Dear Doctor: My husband was diagnosed with Parkinson's disease last year. One of the biggest challenges for our family has been how depressed he became. The antidepressants he takes don't seem to help at all, and my daughter says that's because he's actually demoralized, not depressed. What does this mean?

Dear Reader: We're very sorry to learn of the challenges your husband and your family are facing. As any of us who have had an illness knows, even when it's something as minor as a bad cold, the entire family is affected. And with a diagnosis like your husband's, the effect is greatly magnified.

The tendency in the past regarding Parkinson's disease had been a focus on the physical manifestations of the condition, such as tremors and stiffness, which are plainly visible. More recently, there has emerged a growing awareness that anxiety and depression are as much a part of the primary disease process as the motor disorders themselves. And now, according to research recently published in the journal Neurology, the diagnosis of depression in some Parkinson's patients may be incomplete or even incorrect. Instead, they may be dealing with something known as demoralization syndrome. That is, they are overwhelmed by and unable to cope with the physical changes and challenges presented by the disease.

Although individuals who are depressed and demoralized may exhibit similar symptoms, the avenues of treatment for the two conditions are different. Whereas treatment for depression often includes drug therapy, when it comes to demoralization syndrome, behavioral and cognitive interventions are often effective. It's also important to note that when it comes to being demoralized or depressed, it's not always an either/or situation. A patient can certainly experience both. But according to the study, demoralization is not a symptom of depression. It's a category of its own that is best addressed separately.

Someone with demoralization syndrome feels hopeless. The world that they knew and the things that they loved suddenly seem far away. There are activities they may no longer be able to take part in, interests that shrink in importance in light of the diagnosis, and interactions with family members where the balance of power has shifted dramatically. They are suddenly not the people they once were, and they are devastated and grieving.

For Parkinson's patients, this erosion of self is often associated with the effects of motor dysfunction. Experts recommend that patients who appear to suffer from depression undergo a comprehensive psychiatric workup to identify whether demoralization may be part of the problem. Antidepressants may indeed be included in the regimen. But for those who are demoralized, treatment focuses on ways to help the patient feel less isolated. This includes verbally validating a person's experience of the ongoing losses the illness is causing, identifying solutions to challenges in the physical world, and setting and marking an ongoing series of concrete goals that can show proof of achievement.

The depressed/demoralized discussion may sound like nothing more than semantics. At its core, though, it's about helping someone with a grave illness to regain a modicum of control.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o Media Relations, UCLA Health, 924 Westwood Blvd., Suite 350, Los Angeles, CA, 90095. Owing to the volume of mail, personal replies cannot be provided.)

Dear Doctor: I have been taking levothyroxine for an underactive thyroid for about 40 years. I have progressed from 0.025 milligrams to 100 milligrams currently. I recently read an article indicating that long-term use of this drug increases the incidence of bone fractures by about 80 percent. I am 74 years old. What alternatives are available to treat this condition?

Dear Reader: I can understand your worry about thyroid hormone and an increased risk of fractures, especially after being on the medication for 40 years. After all, people with hyperthyroidism (an excess of thyroid production) have a greater risk for osteoporosis, and studies have found that thyroid hormone increases bone resorption while interfering with calcium metabolism within the bone.

In fact, people with hyperthyroidism have a 10 to 20 percent decrease in bone density compared to people with normal thyroid levels; they also have an increased risk of fracture. A 2014 study from Denmark showed that, after 7.5 years, women with hyperthyroidism showed a fracture rate of 12.5 percent while those who had normal thyroid levels had a fracture rate of 7.6 percent. (This increased fracture rate was not seen in men.)

The impact of taking thyroid hormone to keep your levels normal is less clear. So far, it appears to depend on where in the normal range you end up. A 2017 study combined data from 13 different studies with a total of 56,835 people who took thyroid hormone replacement therapy. The studies, on average, followed people for 12 years; the average age of participants was 64, and 60 percent were women. Thyroid levels were assessed by measuring both TSH (thyroid-stimulating hormone) and T4 (the thyroid hormone thyroxine).

Now, remember: A lower TSH is associated with a higher thyroid level.

