recently retired players; N 5 13) experienced a surge in thenumber of home runs toward the end of their career (Figure1, top panel). This may be the first observation that a groupof athletes as a whole improved their athletic performancewith aging toward the end of their career. Such a trend isabsent in baseball sluggers (with career home runs of4400) who played in a different era. Could this be due to abetter training and preparation regimen than the currentathletes have? If so, such improvement should manifest indifferent baseball statistics, but age-related changes in bat-ting average of Hall of Fame baseball players remained re-markably constant over half a century (Figure 1, middlepanel). The current baseball pitchers are also suspected ofusing performance-enhancing drugs, but measures of theirperformance (earned run average (Figure 1, bottom panel)and strikeouts per batter (not shown)) demonstrate con-stant levels of performance throughout their career, and ifanything, there is a trend toward reductions in performancetoward the end of their career. So the surge in baseball per-formance toward the end of their career appears to be anisolated incident found only in the current baseball sluggers.Did they use performance-enhancing drugs, as implicated inthe media? Or did they discover the fountain of youth? Itremains to be determined!

Hirofumi Tanaka, PhDDepartment of Kinesiology and Health Education

University of Texas at Austin,Austin, TX

Justin Wienke, BSChad Scherr, BS

Department of KinesiologyUniversity of Wisconsin at Madison,

Madison, WI

ACKNOWLEDGMENTS

No conflict of interest to report. All the authors contributedto this letter, and there were no sponsors.

DEPRESSIVE SYMPTOMS AND COGNITIVE STATUSAFFECT HEALTH-RELATED QUALITY OF LIFE INOLDER PATIENTS WITH PARKINSON’S DISEASE

To the Editor: Parkinson’s disease (PD) is a multidimen-sional disorder affecting motor function, mood, and cog-nitive function, all of which might affect health-relatedquality of life (HR-QoL). The EuroQoL is an instrumentthat has been validated in Parkinson’s disease and has beenshown to accurately reflect patients’ perceptions of theirhealth.1,2 Previous studies have shown that patients withPD with on/off fluctuations, falls, insomnia, depression, andcognitive impairment have lower HR-QoL than their coun-terparts without these problems.3 No study we know of hasfocused solely on older North American patients. We set outto examine the correlates of HR-QoL in patients with PDaged 65 and older.

METHODS

Participants aged 65 and older were recruited from theMovement Disorders Clinic at the University of Alberta orfrom the Parkinson’s Society of Alberta from advertisementfor a longitudinal study. Patients were from Edmonton, Al-berta, or its surrounding rural areas. Patients with a historyof unstable heart disease, ischemic changes (e.g., stroke ortransient ischemic attack), active cancer, and dementia wereexcluded. Control participants matched for age, sex, andeducation were recruited by advertisement in local seniorcenters, and by word of mouth.

The study design was cross-sectional. As described,4

subjects and their informants were interviewed, andstandardized assessments were used. A neurologist (RC)administered the Unified Parkinson’s Disease Rating Scale(UPDRS) and the Cumulative Illness Rating Scale (CIRS); atrained research assistant (TG) administered the Mini-Mental State Examination (MMSE), Geriatric DepressionScale (GDS), and EuroQoL 5-item questionnaire (EQ-5D),which measures participant problems in mobility, self-care,social activities, pain, anxiety, and depression. The partic-ipants were also asked to complete the EuroQoL visual an-alog rating, which asks participants to rate their health on ascale of 0 to 100.

EQ-5D responses were categorized as no problemsversus some or extreme problems for chi-square analysis.Multivariate linear regression was used to determine whichfactors most strongly contributed to HR-QoL on theEuroQoL visual analog.

RESULTS

Fifty-one patients with PD and 50 age- and sex-matchedcontrols participated in the study. Patients with PD hadsignificantly higher (worse) GDS scores than matchedcontrols and were more likely to take antidepressantmedication.

