Depression

Caring for mental health is extremely important in Parkinson's disease (PD). Research estimates that at least 50% of people with PD will experience some form of depression during their Parkinson's journey and up to 40% will experience an anxiety disorder.

50%

of people with PD will experience some form of depression.

40%

of people with Parkinson’s 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 well-being – even more than common motor symptoms.

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. Unlike sadness, which is temporary, depression can last for weeks or longer. Depression is a part of Parkinson's itself, resulting from PD-related changes in brain chemistry. Parkinson's impacts areas of the brain that produce dopamine, norepinephrine and serotonin — chemicals involved in regulating mood, energy, motivation, appetite and sleep.

Depression, while common in PD, is often overlooked and undertreated. Treating it is one of the most significant ways to decrease disability and improve quality of life.

A person may experience depression at any time in the course of PD, even before diagnosis. In addition, depression symptoms may come and go. It’s important to know that depression can intensify both movement and cognitive Parkinson's symptoms. Just as medications can improve tremors and other Parkinson's movement symptoms, they can also alleviate depression.

Discuss treatment options with your doctor. Researchers have found that people with Parkinson's who experience depression begin medications for motor symptoms earlier.

Guidelines that can help you prevent or get treatment for depression:

Get screened for depression at least once a year.
Discuss mood changes with your doctor.
Bring a family member to your doctor appointments who can help you talk about depression symptoms.

What causes depression?

Depression — overwhelming feelings of sadness, loss and hopelessness — can interfere with a person’s ability to function at home or work. People with PD have an imbalance of certain neurotransmitters (brain chemicals) that regulate mood. This is thought to play a major role in depression.

Other dynamics that can contribute to the development of depression include:

- Negative thoughts — 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 a lack of a supportive social network that can result from a more restricted lifestyle. Early retirement or loss of independence can increase depression risk, too.
- A history of mental health issues — research suggests many people with PD experience depression or anxiety two to five years before a Parkinson's diagnosis. This may mean depression is not simply a psychological reaction to the disease, but rather a part of the underlying disease process.
- Brain changes — PD and depression affect the same parts of the brain involved in thinking and emotion. Both conditions also impact levels of three important neurotransmitters (dopamine, serotonin and norepinephrine) that influence mood and movement.
- Severe stress, such as ongoing distress from living with chronic illness, can trigger depression for some people.
- Medication side effects — certain prescription drugs can cause symptoms that mimic depression.

Depression Symptoms

Symptoms of depression differ from person to person and can range from mild to severe. While people experience depression in differently, there are common symptoms.

- 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 (such as poor appetite or overeating)
- Loss of motivation
- Aches and pains
- Feelings of being a burden to loved ones
- Feelings of helplessness or hopelessness
- Reflections on disability, death and dying
- Sleep difficulties (too little or too much)
- Poor attention or difficulty concentrating
- Feeling slowed down or restless
- Thoughts of death or suicide

How is depression diagnosed?

Diagnosis is vital to effective treatment and recovery. 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

Depression Diagnosis Challenges in PD

Depression in Parkinson's can be hard to recognize. Certain depression symptoms overlap with those 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 daily sadness. Other things that can complicate a Parkinson's depression diagnosis include:

Facial masking, a symptom cause by Parkinson's effect on face muscles that can make it difficult for a person with Parkinson's to visibly express emotion.
People with Parkinson’s often do not recognize they have a mood problem or are unable to explain symptoms, so they don't seek treatment. It's helpful to ask a care partner or loved one if they have noticed any mood changes.

Taking Action

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. Your doctor can work with you to:

Evaluate your Parkinson's medications. People with PD who experience uncontrolled motor fluctuations, or “on-off” periods, and freezing episodes are more prone to depression. Your doctor can ensure both your motor and non-motor symptoms are being treated optimally.
Identify depression medications that might interact with PD medications.
Tailor a treatment approach that works for you — prescription therapies work in different ways for different people.
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.
Identify anxiety and treat anxiety, since it is often diagnosed alongside depression.
Create an exercise routine — walking, yoga, gardening or another activity you enjoy can ease symptoms of depression.

Treatment Options

Just as the symptoms and causes of depression can differ from person to person, so too can suitable treatment approaches. Exercise is a vital component of alleviating depression in PD. Primary treatments also include 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.

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. Hang in there. Finding the right treatment can take some trial and error.
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 Outcomes Project found that rates for depression were lowest among people receiving care from clinics with the most active approach to counseling.

Ways therapy can be beneficial:
- Cognitive behavioral therapy (CBT) has been shown to reduce symptoms of depression by helping people change negative thinking patterns and behaviors. Learning these skills offers long-term strategies for well-being.
- Counseling sessions can provide vital support, understanding and education. People with PD may be seen alone, with a loved one or family or in a group.
- Psychotherapy offers an alternative to antidepressants if a person with PD doesn't tolerate, respond to or want to take an antidepressant.
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
- possible memory problems or confusion as a complication
Transcranial Magnetic Stimulation (TMS) is an FDA-approved treatment for depression and can be effective and safe for depression in Parkinson’s. This non-invasive and painless procedure uses brief magnetic pulses in the brain.

More research is needed to examine other potential benefits of TMS for Parkinson's symptoms, specifically for motor symptoms, apathy, cognitive changes and medication side effects. Possible side effects of TMS include scalp discomfort, headaches, facial muscle twitching (during treatment only) and light headedness. Insurance may or may not cover TMS.
Complementary therapies are designed to support traditional treatments. These can include:
- Light therapy
- Relaxation techniques
- Massage therapy
- Acupuncture
- Aromatherapy
- Meditation
- Music therapy
- Parkinson’s support group
Discuss any supplementary wellness strategies with your care provider. This can uncover potentially serious side effects, prevent prescription medication interactions and ensure well-being.

Tips for Coping with Depression

Caring for your mental well-being is key to living well with Parkinson's. These strategies can help you manage depression:

Empower yourself with knowledge 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 Parkinson's, 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.