Episode 118: Managing Mental Health Problems with Parkinson’s Disease

Dan Keller 0:02 Welcome to this episode of Substantial Matters: Life and Science of Parkinson's. I'm your host, Dan Keller. At the Parkinson's Foundation, we want all people with Parkinson's and their families to get the care and support they need. Better care starts with better research and leads to better lives. In this podcast series, we highlight the fruits of that research—the treatments and techniques that can help you live a better life now, as well as research that can bring a better tomorrow.

Mental health problems are remarkably common with Parkinson's disease, affecting up to 50% of people at some point in their lives, whether related to the disease pathology itself, the medications used to treat motor symptoms, or simply accompanying the psychological burden of a chronic disease. The critical first step is to recognize these problems and then to find appropriate treatment, since many of these psychiatric issues can be successfully alleviated. As we always say at the conclusion of these podcasts, our mission at the Parkinson's Foundation is to help you live the best possible life today, and mental health is an integral contributor to overall quality of life.

In this episode, geriatric psychiatrist Dr. Mary Hart Bryan of the Medical University of South Carolina elucidates some of the more common mental health problems that occur with PD. The first step in overcoming them is to recognize them, then to bring them to the attention of your neurologist, and ultimately to connect with an appropriate mental health professional, since most of these problems can be significantly mitigated with proper clinical care.

Dr. Mary Hart Bryan 1:49 Up to 50% of people living with Parkinson's will experience some psychiatric symptoms at some point during their journey, and these can sometimes even precede the official diagnosis or the onset of motor symptoms. Some of the most common psychiatric conditions we see in our clinic include depression, anxiety, and apathy. We also frequently evaluate and manage psychosis or psychotic symptoms. While there are other neuropsychiatric features, those are the primary conditions we treat.

Dan Keller 2:22 Is apathy distinct from clinical depression, or can the two conditions easily be confused?

Dr. Mary Hart Bryan 2:27 They can absolutely be confused. Depression is incredibly common in Parkinson's disease and, as I mentioned, it can even serve as a prodromal symptom that precedes motor deficits. Depression presents with a persistently down mood, feelings of sadness, helplessness, or hopelessness, and an inability to enjoy things as much as one once did. It can also bring profound changes in appetite or sleep patterns. Naturally, a person who is depressed may withdraw from social activities and stop initiating things they used to love.

If someone has apathy, they may outwardly appear to be depressed because they similarly exhibit a lack of drive and stop initiating activities. However, the key clinical distinction is that once a person with apathy is gently prompted or encouraged to start an activity, they are fully capable of engaging in and enjoying it. A person with clinical depression cannot; they are unable to find pleasure in those activities because of the pervasive nature of their depression.

Apathy is a distinct neurochemical symptom that can come directly with Parkinson's disease. Frequently, the individual experiencing the apathy will not recognize it themselves and they are completely unbothered by it. However, it can be deeply distressing and upsetting to family members and friends who don't understand why their loved one is suddenly refusing to get up and do the things they once enjoyed, appearing entirely content to just sort of opt out of life.

Dan Keller 3:41 What kind of clinical interventions and treatments are available for both apathy and depression?

Dr. Mary Hart Bryan 3:46 Apathy can be a bit more challenging to treat if it is not accompanied by underlying depression. True isolated apathy will not typically respond to an antidepressant medication. Rather than jumping straight to a pharmacological prescription, we usually implement a structured behavioral approach. We enlist the support of care partners, friends, and family to proactively schedule daily activities, provide external motivation, and help the individual get re-engaged in the aspects of life they have dropped.

For depression, depending on its severity, we utilize two primary modes of treatment. One is evidence-based psychotherapy, and the modality we most commonly recommend is cognitive behavioral therapy, or CBT. This is an excellent avenue. However, sometimes a patient does not wish to participate in psychotherapy, or their depression is severe enough to necessitate pharmacological management. There are several classes of antidepressants that have demonstrated good clinical efficacy in people with Parkinson's disease. There is no single antidepressant that is universally recommended above the rest, though we select specific medications based on the scientific evidence and individual patient profiles. Often, the most effective approach ends up being a tailored combination of both psychotherapy and medication.

Dan Keller 5:02 Does physical exercise play a role in ameliorating either of these conditions? We frequently hear that exercise is vital for people with Parkinson's in terms of managing physical progression and motor symptoms.

Dr. Mary Hart Bryan 5:13 Yes, absolutely. Exercise is an exceptional, evidence-based treatment for depression. Similarly, with apathy, while a person may entirely lack the internal motivation to initiate an exercise routine, once they are guided into doing it, they feel substantially better. Physical activity naturally boosts endorphins and has a profoundly beneficial effect on mood regulations. Exercise should absolutely be a core component of the lifestyle recommendations for any patient dealing with depression or apathy.

Dan Keller 5:41 You also mentioned the potential for psychosis in Parkinson's disease. How does that typically manifest, and how is it treated?

Dr. Mary Hart Bryan 5:46 While depression is the most frequent mood disturbance, we do see quite a bit of psychosis as the disease advances. Parkinson's disease psychosis primarily manifests as delusions and hallucinations.