The authors found that those with the lowest range of TSH (0.45-0.99 mIU/L) had a 24 percent increased risk of hip fracture compared to those with the highest range of TSH (3.5-4.49 mIU/L). Note that both of these groups were in the normal range, but those with the higher level of thyroid hormone had a greater risk. For non-hip fractures, the association with thyroid hormone intake and fracture risk was not as great, with an 8 to 10 percent increase in risk.

The study also found that higher levels of T4 were associated with an increased risk of fractures, a finding that has been corroborated in studies in both Europe and Taiwan.

Keep in mind that the studies have been of relatively short duration, so it's difficult to know how taking thyroid hormone may have affected you specifically. I wonder, however, about your current bone density. If it's low, you should consider supplementation with calcium, vitamin D and possibly a medication to help build up bone.

Regardless, I would try to take the lowest possible dose of thyroid hormone required to keep your thyroid levels on the lower end of normal. You should also make sure you walk and do weight-bearing exercises to help decrease your risk of osteoporosis.

As for supplements or lifestyle changes that promise to naturally boost thyroid hormone production, these are not reliable options. Nor will they reduce the risk for fractures. Stick with medications proven to work -- and at the lowest possible level.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o Media Relations, UCLA Health, 924 Westwood Blvd., Suite 350, Los Angeles, CA, 90095. Owing to the volume of mail, personal replies cannot be provided.)

Hello, dear readers! Spring is officially here, and the weather is mostly cooperating. (Like many of you, we were awed by the late-season snowstorms some of you had to cope with!) The change in seasons means fewer layers of clothes and more outdoor activities. With that in mind, we'd like to remind you to please use sunscreen, consider bug sprays to deal with the return of mosquitoes and ticks, and to ease into the return to physical activity to avoid injuries.

And now, onward.

-- A lot of you asked about Shingrix, the new shingles vaccine. For those of you age 50 and over, our answer is yes, please get vaccinated. The new vaccine was 96.6 percent effective in clinical trials, a significant improvement over the older vaccine, Zostavax. And, yes, even if you've had the older vaccine, the new guidelines recommend that you get vaccinated with Shingrix as well.

-- In a column about avoiding air pollution while walking for exercise in cities, we suggested seeking out areas with less traffic. However, a reader from Lincoln, Nebraska, worries this can put older adults at risk of becoming victims of robbery or assault. Instead, he recommends indoor malls, which actively encourage walkers.

"Our indoor mall marks the floor, so walkers can gauge how far they have walked," he writes. "They are then encouraged to have coffee or tea with a donut or roll at the mall after their walk. Thus, they are walking in a safe, air-conditioned area and also have a chance for social interaction."

-- We had an unusual letter from a reader in Terre Haute, Indiana, asking about the relationship between cannabis and spontaneous orgasms. The reader, who is 73 and uses cannabis to help with insomnia, said this has been happening to her for the last three months.

While there are several anecdotal accounts of spontaneous orgasms associated with cannabis, we were unable to locate any clinical research on the topic. We imagine that at some point, if this is indeed a widespread phenomenon, there will be a study or two to report on it.

-- A number of you are confused by the recent changes to blood pressure guidelines. Let us assure you that you're not alone. Part of the problem is that in the initial category for abnormal blood pressure, which is referred to as "elevated," the lower number (diastolic pressure) remains the same as the number for normal blood pressure.

What's happening is that the new guidelines consider blood pressure to be elevated even if only the systolic, or top number, exceeds its bracket. The bottom number can remain in "normal" territory and, due to the higher top number, be considered out of the normal range.

To clarify, here is the complete chart:

-- Normal: Less than 120/80

-- Elevated: Systolic between 120-129 and diastolic less than 80

-- Stage 1: Systolic between 130-139 or diastolic between 80-89

-- Stage 2: Systolic at least 140 or diastolic at least 90

-- Hypertensive crisis: Systolic over 180 and/or diastolic over 120

Thank you for the many kind and encouraging (and occasionally critical) notes you sent. We love this ongoing conversation with you and look forward to continuing it next time.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o Media Relations, UCLA Health, 924 Westwood Blvd., Suite 350, Los Angeles, CA, 90095. Owing to the volume of mail, personal replies cannot be provided.)