Managing Depression in Parkinson’s Disease

Parkinson's disease (PD) occurs when dopamine-producing cells in the brain die. Dopamine is a chemical that carries messages between nerve cells. This loss of dopamine causes motor (movement-related) symptoms like uncontrollable shaking and stiffness.

Dopamine depletion in PD is also associated with non-motor symptoms like depression, a serious mental health condition that negatively impacts how you feel and think.

Depression is common in PD and is often an early (if not first) symptom of the disease. If left untreated, depression can have a drastic, negative effect on a patient's quality of life and daily functioning.

This article addresses how depression develops in PD, including the role dopamine plays. You'll also learn about the symptoms of depression in patients with PD and how doctors go about treating it.

How Does Depression Work?

Depression is more than simply feeling sad. It's a common condition that interferes with how you function in your everyday life, whether at home or work.

Why depression occurs in some people and not others remains unclear, although it's likely that some combination of your DNA and environmental factor(s) play a role.

One interesting theory relating to the development of depression in PD revolves around stress and the neurotransmitter (chemical messenger) dopamine.

We know that psychological stress activates your hypothalamic-pituitary-adrenal axis (HPA axis) and that depression is associated with HPA-axis hyperactivity.

Activation of the HPA axis triggers the release of cortisol, which leads to all sorts of inflammatory and hormone changes in your body, including the possible lowering of dopamine production in your brain.

Since PD is also characterized by the loss of dopamine in the brain, experts believe that low dopamine levels from early life stress may make a person more vulnerable not only to depression but also eventually to PD. Even more, depression may be a risk factor for developing PD later on in life.

Effect on Parkinson’s Patients 

Depression affects around 40% of patients with PD, but its diagnosis is often missed. One reason for this is that the symptoms of PD and depression, like lack of energy or trouble sleeping, often overlap.

Depression may also be missed as doctors focus the bulk of their appointment time on addressing more obvious or "visible" physical/motor symptoms like speech or walking problems.

Likewise, patients may be hesitant to discuss their feelings or emotions with their doctor. Perhaps they worry about being a burden to their family or care partner or assume their depressive symptoms are unfixable or simply part of their PD.

Unfortunately, the unintended effect of not diagnosing and treating depression worsens disability and leads to a poorer quality of life for patients with PD.

Other Stress-Related Disorders 

Besides depression, two other stress-related mental health conditions associated with PD are anxiety and post-traumatic stress disorder (PTSD). Anxiety, in particular, is like depression in PD in that it's often an overlooked but early symptom.

In addition, like depression, PTSD and anxiety are linked to brain changes associated with some form of psychological stress or emotional trauma. PTSD and anxiety have also been found separately to increase a person's risk for developing PD.

Symptoms of Depression in Parkinson’s Disease

The symptoms of depression in PD can be difficult to tease apart from the symptoms of PD itself.

For example, apathy, which is a lack of energy or interest in everyday activities, is a symptom of various mental health disorders, including depression. Apathy is also common in patients with PD, whether or not they have depression.

Fatigue is another common and disabling symptom of PD that may also occur with depression. The fatigue of PD can worsen underlying depression or vice versa, creating a vicious cycle that can be challenging to untangle and treat.

To help screen for depression in patients with PD, doctors often focus on depressive symptoms that do not normally occur in PD. Among them:

• Sadness occurring for more than two weeks
• Guilt
• Inability to feel pleasure (anhedonia)
• Feelings of worthlessness
• Social withdrawal that is not a result of reduced mobility or speech problems
  
  

Coping With Mental Health

Once diagnosed with depression, treating it is paramount to feeling, functioning, and living well with PD. The good news is that there are several treatment options available.

Non-Pharmacologic Treatments

Some patients with PD prefer to start with natural or non-pharmacologic treatments or use them as add-on therapies to medication.

Among those that may help with depression in PD are:

• Cognitive-behavioral therapy has been found to be a safe and effective therapy for patients with PD and depression. This type of therapy entails talking with a psychologist or therapist to help change the way you think and act.
• Taking fish oil with or without an antidepressant may be helpful in patients with PD and depression, although further research is needed.
• An intervention called repetitive transcranial magnetic stimulation (rTMS) has been found to improve depression in PD to a similar degree as taking an antidepressant.
• Joining a support group, either virtually or in-person, can also be beneficial. PD support groups have been found to help lower stress, serve as a source of comfort, and improve quality of life.

Self-Care

Managing depression and a disease that slowly worsens over time, like PD, requires care from medical professionals and care from within yourself.

Here are some self-care strategies that may help you maintain your overall health and well-being:

• Stay active—you might try yoga or tai chi.
• Eat a balanced diet and keep yourself at a healthy weight.
• Take your medications on time to avoid worsening your symptoms.
• Engage in regular deep breathing exercises or mindfulness meditation.
• Practice self-compassion (allowing yourself the freedom to be imperfect).
• Learn how to set limits and boundaries.
  

Prescription Treatments

The scientific data supporting the benefit of treating depression in PD with medication is still being explored.

The antidepressants with the best evidence include:

• The selective serotonin reuptake inhibitors (SSRIs) Celexa (citalopram), Zoloft (sertraline), Paxil (paroxetine), and Prozac (fluoxetine)
• The serotonin-norepinephrine reuptake inhibitor (SNRIs) Effexor (venlafaxine)
• The tricyclic antidepressant Elavil (amitriptyline)

Interestingly, Mirapex (pramipexole), a dopamine agonist (a drug that mimics the effects of dopamine), has also been shown to reduce depressive symptoms in patients with PD.

If you and your doctor decide to try an antidepressant, the potential side effects of the drug, especially in relation to your underlying PD, will be a major deciding factor when choosing among the various options.

An SSRI is typically tried first, considering its low side effect profile. Your doctor will monitor you closely, though, as there is some concern that SSRIs can worsen a person's motor symptoms.

Helping as a Caretaker or Ally 

Whether you are a neighbor, friend, family member, or caregiver (or some combination) to someone with PD and depression, know that it's normal to feel powerless and overwhelmed by their condition and your relationship.

Even though you cannot "fix" what is going on, there is a lot you can do to provide comfort and support. Among them:

• Organize a simple outing to get coffee or see a movie.
• Prepare a home-cooked meal or bring over their favorite snack or flower to show you are thinking of them.
• Assist with household tasks (e.g., grocery shopping or pet care).
• Offer to drive them to therapy or doctor appointments.
• Attend a support group meeting with them.

Summary

Depression is common in people with Parkinson's disease and may be an early symptom of the condition. It may not be recognized as its symptoms can overlap with those of PD. Treatment for depression in Parkinson's disease can include talk therapy, support groups, self-care, and medications.

A Word From Verywell

If you suspect you or your loved one with PD is experiencing depressive symptoms, please reach out to your neurologist or primary care physician. While a new diagnosis of depression can be frightening or upsetting, know that the right treatment plan can help manage the condition.

It's also sensible if you have PD to ask your doctor to screen you for depression because you or your doctor may be unintentionally attributing depressive symptoms to PD, stress, or something else.