN guideline regarding the management of hallucinations and psychosis in PD.


METHODS
A literature search of the PubMed, CINAHL, and PsychInfo databases was conducted for human studies published in English from January 2004 to June 2010. All clinical studies were included except case reports and case series. Studies with <20 participants were also excluded. Search terms included psychosis, hallucinosis, hallucination, delusion, Parkinson, atypical antipsychotic, neuroleptic, aripiprazole, clozapine, olanzapine, quetiapine, risperidone, and ziprasidone.


RESULTS
Thirteen studies were included in the review: 3 studies of clozapine, 7 studies of quetiapine, 2 head-to-head trials comparing quetiapine and clozapine, and 1 noncomparative trial of clozapine or quetiapine interventions. Most of the studies included participants with a mean age in the early to mid 70s and a mean duration of PD typically >10 years.


CONCLUSIONS
Results of the identified studies suggested that patients with PD might benefit from long-term clozapine therapy. Results of the quetiapine studies were conflicting. However, no statistically significant difference in effectiveness was found between quetiapine and clozapine in comparative trials. The significance of the differences in treatment responses between patients with dementia and those without dementia remains unclear, and it was not possible to draw conclusions for or against other atypical antipsychotics because of insufficient evidence. Further studies are needed to address the methodologic issues in the current trials and to assess safety issues in larger cohorts.
Eng
Marty L
ML
Department of Pharmacy Practice, University of Kansas School of Pharmacy, Kansas City, Kansas 66160, USA. meng@kumc.edu
Welty
Timothy E
TE
D000368:Aged; D014150:Antipsychotic Agents / Q000494:pharmacology; D010054:Brief Psychiatric Rating Scale; D003024:Clozapine / Q000494:pharmacology; D015897:Comorbidity; D003702:Delusions / Q000188:drug therapy* / Q000209:etiology / Q000503:physiopathology; D003704:Dementia / Q000209:etiology; D003863:Depression / Q000150:complications / Q000523:psychology; D003987:Dibenzothiazepines / Q000494:pharmacology; D018450:Disease Progression; D017408:Guidelines as Topic; D006212:Hallucinations / Q000188:drug therapy* / Q000209:etiology / Q000503:physiopathology / Q000523:psychology; D006801:Humans; D008875:Middle Aged; D010300:Parkinson Disease / Q000150:complications* / Q000523:psychology; D011618:Psychotic Disorders / Q000188:drug therapy* / Q000209:etiology / Q000503:physiopathology / Q000523:psychology; D000069348:Quetiapine Fumarate; D016032:Randomized Controlled Trials as Topic; D058028:Research Report / Q000592:standards; D018967:Risperidone / Q000494:pharmacology
D014150:Antipsychotic Agents; D003987:Dibenzothiazepines; D000069348:Quetiapine Fumarate; D003024:Clozapine; D018967:Risperidone