Controlling for age, sex, education, and CIRS score,GDS score was the strongest contributor to health ratingbased on the EuroQoL visual analog scale (beta 5 �0.425,Po.005). MMSE also significantly predicted HR-QoL (be-ta 5 0.296, Po.05) on the EuroQoL visual analog. NeitherUPDRS III (beta 5 �0.075, P 5.610) nor CIRS score(beta 5 �0.159, P 5.219) were significant predictors ofHR-QoL in patients with PD.

Patients were more likely than control volunteers toreport problems associated with mobility, self-care, socialactivities, anxiety, and depression, but not pain, on theEQ-5D.

DISCUSSION

Depressive symptoms were the strongest predictor ofHR-QoL in older people with PD, despite the fact thatmany people were treated for depression. The findings aresimilar to European studies,3,5–8 which have shown thatpatients with PD with depressive symptoms report lowerHR-QoL but which did not focus on older patients. Thissuggests that HR-QoL of patients with PD might poten-tially be improved with proper management of depression.Depression may be underreported and often untreated inpatients with PD. Effort should be made to detect, diagnose,and properly treat depression in patients with PD, although

1888 LETTERS TO THE EDITOR NOVEMBER 2007–VOL. 55, NO. 11 JAGS

appropriate decision-making regarding treatment is diffi-cult, given the paucity of clinical trials of depression in PD.9

The data suggest that minor deficits in cognitive func-tioning appear to affect HR-QoL. All participants wereconsidered cognitively healthy, although three presentedwith mild cognitive impairment. Despite the overall highscores on the MMSE, it still significantly predictedHR-QoL visual analog ratings.

The fact that the current study was not population-based limited it. Because of selection criteria, younger pa-tients with PD are not represented in the results, althoughthe sample may be representative of patients seeking sub-specialty care. The results of our study are consistent withpopulation-based studies and studies examining a broaderage range of patients.3,10 The study was cross-sectional andtherefore examined prevalence, not incidence of depressivesymptoms and HR-QoL. Future studies should be longitu-dinal to address the question of whether depression is aprecursor to or consequence of poor HR-QoL.

CONCLUSION

The results reinforce the need for proper management ofdepressive symptoms in patients with PD. Healthcareproviders for older people should be aware of the highprevalence and underreporting of depression in patientswith PD. Understanding the link between depressivesymptoms and HR-QoL might lead to improved qualityof life for patients.

Tracy Greene, BScRichard Camicioli, MD

Faculty of MedicineUniversity of Alberta

Edmonton, ABCanada

ACKNOWLEDGMENTS

We thank the staff at the Movement Disorders Clinic forhelp with recruitment of participants and ThomasBouchard for help with data collection and follow-up ofparticipants in the study.

Financial Disclosure: Funded by the Canadian Instituteof Health Research. The Editor has reviewed the submittedfinancial and personal conflicts list and determinedthat there are no conflicts with either of the authors in thisletter.

Author Contributions: Dr. Camicioli devised the studyconcept, designed the study, and obtained funding for itsexecution. Subjects were recruited from routine clinic visitswith help from staff at the Movement Disorders Clinic. Dr.Camicioli neurologically assessed all participants, and Tra-cy Greene administered standardized cognitive tests. TracyGreene performed data analysis and manuscript presenta-tion with guidance from Dr. Camicioli. Thomas Bouchardhas given written consent to be included in the acknowl-edgment section.

Sponsor’s Role: The sponsor had no role beyond fund-ing the study.

REFERENCES

1. Szende A, Williams A eds. Measuring Self-Reported Population Health: An

International Perspective Based on EQ-5D. Hungary: Spring Med Publishing,

2004.

2. Schrag A, Selai C, Jahanshahi M et al. The EQ-5DFa generic quality of life

measureFis a useful instrument to measure quality of life in patients with

Parkinson’s disease. J Neurol Neurosurg Psychiatry 2000;69:67–73.

3. Schrag A. Quality of life and depression in Parkinson’s disease. J Neurol Sci

2006;248:151–157.

