Many patients with Parkinson's disease develop depressive symptoms severe
enough to discuss with their physician. Below I will address some of the
questions we hear from patients and family about depression in PD.
Is this a big problem?
Roughly 40% of PD patients develop a degree of depression that requires
medical attention. We all know that when you feel bad everything seems
worse. People with depression are more likely to notice their bodily symptoms
and more likely to feel that they can't do what they would like to because
of them. More importantly, major depression is a miserable illness. For
many patients, the depressive symptoms can be a much bigger problem than
the trouble moving.
What can you do about depression in PD?
This depends on the pattern of the depressive symptoms.
Dopa-related mood fluctuations: If you predictably feel down and sad -- or very anxious -- when your Parkinson's medicine wears off, but fine or even a little "high" the rest of the day, this is a known complication of PD. It affects perhaps 5-10% of people with PD, though many patients and doctors have not heard of it. In this case the ideal treatment is to attempt to smooth out your anti-PD medications' effect throughout the day, or to raise your total daily dose. This is done on an individual basis with your doctor, but some of the available strategies include: larger doses, addition of a medicine like selegiline or tolcapone, or use of a long-lasting medication such as Sinemet CR or pramipexole. Antidepressant medications or psychotherapy are often not needed, though sometimes they can help. We are now doing some exciting research in this area (for further information, see nil.wustl.edu/labs/kevin/studies/onoff.htm or call us at 314-362-6514).
Easy crying: Fairly commonly, people with early PD notice that they cry more easily "out of the blue," at movies, or at other times, even if they're not really sad. (Less often people also find themselves laughing when nothing is very funny.) This pattern of easy crying is probably due to loss of dopamine input to the part of the basal ganglia that controls the brainstem, where our laughing and crying reflexes are located. It usually responds to PD medications or to a rather low dose of an antidepressant.
Normal sadness: If you get down sometimes, feel frustrated with your symptoms and how they affect your life, and have trouble falling asleep from time to time because you are thinking about the real problems in your life, but most of the day you are fine and your sad spells don't correlate with your medicine doses, this is not necessarily an illness. No one has a corner on one right way to treat this, but answers include talking to friends, family, or religious leaders about how you feel; doing things you usually like; and picking up new hobbies, work or volunteer activities (an occupational therapist can be very helpful in this regard). For some people professional counseling may be helpful.
Apathy: Many people with PD lose interest in things and feel unmotivated. Often this comes with other symptoms of major depression and should be treated as such (see below). Other times the apathy comes on its own. In this case, research suggests apathy is a symptom of PD which may respond to an increase in the dosage of one's PD medications.
Steady sadness: If you are sad or disinterested in things most
of the day, nearly every day, for weeks on end, you may have major depression.
This is a real medical illness and should be treated. In my opinion, you
deserve specialty care from a psychiatrist if you are depressed and any
of the following happen: you are not better after 4-6 weeks of any treatment,
you are disabled by your depression, you have thoughts of suicide, someone
in your family has manic-depressive illness, you have hallucinations, or
you wish to be treated with counseling rather than with medications. There
are many treatment options for depression in people with PD. If your PD
is undertreated, raising the dose of your PD medicine can occasionally
help depression in some people. Usually, though, we add a newer antidepressant
such as paroxetine (Paxil) or mirtazapine (Remeron). These tend to be well
tolerated by most PD patients. However, if you are taking selegiline (Eldepryl),
you should discuss this carefully with your doctor; we usually stop the
selegiline but if there is a strong reason to continue it in your case,
I would recommend combining the selegiline with desipramine rather than
most other antidepressants. It often takes 4-6 weeks of an adequate dose
(e.g., 20mg/day of paroxetine) to see complete results. Many patients also
benefit from expert counseling, say every week or two for 2-3 months. Most
people are helped by one of the foregoing options, but some patients benefit
most from a hospital stay, or from modern ECT (electroconvulsive therapy).
The bottom line is that we have lots of tricks up our sleeves to treat
depression and most people can be helped.
What causes depression in PD?
Experts talk about 3 possibilities: (1) It is just a coincidence since both Parkinson's disease and depression are common. (2) We already know something goes wrong with the brain in PD, and since the brain is what makes us happy or sad, depression is just another symptom of PD. (3) Of course people get sad -- they don't like having a physical illness.
In an individual person, we can not usually sort out these 3 possibilities. However, research can help us figure it out in general. Here are my conclusions from seeing patients and reading the available research studies. (1) Yes, some people were going to be depressed anyway. They may have already had major depression earlier in their life, or it may run in their family. (2) But in many people, depression is clearly a symptom of PD. Reasons for saying this include: major depression is more common in PD than in people with non-brain diseases like arthritis, it happens equally in men and women with PD whereas generally depression is twice as common in women, its symptoms are different from those of ordinary major depression in certain ways, it can start for the first time late in life when things are going well and the person has weathered many life storms without depression, and it can start before the person even knows he has PD. (3) Almost everyone with PD has mild sadness and frustration from time to time and I think this is normal.