Episode 145: Treating Depression

Dan Keller 0:08 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.

Depression is common in Parkinson's disease, in part caused by a change in brain chemistry and affecting at least 50% of people with the disease. It's not merely temporary sadness, but manifests as overwhelming feelings of sadness, loss, and hopelessness. There are effective medication and non-medication treatments, but because depression is often under-recognized by healthcare providers and underreported by people with PD, it may go untreated, resulting in diminished quality of life.

To get some insights on depression in PD, I spoke with Veronica Bruno, a movement disorders neurologist at the University of Calgary in Canada, a Parkinson's Foundation Center of Excellence. We talked about the need for better recognition and treatment of depression in PD, as well as some of the pharmacologic and non-pharmacologic treatment strategies. Being such a common feature of the disease, I asked her when depression may occur.

Veronica Bruno 1:56 It can appear, interestingly, at any point during the course of the disease. So for many of the people diagnosed with Parkinson's, it may have been a problem years before the onset of the motor symptoms of the disease, and they may have been diagnosed with something unrelated or something else for some time, until finally the diagnosis of Parkinson's is reached. For many other people, it can be part of the time of the diagnosis itself, when they have to learn a lot about the new diagnosis and the disease. And in many other cases, it can appear as a later non-motor symptom of the disease in mid to late stages.

Dan Keller 2:38 So it can be sort of a prodrome; it may eventually reveal Parkinson's disease.

Veronica Bruno 2:45 Exactly, it's one of those prodromal premotor symptoms. In conjunction with constipation, some sleep disturbances, depression, and anxiety—usually combined—can be some of those symptoms that may precede the onset of the motor symptoms up to 20 years.

Dan Keller 3:02 Does it respond to dopamine or does it respond to typical antidepressants?

Veronica Bruno 3:08 So this is a great question. In fact, the physiopathology or the mechanisms of depression in Parkinson's seem to be a bit mixed and different than depression in non-Parkinson's patients or people without Parkinson's disease. So in some instances, when depression is present before the diagnosis and the treatment with dopamine therapy is started, patients notice—people notice—a significant improvement in the depression because of the dopamine medication.

So as a first stage, the most important thing is to chat with the doctor to see, is this depression? If it's depression, could this be related to Parkinson's disease? And if it's related to Parkinson's disease, maybe see if there is any room for optimization of the dopaminergic therapy. If the dopaminergic therapy is at the optimum point, then there is also evidence that many of the regular antidepressants that, instead of working on the dopamine system, work with other neurotransmitters inside the brain, can also be helpful, and it may always make sense to try to see if it produces a further improvement in the symptoms.

Dan Keller 4:21 Can they ever interfere with the dopamine?

Veronica Bruno 4:24 Not with the levodopa, or with most of the medications that people with Parkinson's usually have as a prescription. There is one exception, however, that is important to discuss with the pharmacist and with the physicians. That is when the patients are taking inhibitors of the monoamine oxidase B—this is a difficult name, but medications that maybe are familiar for many people, like rasagiline or selegiline, or safinamide. Those medications have a potential interaction with many of the commonly used antidepressants, so it's important to consider this.

Usually in practice, it's no big deal, but theoretically it can produce a severe side effect. So, at least the patient, the physician, and the pharmacist need to be aware, so they can monitor for potential interactions if they are taking those medications. Safinamide is a bit newer and is supposed to have less of a formal contraindication; however, we still have to monitor for this potential interaction.

Dan Keller 5:30 What about non-pharmacologic interventions, often called talk therapy?

Veronica Bruno 5:35 Yes, so of course the evidence, in terms of publications or studies comparing, say, cognitive behavioral therapy, counseling, or psychotherapy, is less than the ones that we have for pharmacological therapies. However, as in many other populations, people that can experience depression benefit from being able to share the emotions that are maybe triggering or worsening those symptoms, identifying if there is something triggering those types of thoughts or symptoms, and also being able to share.

Because sometimes what everyone assumes is depression may be something different, like some anxiety, or maybe just sadness, or the patient may be feeling lonely or isolated, or you may just be experiencing other symptoms of Parkinson's disease, like some memory changes or apathy. So, it's very important to find your space to discuss what you're experiencing with someone that can be your neurologist, can be your family physician, can be your family, or any other health professional, like a specialized nurse or a counselor. Once that you can put into words what symptoms you're experiencing, it's easy to reach, get a diagnosis of what's the main problem, and then tackle the problem appropriately with pharmacological or non-pharmacological approaches, and whatever it may be necessary to make you feel better.