4. Camicioli RM, Hanstock CC, Bouchard TP et al. Magnetic resonance spec-

troscopic evidence for presupplementary motor area neuronal dysfunction in

Parkinson’s disease. Mov Disord 2007;22:382–386.

Table 1. Demographics and Measures

Characteristic PD Control P-Valuew

Age, mean � SD (range) 71.5 � 4.7 (65.1–84.3) 71.5 � 4.8 (65.0–83.3) .97

Sex (male/female) 30/21 29/21 .93

Education (years, mean � SD (range)) 13.9 � 3.0 (9–25) 15.0 � 3.5 (8–23) .11

Parkinson’s disease duration (years, mean � SD (range)) 8.7 � 4.4 (1–18) F F

Modified Cumulative Illness Rating Scale score, mean � SD (range) 19.4 � 3.0 (15–26) 18.4 � 2.5 (14–26) .06

Mini-Mental State Examination score, mean � SD (range) 28.1 � 1.7 (23–30) 28.4 � 1.6 (24–30) .33

Unified Parkinson’s Disease Rating Scale score, Part III (motor symptoms), mean � SD (range) 17.3 � 8.6 (3–39) 2.1 � 2.9 (0–15) o.001*

Geriatric Depression Scale score, mean � SD (range) 2.1 � 2.8 (0–14) 0.7 � 1.07 (0–5) .001*

Antidepressant (yes/no) 11/40 0/50 .001*

EuroQoL quality of life visual analog, mean � SD (range) 78.5 � 11.8 (30–98) 84.1 � 10.0 (48–100) .01*

EuroQoL 5-item questionnaire (no vs some or extreme problems)

Mobility 25/26 42/8 o.001*

Self-care 39/12 49/1 .001*

Usual activities 29/22 48/2 o.001*

Pain 26/25 28/22 .61

Depression/anxiety 38/13 48/2 .002*

*Statistically significant (Po.05) result.wP-values are the result of analysis of variance for continuous variables and chi-square analysis for categorical variables.

SD 5 standard deviation.

LETTERS TO THE EDITOR LETTERS TO THE EDITOR 1889JAGS NOVEMBER 2007–VOL. 55, NO. 11

5. Caap-Ahlgren M, Dehlin O. Insomnia and depressive symptoms in patients

with Parkinson’s disease. Relationship to health-related quality of life. An

interview study of patients living at home. Arch Gerontol Geriatr 2001;32:

23–33.

6. Kuopio AM, Marttila RJ, Helenius H et al. The quality of life in Parkinson’s

disease. Mov Disord 2000;15:216–223.

7. Schrag A, Jahanshahi M, Quinn N. What contributes to quality of life in

patients with Parkinson’s disease? J Neurol Neurosurg Psychiatry

2000;69:308–312.

8. Martinez-Martin P, Benito-Leon J, Alonso F et al. Health-related quality of life

evaluation by proxy in Parkinson’s disease: Approach using PDQ-8 and

EuroQoL-5D. Mov Disord 2004;19:312–318.

9. Chung TH, Deane KH, Ghazi-Noori S et al. Systematic review of antidepres-

sant therapies in Parkinson’s disease. Parkinsonism Relat Disord 2003;10:

59–65.

10. Schrag A, Jahanshahi M, Quinn N. How does Parkinson’s disease affect

quality of life? A comparison with quality of life in the general population.

Mov Disord 2000;15:1112–1118.

NOT ALL MONOAMINE OXIDASE INHIBITORS ARECREATED EQUAL

To the Editor: Refractory depression is commonly encoun-tered in psychiatric practice; it has been estimated that up to15% of patients will fail to respond to aggressive treatmentwith multiple agents.1 Refractory depression is especiallyproblematic for older patients, who are unable to withstandthe ravages of a severe and prolonged depression as well asyounger individuals;2,3 it is common for such patients to beleft with permanent disabilities even after finally treatingthe depression.