A delusion is a fixed, false belief that is not grounded in reality, and in this population, it is often paranoid in nature. For example, a patient may experience delusions of infidelity, believing their spouse is being unfaithful, or paranoia that a close friend has suddenly turned against them.

Hallucinations, on the other hand, are sensory perceptions in the absence of an external stimulus, and in Parkinson's, they are overwhelmingly visual. This can range from an illusion—where a patient sees an object that is actually in the room, but their brain misinterprets it as something else, like seeing a coat rack and perceiving a person—to frank visual hallucinations, where they see vivid people, children, or animals that are not there at all.

Oftentimes, in the early stages, people with Parkinson's retain good insight; they are fully aware that they are experiencing a visual hallucination and can reassure themselves, saying, "I know that isn't real." However, as these symptoms progress, they can become deeply terrifying and distressing. At that point, we will introduce specialized atypical antipsychotic medications to manage the psychotic symptoms.

It is vital to note that while psychosis can be a natural feature of advanced Parkinson's pathology itself, the dopamine-replacement medications used to treat the primary motor symptoms can also induce or significantly exacerbate delusions and hallucinations as a side effect.

Dan Keller 7:21 Certain Parkinson's medications are associated with impulse control disorders and hallucinations. But what about pre-existing, underlying psychiatric conditions that individuals lived with long before developing Parkinson's disease—such as bipolar disorder, obsessive-compulsive disorder, or schizoaffective disorder? Where exactly does the neurologist's role end and the psychiatrist's role begin, and should a psychiatrist automatically be integrated into the care team?

Dr. Mary Hart Bryan 7:49 Yes, absolutely. Especially when a patient has a severe, pre-existing psychiatric disorder like major depression, generalized anxiety, bipolar disorder, schizophrenia, schizoaffective disorder, or a substance use disorder, having a specialized psychiatrist on the care team is highly beneficial.

Typically, the neurologist will recognize the complexity and make that referral. It is incredibly challenging to manage advanced Parkinson's symptoms alongside a complex, long-standing psychiatric regimen, largely because of profound pharmaceutical drug-disease interactions. The dopamine agonists and levodopa formulations that are absolutely necessary to alleviate Parkinson's motor symptoms work by increasing dopamine, which can directly interfere with and disrupt the antipsychotic or mood-stabilizing medications necessary to keep a primary psychiatric condition stable.

It requires a delicate, expert clinical balancing act. Many psychiatrists, particularly geriatric psychiatrists like myself, specialize in this exact intersection and collaborate closely with neurologists to safely co-manage these complex patients.

Dan Keller 8:48 Do you find that neuropsychiatric disorders in Parkinson's disease remain heavily underrecognized and, as a result, undertreated?

Dr. Mary Hart Bryan 8:55 They certainly are. In general, psychiatric symptoms and mental health diseases are underrecognized across medicine, often driven by the societal stigma that prevents patients from feeling comfortable discussing these issues openly with their physicians.

Furthermore, when a patient goes into a standard neurology appointment, there is an overwhelming amount of information to cover in a limited timeframe. The physician must evaluate gait, tremors, bradykinesia, and medication timing, meaning that emotional and psychiatric symptoms frequently get pushed to the bottom of the list. Because of this, they go underdiagnosed and undertreated.

Yet, mental health is the fundamental cornerstone of overall wellness and a happy, productive life. Being able to recognize these shifts in yourself, or listening when a loved one points them out, and then proactively bringing them to your neurologist is a vital first step.

Dan Keller 9:38 What specific feelings or changes should patients and families be actively watching for to bring up during their appointments? As you noted, the conversation usually defaults to motor function, but quality of life depends on the entirety of this psychological experience.

Dr. Mary Hart Bryan 9:53 Patients should report if they are experiencing anhedonia—an inability to derive pleasure or enjoyment from life. They should also bring up persistent anxiety. Anxiety is incredibly common in Parkinson's and often presents as excessive, uncontrollable worry that disrupts daily function or keeps people awake at night. Other key signs include unexplained changes in appetite, cognitive withdrawal from social circles, and sleep disturbances.

On the more severe end of the spectrum, symptoms like feeling hopeless, experiencing a passive death wish where you find yourself wishing you were dead, or having active suicidal thoughts require immediate, urgent medical intervention. Any of these emotional shifts are highly clinically significant and must be discussed with your doctor.

Dan Keller 10:31 Without straying too far from the clinical scope, is the person carrying the diagnosis of Parkinson's the only individual affected by these mood and mental health disruptions, or does this intimately impact the care partner as well?

Dr. Mary Hart Bryan 10:43 That is an incredibly profound question. Caregivers are at an exceptionally high risk for developing clinical depression and anxiety—at rates significantly higher than peers who are not in a caregiving role. Data indicates that at least 50% of care partners will experience a depressive episode at some point during the caregiving journey.

This happens for a multitude of reasons: the relentless physical demands of the role, chronic sleep deprivation, and the constant psychological worry over their loved one's progressive decline. It takes a severe toll on both the physical and mental health of the caregiver. Because of this reality, we actively screen caregivers for depression and anxiety in our clinic. We strongly encourage care partners to reach out and build a robust support network, whether that involves joining a dedicated Parkinson's disease caregiver support group, pursuing individual psychotherapy, or speaking with their primary care physician about medical options.

