Combating Depression in Parkinson's Disease
By Matthew Menza, M.D.
Robert Wood Johnson Medical School,
New Brunswick, New Jersey
Updated version published in the Spring 2009 issue of PDF News & Review
Depression is one of the major, and most common, challenges for people living with Parkinson’s disease (PD). Everyone feels sad from time to time and it is normal to experience sadness and stress when faced with a difficult disease such as Parkinson’s. However, the sadness that is part of being human can become a significant problem if it crosses into the realm of clinical depression and is left untreated.
Just four years ago, when this article was originally written, health professionals, researchers and people living with or affected by PD were just beginning to recognize the extent of the prevalence of depression in Parkinson’s and its impact on daily life. Since that time, there has been a sharp and welcome increase in the awareness of depression as a common feature of the PD experience and of the importance of treating it. Not only that, but new research has also advanced our understanding of how to treat PD-related depression and has increased the range of the treatment options we have available.
What is the difference between sadness and depression? While sadness is temporary, depression is persistent, and the people who experience it find that they cannot enjoy life as they used to. A person who is depressed may have little energy and may struggle to get out of bed in the morning. Other symptoms of depression can include poor appetite, sleep disturbances, fatigue, feelings of guilt, self-criticism and worthlessness, irritability and anxiety. Some people may begin having persistent thoughts that they would be better off dead or may even begin planning on ending their life. The presence of these symptoms on most days for two weeks suggests a diagnosis of depression and should be discussed with a physician.
At least 40 percent of people with PD experience clinical depression at some time during the disease. It may occur early or late in the course of Parkinson’s, and may wax and wane in severity. It causes personal suffering and also appears to intensify problems with mobility and memory. A person with Parkinson’s, or his or her caregiver or physician, may at first dismiss the signs of depression because they assume that it is Parkinson’s that is causing the problem or because they assume it is normal to be depressed when faced with this illness. This can lead to feelings of helplessness and confusion, which may further exacerbate the problem.
What causes depression in PD? There is no clear answer but most specialists agree that it is probably a combination of living with the stress of a progressive chronic disease, along with changes in the neurochemistry of the brain that accompany Parkinson’s. The experience of depression early in the disease may be a natural reaction to an anticipated loss of ability and quality of life, but research suggests that it may also be directly due to PD-related chemical changes in the brain. Many of the areas of the brain that are affected in PD are also important in controlling mood. Specifically, Parkinson’s causes changes in areas of the brain that produce serotonin, norepinephrine and dopamine — chemicals that are involved in regulating mood, energy, motivation, appetite and sleep. In addition, the frontal lobe of the brain, which is important in controlling mood, is known to be underactive in Parkinson’s.
It is very important to address depression because of the effects it can have on other symptoms and on quality of life. If you are concerned that you or a loved one with Parkinson’s may be depressed, you should raise it with your doctor. If you have been diagnosed with clinical depression, there is no simple formula for treating it, but there are several principles that are true for nearly everyone.
First, it is extremely important that Parkinson’s disease itself be optimally treated. People with Parkinson’s who experience uncontrolled “on-off” periods and freezing episodes are more prone to depression, so it is important to talk with a doctor about the best approach to controlling these symptoms. The same is true of some other, nonmotor symptoms of PD — for example, poor sleep, constipation and fatigue — that need to be treated to decrease the burden of living with the disease.
Second, it is important to make the effort to exercise regularly, to eat well and to stay socially involved. Exercise is an effective tool in helping the symptoms of both depression and PD. The exercise does not need to be rigorous, but it does need to be regular. Eating a healthy diet is another lifestyle approach that can help your overall wellness. Staying involved in social and recreational activities is also very important. Everyone needs something to look forward to, whether it be working on a hobby or socializing with friends and family.
Third, people should consider taking advantage of psychological treatments such as stress management, relaxation and cognitive behavioral therapy, as well as the kind of peer support that can be found in support groups. Receiving help from professionals and peers can help you learn to cope with stresses, improve social relationships and find solutions to practical day-to-day impairments. For instance, your peers at a support group may have a lot of wisdom to share with you (and you with them) about the practical aspects of daily living with PD, such as handling finances or managing travel.
Lastly, people with Parkinson’s should be aware that many medications are available for depression in PD. Recent studies have suggested that one class of antidepressants, called “dual reuptake inhibitors,” which affect both serotonin and norepinephrine, do improve depressive symptoms in people with PD. These include medications such as Effexor® (venlafaxine), Cymbalta® (duloxetine), and Pamelor® (nortriptyline hydrochloride). Another class of antidepressants, called selective “serotonin re-uptake inhibitors” (SSRIs), work by making serotonin available for use by the brain. These are also sometimes useful. Among the most common SSRIs are Paxil® (paroxetine), Prozac® (fluoxetine) and Zoloft® (sertraline).
The pharmacological treatment of depression in Parkinson’s disease needs to be individualized and may involve a variety of strategies. If you or your loved one is currently taking an antidepressant that does not appear to be helping, talk to your doctor to see if a switch to a different agent may better benefit your symptoms.
There remain many unanswered questions about the causes and the treatments of depression in people with PD and the problem is receiving increasing attention from the scientific community. The National Institutes of Health, at the urging of clinicians and advocacy groups, has begun to fund studies on depression and some of these results are becoming available. (To learn more about clinical trials, visit www.PDtrials.org.)
One thing is certain: there is a clear consensus that awareness about depression in PD needs to be raised among people with PD, caregivers and health professionals. More needs to be done to explore better ways to treat this illness in people living with Parkinson’s, and to better understand how the treatment of depression affects other aspects of life, including sleep, anxiety, memory and concentration. In the meantime, if you or a loved one with PD experiences symptoms of depression, talk to your doctor and take advantage of the resources that are already available.
10 Signs of Depression in Parkinson's
1. Excessive Worrying
2. Persistent Sadness
4. Loss of interest in usual activities and hobbies
5. Increased fatigue and lack of energy
6. Feelings of guilt
7. Loss of motivation
8. Complaints of aches and pains
9. Feelings of being a burden to loved ones
10. Ruminations about disability, death, and dying
People with these symptoms should discuss them with a physician.