Monoamine oxidase inhibitors (MAOIs) have beenavailable since the late 1950s and have proved to be effec-tive in up to 50% of patients with refractory depression.4,5

The older MAOIs are infrequently used now, mainly be-cause of their potentially fatal interactions with a variety ofmedications and foods; although Food and Drug Admin-istration approval of transdermal selegiline has engenderedsome renewed interest, many psychiatrists are inexperi-enced with these valuable drugs.

Because MAOIs are usually reserved for refractory de-pression, the question of whether a patient that fails oneagent might respond to another is an important one but onethat has never been addressed in the literature. Two elderlypatients who failed to respond to phenelzine but had a rapidand dramatic improvement when switched to tranylcypro-mine are reported here.

CASE 1

An 80-year-old man presented with an 8-month history ofsevere major depression with prominent somatic and nihil-istic delusions. Over the subsequent 4 months of treatment,he failed to respond to multiple trials of antidepressants,augmenting strategies, and a course of nine bilateral elect-roconvulsive treatments. Ultimately, a trial of phenelzinewas initiated and titrated to a maximal dosage of 75 mg perday; this was ineffective. Lithium was added, also with noeffect. After 5 weeks, phenelzine was discontinued andtranylcypromine substituted, titrating to a maximal dosageof 60 mg per day. This resulted in a dramatic improvementin his depressive symptoms within approximately 10 days;he developed some subtle confusion, which resolved on

discontinuation of lithium. His depression remained in fullremission on tranylcypromine monotherapy until his deathfrom congestive heart failure 5 years later.

CASE 2

A 76-year-old man with a 13-year history of recurrentmajor depression with prominent somatic delusions hadinitially responded to electroconvulsive therapy andphenelzine but had eventually become refractory to both.His depression remained in remission for the following 5years on lithium monotherapy but then recurred and againproved to be refractory to phenelzine in doses as high as90 mg per day with continued lithium augmentation.Phenelzine was washed out and tranylcypromine substitutedat a final dosage of 40 mg per day. His response totranylcypromine was dramatic, with complete resolutionof all depressive symptoms within 12 days; he developedmoderate delirium that completely resolved with reductionof his lithium dosage.

Both of these patients suffered from highly morbid, re-fractory depression, and their response to a second MAOIwas gratifying. Because of their interactions with many an-tidepressants, switching to a non-MAOI strategy wouldhave been much more cumbersome (although a wash-outperiod between MAOIs may be necessary as well6) andperhaps less effective. Although the past 5 decades havewitnessed extraordinary progress in psychopharmacology,older medications should not be forgotten.

Jonathan T. Stewart, MD, AGSFGeropsychiatry Section

College of MedicineUniversity of South Florida

Bay Pines Veterans Affairs Medical CenterBay Pines, Florida

ACKNOWLEDGMENTS

Financial Disclosure: The Editor in Chief has determinedthat the author has no conflict of interest related to thisletter.

Author Contributions: Jonathan T. Stewart was re-sponsible for the entire content of the letter.

Sponsor’s Role: None.

REFERENCES

1. Berlim MT, Turecki G. Definition, assessment, and staging of treatment-resis-

tant refractory major depression: A review of current concepts and methods.

Can J Psychiatry 2007;52:46–54.

2. Kamholz BA, Mellow AM. Management of treatment resistance in the de-

pressed geriatric patient. Psychiatr Clin North Am 1996;19:269–286.

3. Schulz R, Drayer RA, Rollman BL. Depression as a risk factor for non-suicide

mortality in the elderly. Biol Psychiatry 2002;52:205–225.

4. Thase ME, Frank E, Mallinger AG et al. Treatment of imipramine-resistant

recurrent depression: III. Efficacy of monoamine oxidase inhibitors. J Clin Psy-

chiatry 1992;52:5–11.

5. McGrath PJ, Stewart JW, Nunes EV et al. A double-blind crossover trial of

imipramine and phenelzine for outpatients with treatment-refractory depres-

sion. Am J Psychiatry 1993;150:118–123.

6. Szuba MP, Hornig-Rohan M, Amsterdam JD. Rapid conversion from one

monoamine oxidase inhibitor to another. J Clin Psychiatry 1997;58:307–310.

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