Sometimes many clinics, many of the centers that treat patients or people with Parkinson's, mostly they have neuropsychiatrists or psychiatrists that are specialized in the management of people with movement disorders and people with Parkinson's disease, and that's usually extremely useful. Because it's not like just treating depression like in the general population, but taking into account all these elements that are very unique for Parkinson's disease, and they consider them when they are planning the best possible management plan.

There are other non-pharmacological interventions that are important, and they are useful, and they have shown to be very useful, independently of psychotherapy, or as you mentioned, counseling, or talk therapy, like exercise. Exercise has a dramatic effect on mood in Parkinson's disease. There is, like, evidence in terms of studies that have shown it, but in clinical experience, we can probably all say that every single person that I know with Parkinson's who has started a good exercise program not only notices the benefits on the motor aspects of the disease, but a significant improvement in mood and anxiety and depression as part of that spectrum.

Dan Keller 8:33 Also, thinking fatigue, things like that—does treating depression help with those, or does exercise in itself help with those?

Veronica Bruno 8:41 Yeah. Well, fatigue seems to be, for what we know today, a separate symptom that sometimes can be associated with depression in Parkinson's, and sometimes it's not associated with depression. But for sure, fatigue itself in the general population is a symptom of depression. So when you're experiencing fatigue and there's not a clear cause, it's again very important to discuss this—not assume that this is normal or this is part of the disease and you have to deal with it, but maybe discuss this with your health providers.

Because maybe, again, optimizing the management of your medications, evaluating if there is a component of depression, and treating it with different types of interventions can reduce the fatigue, and also give you more energy to then engage in an exercise program, in a psychotherapy, in seeing your friends and family, and like doing more things that you are engaged with and that you enjoy. And that, for sure, like a vicious positive cycle, ends up improving all the symptoms.

Dan Keller 9:45 I understand that depression has been correlated with later dementia. Does treating depression stave off or lessen the risk of dementia, or isn't it known?

Veronica Bruno 9:58 This is an amazing question. This is still unknown for multiple reasons. I think first, depression is so prevalent in people without Parkinson's that it's very hard to characterize: is this like a depression that is directly related to Parkinson's disease, or is it just like a co-occurrence of health issues? The second thing is like cause and effect is hard to determine.

What we know, and I think at this stage is very important, is that if we treat depression, people with Parkinson's quality of life improves significantly. If quality of life improves, patients are more engaged in other therapies. The motor symptoms also improve, the participation in social and family lives improves, and all those, like exercise, social interactions, intellectual stimulation, for sure help reduce the risk of cognitive impairment and dementia. So, even if I don't have the hard evidence to say yes, for sure, treating depression reduces the risk of dementia in X percent, we can say that it helps so many aspects of the disease that the outcome by the end is reducing the risk of a significant impact on cognition.

Dan Keller 11:18 What do you see for the future in terms of depression in PD?

Veronica Bruno 11:23 As you know, Parkinson's disease has more than 200 years, but the focus on non-motor aspects of the disease, such as depression, is not as old, because for many years those symptoms were kind of neglected. So now that we are all on the same page in terms of how important recognizing these non-motor symptoms is, including depression, I see that many good outcomes are coming in terms of non-pharmacological therapies. We know a lot—there have been many at least done, but maybe they need to be refined in terms of methodology to make sure we are treating the right symptoms at the right time.

In terms of medications, we also know a lot, and we know that there are a variety of options that people with Parkinson's can try safely. So what I can see as the future initially is more recognition of a very common problem that can have a significant impact on people's life, and then potentially more targeted therapies that would contemplate the particular aspects of depression in Parkinson's disease, not treating it as in a person without Parkinson's.

Dan Keller 12:41 Do patients tend to gloss over it with their physicians? They're more focused on motor symptoms, and they just figure this is something else that really doesn't have to do with Parkinson's. So, if it's under-recognized, it's under-treated.