A caregiver simply cannot effectively support their loved one if their own mental health is actively suffering. Ensuring the caregiver is taken care of is absolutely essential for the survival and well-being of the entire family unit.

Dan Keller 11:44 What about the development of dementia in Parkinson's disease? We cannot fully unpack that complex topic here, but how should families approach recognizing and addressing cognitive decline?

Dr. Mary Hart Bryan 11:53 Cognitive decline and dementia are common neurodegenerative features of advanced Parkinson's disease, and it represents a major neuropsychiatric challenge. There is a vast amount of clinical nuance when discussing Parkinson's disease dementia, and we do have targeted medications that can offer cognitive benefits.

However, one critical concept to highlight is the phenomenon of pseudodementia. When a patient is severely depressed or intensely anxious, they cannot think clearly, focus, or process information efficiently. When a patient presents with new cognitive complaints—such as short-term memory lapses or an inability to concentrate—our first clinical priority is to carefully tease apart whether underlying depression or anxiety is driving those deficits. If mood disorders are present, treating them aggressively can often reverse those apparent cognitive impairments. If true, structural neurodegenerative dementia is present, it must be addressed, but it requires an entirely different management paradigm.

Dan Keller 12:45 What is your definitive take-home message for people living with Parkinson's and their caregivers who suspect they are experiencing any of the symptoms we have discussed today?

Dr. Mary Hart Bryan 12:56 My primary take-home message is: please do not suffer in silence; talk to your doctor immediately. Whether you are the person living with Parkinson's or the care partner who is actively drowning under the weight of caregiver stress, report it. If you do not feel comfortable opening up to your neurologist, make an appointment with your primary care physician. If you prefer to bypass those channels, seek out a specialized psychiatrist. These psychiatric conditions are highly treatable, and addressing them is the single most powerful way to restore your quality of life.

Dan Keller 13:29 Beautifully stated. Thank you, Dr. Bryan, for your vital insights and your dedication to this critical area of care.

To learn more about managing mental health issues in Parkinson's disease, you can search for "mental health" directly on our website at parkinson.org. There you will find an excellent, comprehensive overview regarding clinical screening for mood disturbances authored by our Chief Scientific Officer, James Beck, titled Mental Health in Parkinson's disease during the COVID-19 pandemic.

If you explore our digital archive at parkinson.org/library, you will find a wealth of evidence-based articles, expert briefings, and archived podcasts covering every facet of neuropsychiatric health—including anxiety, sleep disorders, social isolation, and loneliness, alongside resources on psychotherapy, counseling, and mindfulness techniques.

The foundation also publishes four comprehensive books addressing these topics, titled Caring and Coping, Cognition, Mood, and Psychosis. You can read these educational guides online, download them directly to your computer or Kindle, or order complimentary physical copies. Caring and Coping is particularly valuable, offering dedicated chapters on mitigating caregiver strain, step-by-step psychological tip sheets, and a curated registry of national and community resources. It also includes a practical contact directory where you can centralize emergency contacts, physicians, and pharmacies.

As always, if you need immediate, personalized guidance, the Parkinson's Foundation Helpline is available to assist you. Our information specialists provide expert resources in both English and Spanish and can be reached toll-free at 1-800-4PD-INFO. To receive updates regarding future educational webinars, local events, and community resources, you can easily subscribe to our email list at the bottom of our homepage.

If you would like to leave feedback regarding this podcast or suggest future topics, please visit parkinson.org/feedback. If you are enjoying this series, please take a moment to subscribe, rate, and review Substantial Matters on Apple Podcasts or your preferred streaming platform.

At the Parkinson's Foundation, our mission is to help every person diagnosed with Parkinson's live the best possible life today. To that end, we will be back with a brand-new episode every two weeks. Until next time, for additional resources, please visit parkinson.org or call our helpline at 1-800-4PD-INFO, which is 1-800-473-4636. Thank you for listening.

Mary Hart Bryan, MD is an assistant professor in geriatric psychiatry at the Medical University of South Carolina (MUSC). She completed her medical degree at MUSC, psychiatry residency at UNC Chapel Hill where she also served as chief resident, and geriatric psychiatry fellowship at MUSC. She is board certified in geriatric psychiatry by the American Board of Psychiatry and Neurology (ABPN). Dr. Bryan is the assistant director of the geriatric psychiatry fellowship and clinical director of the geriatric psychiatry outpatient clinic. She enjoys teaching residents and training fellows in the field of geriatric psychiatry. Dr. Bryan works in long term care facilities including skilled nursing, assisted living and memory care. She often treats patients in these settings who have movement disorders and overlying neuropsychiatric symptoms. She is part of the MUSC neurology interdisciplinary clinic which is a multidisciplinary team that evaluates patients with movement disorders. She often gives talks on mental health issues related to Parkinson’s disease and other movement disorders at educational events. She is a member of the American Psychiatric Association and the American Academy of Geriatric Psychiatry.