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Combating Depression in Parkinson's Disease

Matthew Menza, M.D.
Robert Wood Johnson Medical School,
New Brunswick, New Jersey

Depression is one of the major, and most common, difficulties that faces people living with Parkinson's. Everyone feels sad from time to time and it is normal to experience sadness and stress when faced with a difficult medical illness such as Parkinson's disease. 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. People who are depressed often feel sad and don't enjoy life as they used to. They have little energy and struggle to get out of bed in the morning.

Other symptoms of depression include poor appetite, sleep disturbances, fatigue, feelings of guilt, self-criticism and worthlessness, irritability and anxiety. 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 illness. It tends to occur early in the illness and may wax and wane in severity. It causes personal suffering and also appears to accelerate problems with mobility and memory. A patient or caregiver may dismiss signs of depression because he or she assumes the Parkinson's disease itself is causing the problem, as if it is normal to be depressed. 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 illness and changes in the neurochemistry of the brain that accompany Parkinson's. Depression early in the disease may be a reaction to an anticipated loss of ability and quality of life, while depression in later stages may actually be due to chemical deficiencies. Research suggests that there are PD-related chemical changes in the brain that may lead directly to clinical depression. Many of the areas of the brain that are affected in PD are also important in controlling mood. One of these is the area that produces serotonin, a brain chemical implicated in depression. In addition, the frontal lobe of the brain, which is important in controlling mood, is known to be under-active in PD.

There is no simple formula for treating depression in PD. It is, however, extremely important that the Parkinson's disease itself be optimally treated. Patients with uncontrolled "on-off" periods and freezing episodes are more prone to depression, so it is important to talk with your doctor about the best medications to control these symptoms. Furthermore, some other symptoms of PD-for example, poor sleep, constipation and fatigue-should be treated to decrease the burden of living with the disease. Once detected, depression is often treatable using medication to help correct chemical imbalances.

Psychological treatments such as stress management and relaxation, as well as learning to cope with social relationships, can also be helpful-as can support groups. In addition, it is important to make efforts to increase activity and to exercise regularly. Exercise is an effective tool in helping both the symptoms of depression and PD.

Many medications are available for depression in PD. The selective "serotonin re-uptake inhibitors" (SSRIs)-which work by making serotonin available for use by the brain-are newer and safer medications of this class. Some common SSRIs are Paxil (paroxetine), Prozac (fluoxetine) and Zoloft (sertraline). These drugs generally have fewer side-effects than older antidepressants like Elavil (amitriptyline) and Pamelor (nortriptyline), which can cause low blood pressure. If treatment is administered, remember that antidepressants generally take several weeks to lift symptoms of depression.

There remain many unanswered questions about the cause and the treatment of depression in patients with PD, and the problem is receiving increasing attention from the scientific community. In December, 2003, the National Institute of Neurological Disorders and Stroke (NINDS) and the National Institute of Mental Health (NIMH) co-sponsored a conference to explore the mysteries of depression in Parkinson's. A major topic was the challenge of diagnosing depression in a context of similarities between PD symptoms and classic signs of depression. While the group agreed that the current diagnostic criteria for depression in Parkinson's are valid, it acknowledged that special care is required to distinguish depressive symptoms from PD symptoms.

Currently-accepted rating scales for depression remain useful for screening PD patients for depression, and for measuring the severity of depression and its response to treatment. The conference ended with a consensus that awareness of depression in PD needs to be raised, along with exploration of the best ways to treat this illness in PD patients.

Finding better approaches to detect and treat depression in PD is already underway in several NIH clinical trials. Additional research is needed to understand not only the treatment of depression but also its effects on other aspects of life, including sleep, anxiety, memory and concentration. If you (or a loved one) have PD and symptoms of depression, participating in a research study may help to bring solutions to this disabling problem.

Dr. Matthew Menza, of the Robert Wood Johnson Medical School, is now conducting the first National Institutes of Health-sponsored study of depression in patients with Parkinson's disease. He is a nationally known expert on the treatment of psychiatric problems in patients with PD. Dr. Menza is currently enrolling patients in an NIH sponsored study for research on depression in patients with Parkinson's disease. The study is being conducted at Robert Wood Johnson Medical School in Piscataway, NJ. If you are interested in finding out more about this study you can reach Dr. Menza, toll free 1-877-795-4673.