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8 Neuropsychiatric Symptoms and Treatments of Huntington Disease
In approximately half of patients with Huntington disease, symptoms of depression, irritability/aggression, executive dysfunction, psychosis, cognitive decline, and dementia present long before progressive motor symptoms.
Neuropsychiatric symptoms of Huntington disease (HD) are often present well before motor symptoms appear. These symptoms include depression, irritability/aggression, and executive dysfunction. Here is a quick primer on when and how psychiatrists may recognize and treat these symptoms.
Apathy:
Encourage social and physical activities
Reduce and/or discontinue medications that may worsen apathy (eg, antipsychotics, tetrabenazine)
Treat underlying depression, if present
Use an activating antidepressant or a stimulant drug, if needed
Depression:
Treat underlying medical conditions (eg, hypothyroidism)
Reduce and/or discontinue medications that may worsen depression (eg, antipsychotics, tetrabenazine)
Use SSRIs, SNRIs, mirtazapine, and bupropion. Consider that bupropion’s dopamine reuptake inhibition may potentially worsen movement disorder and choreiform movements
Irritability/aggression:
Identify and treat comorbid conditions, including pain, medical, neurological, drug-related, substance-related, or psychiatric disorders
Modify environmental factors, including an overstimulating environment
Use behavioral strategies to prevent or reduce agitated or aggressive behaviors.
For acute agitation that responds poorly to behavioral strategies, consider a benzodiazepine or an antipsychotic
For chronic agitation, use an antipsychotic or a mood-stabilizing anticonvulsant drug
Obsessive/compulsive behaviors:
Modify environmental factors
Treat underlying medical conditions (eg, hyperthyroidism)
Use selective SSRIs, SNRIs, or clomipramine (anticholinergic adverse effect may further impair cognition), SNRIs
Use antipsychotics in combination with SSRIs, clomipramine, or SNRIs to treat refractory OCBs
Psychosis:
Identify and treat comorbid conditions
Reduce overstimulation
Use behavioral strategies to prevent or reduce agitated or aggressive behaviors
Use antipsychotics (preferably atypicals) to treat symptoms. Do not exceed dosing limits for drugs. Combining antipsychotic drugs is not recommended due to the significant risk for adverse effects
Treatment with clozapine is recommended only for psychotic symptoms that are refractory to other antipsychotics
Anxiety:
Encourage social and physical activities
Modify environmental factors
Treat underlying medical conditions (eg, hyperthyroidism)
Reduce or discontinue medications that may worsen anxiety (eg, bupropion)
For acute anxiety, use benzodiazepines at the lowest effective dose for the shortest possible duration
Use SSRIs, SNRIs, or mirtazapine for long-term treatment
Sleep disorders:
Identify and treat comorbid conditions
Modify environmental factors
Use behavioral strategies to improve sleep (ie, sleep hygiene)
If behavioral strategies do not help, consider melatonin, mirtazapine, quetiapine, olanzapine, or clomipramine
Benzodiazepines are discouraged among ambulatory individuals except in refractory cases
Cognitive dysunction:
Identify and treat comorbid conditions
Modify environmental factors, including an under- or overstimulating environment
Use behavioral strategies, including the use of memory aids, to help prevent or reduce cognitive decline
Use acetylcholinesterase inhibitors if the patient and their family agree, although results of controlled trials did not show benefit with these medications
For more on this topic, see Early Warnings: Neuropsychiatric Manifestations of Huntington Disease, on which this slideshow is based.