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Depression

Mental health is extremely important in PD. Although common in other chronic diseases, research suggests that depression and anxiety are even more common in PD. It is estimated that at least 50 percent of those diagnosed with PD will experience some form of depression during their illness, and up to 40 percent will experience an anxiety disorder. 

The Parkinson’s Foundation Parkinson’s Outcomes Project found that taken together, mood, depression and anxiety have the greatest impact on health status, even more than the motor impairments commonly associated with the disease.

While everyone feels sad from time to time — and while people with PD may experience grief in reaction to a PD diagnosis — depression is different. Sadness is temporary, but depression is persistent, lasting for weeks or longer. Depression is a part of PD itself, resulting from changes in the chemistry of the brain. Specifically, PD causes changes in areas of the brain that produce dopamine, norepinephrine and serotonin — chemicals that are involved in regulating mood, energy, motivation, appetite and sleep.

A person may experience depression at any time in the course of PD, even before diagnosis. In addition, the symptoms of depression may come and go. It’s important to know that depression can intensify both the motor and cognitive symptoms of PD. Researchers have found that people with PD who experience depression begin PD medications for motor symptoms earlier. Treating depression can improve quality of life and movement.

Depression, while common in PD, is often overlooked and undertreated. It is important to be aware of its symptoms, so that if you experience it, it can be treated effectively. Treating depression is one of the most significant ways to decrease disability and improve quality of life. Fortunately, there are effective treatments for depression. In this section, we explore depression and how it is diagnosed and treated.

Recommendations for People with PD

  • Get screened for depression at least once a year.
  • Discuss changes in mood with their healthcare professional and doctor.
  • Bring a family member to doctor’s appointments to discuss changes in their mood.

What Causes Depression?

Depression is a mood disorder in which overwhelming feelings of sadness, loss and hopelessness interfere with a person’s ability to function at home or work. There are many causes of depression, including psychological, biological and environmental factors. Those with PD have an imbalance of certain neurotransmitters (brain chemicals) that regulate mood which is thought to play a major role. Like tremor and other motor symptoms of PD, depression can be improved with medications. The following factors can contribute to the development of depression. 

Psychological factors

  • Negative thoughts in addition to attitude about living with a chronic illness can lead to feelings of sadness, helplessness and hopelessness. Dwelling on these feelings may make a person more vulnerable to depression.
  • Social isolation or the lack of a supportive social network that results from a more restricted lifestyle. Things such as early retirement or loss of independence make depression more likely.

Biological Factors

  • History of mental health issues. Research suggests many people with PD experience depression or anxiety two to five years before the diagnosis of PD, which may mean that depression is not simply a psychological reaction to the illness, but a part of the underlying disease process. 
  • Changes in the brain. PD and depression affect the same physical parts of the brain involved in thinking and emotion. Also, both conditions affect the levels of three important neurotransmitters (dopamine, serotonin and norepinephrine) that influence mood and movement.

Environmental Factors

  • Severe stress. People diagnosed with a chronic illness often get depressed. For some people, the ongoing distress of coping with such a life crisis triggers the disorder.  
  • Side effects from drugs. Certain prescription drugs can cause symptoms that mimic depression.

What are symptoms of depression?

Symptoms of depression will differ from person to person and can range in severity from mild to severe. Although people experience depression in differently, there are common symptoms including:

  • Persistent sadness
  • Crying
  • Loss of interest in usual activities and hobbies
  • Decreased attention to hygiene, medical and health needs
  • Feelings of guilt, self-criticism and worthlessness
  • Increased fatigue and lack of energy
  • Change in appetite or eating habits (either poor appetite or over-eating)
  • Loss of motivation
  • Complaints of aches and pains
  • Feelings of being a burden to loved ones
  • Feelings of helplessness or hopelessness
  • Reflections about disability, death and dying
  • Sleep difficulties (too little or too much)
  • Poor attention and concentration problems
  • Feeling slowed down or restless inside
  • Thoughts of death or suicide

How Is Depression Diagnosed?

Most people with PD will go undiagnosed or undertreated for depression; therefore, being diagnosed is a critical first step towards effective treatment and recovery. To be diagnosed with depression, a person must experience one of the following symptoms most of the time over the previous two weeks:

  • Depressed mood 
  • Loss of interest or pleasure in activities once enjoyed

In addition, some of the following symptoms must be present:

  • Changes in sleep or appetite
  • Decreased concentration or attention problems
  • Increased fatigue
  • Feeling slowed down or restless
  • Feeling worthless and guilty
  • Suicidal thoughts or a wish for death

Difficulties in Diagnosing Depression in Patients with Parkinson's

  • Certain symptoms of depression overlap with symptoms of PD ― for example, sleep problems and feeling slowed down occur in both conditions.
  • Some experts think that depression in PD often involves frequent, shorter changes in mood versus a constant state of sadness daily.
  • Many people with PD express less emotion due to the effect the disease has on the muscles of the face. This symptom, called facial masking, makes a person unable to express emotion through facial expressions.
  • Many people with Parkinson’s do not seek treatment because they often do not recognize they have a mood problem or are unable to explain symptoms. For these reasons, it is helpful to ask a caregiver or loved one if he or she has noticed any changes commonly reported in depression.