Veronica Bruno 12:57 100%. This is a bit dependent on the time that you have for your consultation with your neurologist. The fact that, as I mentioned, for many years these aspects of the disease were not taken into account, so people would go to the neurologist and just discuss the motor signs, like the tremor, the stiffness, the slowness, but would not discuss in detail other aspects, like "I'm experiencing these new feelings, I'm feeling pretty down. Is this part of the disease?"

Or care partners and family members would assume that the person with Parkinson's is feeling down because of the diagnosis, instead of thinking that maybe this is part of the chemical problems that are associated with the disease, and may have a potential treatment. So I think from both sides it's very important for us to keep a lot of information out there for the patients to get to learn more about these non-motor aspects of the disease, and from us—from our perspective, for us physicians and care providers in general—to ask about these things.

Because again, as I said many times, sometimes problems like depression and other non-motor aspects of the disease have a higher impact on quality of life than the tremor, the stiffness, or the slowness. And patients may, and physicians too, may underestimate the relevance of recognizing depression, treating it, and the change that that can produce for that particular person and the rest of the activities in their lives.

Dan Keller 14:37 Sounds like a good message, both to healthcare professionals and to patients to ask about it or tell about it.

Veronica Bruno 14:44 Exactly, and I think this is in fact exceeds Parkinson's disease, but is particularly important in Parkinson's disease. When depression is affecting someone, everything is more complicated. Engaging in therapies that would help your other symptoms becomes harder; it's easier to be more isolated, to stay at home, to stay in bed. All those things will worsen many of the other aspects of the disease.

So, understanding that this is a common problem that we need to be very aware of, and the most important part is for many of the issues that may affect Parkinson's disease patients, we don't have a treatment, but for depression, we have treatments. And usually people with Parkinson's respond very well to the different therapeutic approaches that we have for it. So, let's talk about it, because there's a lot that we can do.

Dan Keller 15:41 Excellent. Thank you.

There are a few simple guidelines to help prevent or treat depression. First, get screened for depression at least once a year. Second, discuss mood changes with your doctor, and third, have a family member accompany you to your doctor visit who can help you talk about your symptoms of depression.

For information on the various causes of depression in PD, its symptoms, diagnosis, treatment options, and coping strategies, go to parkinson.org and click on "Understanding Parkinson's" at the top of the page, then select non-movement symptoms and scroll down to depression. There you'll also see links to an Expert Briefing, fact sheets, a podcast, and related blog posts.

More information in the form of podcasts and a book can be found by going to our library at parkinson.org/library and checking the box for mental wellness. Particularly on topic is a podcast called Depression in Parkinson's and two fact sheets called Depression and PD: A Non-Drug Treatment Option, and Combating Depression, as well as an Expert Briefing titled Expert Briefing: Depression and PD. Finally, our free book, called Mood: A Mind Guide to Parkinson's Disease, contains a large section devoted to depression. It's available for reading online, for download, or by ordering a physical copy.

News and updates about future events and resources are available by joining our email list at the bottom of our website's homepage. If you want to leave feedback on this podcast or any other subject, you can do it at parkinson.org/feedback. If you enjoyed this podcast, be sure to subscribe and rate and review the series on Apple Podcasts or wherever you get your podcasts.

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'll be bringing you a new episode in this podcast series every other week. Till next time, for more information and resources, visit parkinson.org or call our toll-free helpline at 1-800-4PD-INFO. That's 1-800-473-4636. Thank you for listening.

Dr. Veronica Bruno, MD, MPH is a neurologist with a subspecialty in movement disorders. She received her medical degree and neurology residency in Buenos Aires, Argentina. She completed her fellowship in Movement Disorders at the University of Toronto and a Master of Public Health degree at the Harvard TH Chan School of Public Health.

Dr. Bruno was recognized with different international awards including the American Academy of Neurology and American Brain Foundation Clinical Fellowship and the Argentine Presidential Fellowship in Science and Technology, part of the U.S. State Department’s ‘100,000 Strong in the Americas’ initiative. 

Dr. Bruno’s primary interest is the treatment of advanced Parkinson’s disease, with a particular research interest in the non-motor symptoms of the disease. She has also a special interest in Global Neurology and the search for innovative solutions to improve the quality of neurological care in low and middle-income countries.