Dan Keller 0:00
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.
Many people with Parkinson’s disease experience depression. Having a chronic disease and possibly being limited in what one can do physically can take an emotional toll. But it’s important to understand that depression is a symptom of Parkinson’s—whether depression is a reaction to the disease or a part of it, it is important to recognize it, report it to one’s health care provider, and work together to treat it.
I spoke with Irene Richard of the University of Rochester, who is both a movement disorders neurologist and a member of the university’s Department of Psychiatry. She explains how depression is quite common in Parkinson’s.
Irene Richard 1:26
Estimates vary, but up to 50% of people who have Parkinson’s disease experience what we’d consider to be clinically significant depression, meaning depression that certainly causes distress or impacts their function. So that’s about half of the people who have Parkinson’s disease will experience it, and that’s more common than in a lot of other diseases that have comparable degrees of disability.
Dan Keller 1:51
So how is it recognized? Does the person with Parkinson’s know they have it? Do they report it?
Irene Richard 1:57
Well, yeah. I mean, that’s interesting. And certainly, as with everything else in Parkinson’s disease, everybody has different manifestations, different symptoms, and it affects them differently.
So what I would say is that very often the person who is depressed will not realize that they are depressed. They probably will not feel well, and they may feel distant from other people. They may not be able to derive pleasure from things that they once found enjoyable, but I think that often people don’t necessarily recognize that as depression.
The important thing, I think, first of all, is just to understand that depression is actually a symptom of Parkinson’s disease. It’s kind of an emotional equivalent to tremor, if that is a motor manifestation. So I think it’s different than being just sad. It’s different than, let’s say, being upset about the diagnosis or frustrated with being unable to do things.
So it’s a disorder that’s made up of a constellation of different symptoms that, again, can differ among people, but the core feature is mood, and in general it’s negative. People may describe it differently—some people may say they are sad, blue, or blah—but in general they don’t feel well emotionally.
In addition to that, they may have other symptoms like problems with sleeping—either too much or too little—problems with appetite—either eating too much or not enough—difficulties with concentrating, fatigue, and perhaps increased pain.
One of the reasons why it’s been so difficult not only for people with Parkinson’s disease and their loved ones to recognize depression in this setting, but also for clinicians, is that there is a lot of overlap in the symptoms between Parkinson’s disease itself and depression.
So if somebody, for example, doesn’t have a lot of facial expression, that can be seen in somebody who is depressed, but it can also be seen in somebody who is perfectly happy but has Parkinson’s disease. People may also have less inflection in their voice and may speak more softly when they are depressed—but that same thing can happen in Parkinson’s disease even when someone is happy.
So a lot of times people may attribute this either to Parkinson’s itself or to a “normal reaction”—you know, you’d be depressed too if you had Parkinson’s disease. Certainly, people may be upset at the diagnosis or frustrated by limitations, but that is different. Sometimes we call that a reactive phenomenon, as opposed to an underlying depression, which is really a manifestation of the disease itself.
I don’t think it’s a coincidence that many signs and symptoms of depression overlap with Parkinson’s disease, because the pathways and circuitry responsible for motor function are interwoven with those that control emotions.
So people really have to be vigilant and have increased awareness of the possibility of depression so it can be recognized by the patient, their loved ones, and clinicians. Under-recognition is a big problem. If you don’t recognize it, you can’t treat it.
Even if you recognize it, people shouldn’t feel hesitant to talk about it. They should feel comfortable bringing it up with their doctor, because many doctors will not necessarily ask about it unless you mention it.
There has long been a stigma around mental health issues, including depression, often because people think it is under volitional control—that you could just snap out of it or have a more positive outlook. But once people understand this is analogous to tremor and not under control, and is part of the disease, then acknowledging it and seeking help is important.
There are treatments available, but you cannot treat it if you do not recognize it.
Dan Keller 6:29
It seems that neurons that produce dopamine radiate into all sorts of parts of the brain, and dopamine is sort of a reward neurotransmitter. Is it that if you lack dopamine, you’re really feeling unrewarded for everything? Is that a basis of depression?
Irene Richard 6:47
That’s a really interesting question, because there have been a number of hypotheses about what causes depression in general, and like Parkinson’s disease, there are probably multiple mechanisms that can result in similar symptoms.
However, you have to distinguish between a depressive disorder—which is more pervasive, lasting weeks, months, or even years—and fluctuating episodes of depressed mood that vary with motor fluctuations in people treated with carbidopa/levodopa.
When dopamine levels are low, people may have worsening motor symptoms and also depressed mood. When they take levodopa and dopamine levels improve, they often feel better.
So there is a dopamine-sensitive component of mood. However, the longer-standing depressive disorder is likely not directly related to dopamine. Other neurotransmitters such as serotonin and norepinephrine are involved.
Antidepressants such as SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin-norepinephrine reuptake inhibitors) have been shown in clinical trials to be effective in treating depression in Parkinson’s disease.
Importantly, Parkinson’s medications that treat motor symptoms do not generally cause depression. One exception is dopamine agonists, which may have some antidepressant effects.
Overall, antidepressants are effective and well tolerated and do not worsen motor function.
Dan Keller 10:16
Is apathy a symptom of depression? Does it go along with it? Or are they the same thing?
Irene Richard 10:30
Apathy is a great point. It can occur in depression, but in Parkinson’s disease it can also occur as its own symptom.
Someone can be apathetic without being depressed. There may be some correlation overall with cognitive impairment, but not in all individuals.
In depression, people feel distress or negativity. In apathy, people often do not feel distress—they simply do not care. It is often the family who becomes distressed.
There are currently no strong medications for apathy, whereas depression does have effective treatments.
Dan Keller 12:33
So what is a person to do? First report it to their movement disorder specialist?
Then who takes over—the psychiatrist or neurologist?
Irene Richard 12:39
It depends on the situation and where someone receives care. The most important thing is awareness that depression is a symptom of Parkinson’s disease.
People may lose pleasure in activities they once enjoyed. They may have trouble concentrating or sleeping. These changes should raise awareness.
Once recognized, patients should speak with their doctor—neurologist or primary care physician. Some neurologists are comfortable prescribing antidepressants. In more complex cases, a psychiatrist or psychologist may be involved.
A team approach is often best.
Non-pharmacologic treatments such as cognitive behavioral therapy can also be helpful. Often a combination of medication and therapy works best.
People often ask whether to stay on medication once they feel better. In many cases, stopping can lead to recurrence of symptoms, so many patients remain on treatment if it is tolerated.
Dan Keller 16:03
Very good. I appreciate it. Thanks.
To find out more about depression and Parkinson’s, visit parkinson.org and search “depression.”
Don’t miss our upcoming expert briefing on mental health and PD with Dr. Laura Marsh at Baylor College of Medicine on September 18, 2018 at 1:00 p.m. Eastern time. Sign up at parkinson.org/expertbriefings.
You can also call our toll-free helpline at 1-800-4PD-INFO.
Feedback can be submitted at parkinson.org/feedback.
At the Parkinson’s Foundation, our mission is to help every person diagnosed with Parkinson’s live the best possible life today. We bring you a new episode every other week.
For more information, visit parkinson.org or call 1-800-473-4636.
Thank you for listening.