What are the treatment options for depression?

Just as the symptoms and causes of depression can differ from person to person, so too can suitable treatment approaches. There are two main types of treatment options for depression: antidepressant medications and psychological counseling (psychotherapy). 

The Parkinson’s Foundation recommends a holistic, comprehensive approach to depression. Although antidepressants are often effective in reducing symptoms, they should seldom be used alone. In most cases, the best approach is a combination of antidepressant medication, counseling, exercise and social support. 

How can you ease depression in PD? First, share your concerns with your doctor. Many movement disorders specialists now include questions about depression in their exams. If your doctor does not, raise the topic. He or she may recommend medical or nonmedical coping strategies, including the following:

  • With your doctor, evaluate your PD medications. People with PD who experience uncontrolled “on-off” periods and freezing episodes are more prone to depression. It is important to talk with a doctor to ensure your PD is being treated optimally — both motor and nonmotor symptoms.
  • Many commonly-prescribed antidepressants are effective for people with PD. Different drugs work in different ways, thus the approach needs to be tailored to each person. Be aware that some medications for depression may interact with PD medications.
  • Consider psychological counseling, specifically an approach called cognitive behavioral therapy (CBT). This therapy helps people recognize and change patterns of thought and behavior to ease depression and anxiety.
  • Be aware of anxiety and ensure it is treated, since it is so often diagnosed alongside depression.
  • Exercise — walking, yoga, gardening or any exercise that appeals to you can help to ease symptoms of depression.

Medication

Most people with depression are treated with a class of drugs called selective serotonin reuptake inhibitors (SSRIs). These may include:

  • Fluoxetine (Prozac®)
  • Sertraline (Zoloft®)
  • Paroxetine (Paxil®)
  • Citalopram (Celexa®)
  • Escitalopram (Lexapro®)

In addition, there are several non-SSRI antidepressants used to treat depression. These may include:

  • Venlafaxine (Effexor®)
  • Mirtazapine (Remeron®)
  • Buproprion (Wellbutrin®)
  • Tricyclic antidepressants (Amoxapine)

These medications work equally well, though their side effects and interactions with other medications slightly differ. Each person does not react the same way to these drugs, so if one antidepressant medication fails, another medication or combination of medications, as well as complementary treatments, should be tried until symptoms are under control. It can take some trial and error to find the right treatment.

Psychotherapy

Psychotherapy is a broad term used to refer to the many varieties of counseling or talk therapy available today. This is an important treatment option for people with depression and is often used in combination with medication. 

Research from the Parkinson’s Foundation Parkinson’s Outcome Project found that rates for depression were lowest among patients receiving care from clinics with the most active approach to counseling. 

Ways therapy can be beneficial:

  • Cognitive behavioral therapy (CBT) has been shown to be effective. It helps people change negative thinking patterns and behaviors to reduce symptoms of depression. Learning these skills helps people cope better and think positively for the long term.
  • Counseling sessions can provide vital support, understanding and education. Patients may be seen alone, as a couple or family or in a group.
  • Psychotherapy offers an alternative to antidepressants. Some people with PD may not tolerate, respond fully or want to take an antidepressant.

Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is a standard treatment option for people with severe or non-responsive depression, meaning no other treatments work. Although in the past movies and other media have portrayed it in a frightening way, it is a relatively safe and effective treatment available for severe depression. It also temporarily improves motor symptoms in PD. Major drawbacks include: time involved in getting the treatment, the need to undergo general anesthesia and possible memory problems or confusion as a complication. It is contraindicated for those with deep brain stimulators. 

Exercise

Exercise has been found to be a simple therapeutic approach for improving mood and depression. It can include walking, stretching, yoga, Tai-chi and all basic forms of physical activity.

Non-Conventional and Complementary Therapies for Depression

  • Light therapy
  • Relaxation techniques
  • Massage therapy
  • Acupuncture
  • Aromatherapy
  • Meditation
  • Music therapy
  • Parkinson’s support group

Tips for Coping with Depression

  • Educate yourself about PD and its symptoms, including depression.
  • Ask for help — it takes courage, but it also puts you in control of finding a way to feel better and overcome feelings of helplessness.
  • Keep an open mind. Depression is not a personal failing or a sign of weakness, it is a chemical imbalance in the brain.
  • Plan short-term goals that you can achieve daily. Makes plans to walk, do a chore or talk to a friend. Small accomplishments contribute to a feeling of self-worth.
  • Maintain social ties. Plan to connect with a friend once a week or take on volunteer work.
  • Plan something to look forward to. Think about things you can do to enhance your quality of life and plan how to achieve them in small steps.
  • If you have stopped or cut back on leisure activities because of PD, try to resume one that you enjoyed or find a new one.
  • Connect with the PD community. Compare notes on coping with depression with members of a support group.

Page reviewed by Dr. Chauncey Spears, Movement Disorders Fellow at the University of Florida, a Parkinson’s Foundation Center of Excellence.

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