Managing Anxiety And Depression In Parkinsons Disease
A combination of medication and other therapies can help ease non-motor symptoms affecting those with Parkinsons disease.
Most people think of Parkinsons disease as marked only by tremors, muscular rigidity and slow, imprecise movements, but Parkinsons is more than a movement disorder.
Most people with Parkinsons also have quite a few non-motor symptoms, such as anxiety, depression and psychosis. Many of these symptoms may have started before the Parkinsons disease became obvious.
The effects are widespread. Several years ago, a large clinical study of more than 1,000 people with Parkinsons disease of various durations demonstrated that only 1.4 percent of the participants did not report any non-motor symptoms.In other words, 98.6 percent of the study participants had some form of NMS. Psychiatric symptoms accounted for 60 percent, while visual hallucinations that could have signified psychosis were present in about 35 percent of patients.
Thats why taking action is important. If you or a loved one has had a new diagnosis of Parkinsons disease, we recommend an immediate evaluation for depression, mood and cognitive problems. Frequent monitoring should also be done throughout the course of the disease.
Here are some of the common symptoms and treatment methods for Parkinsons patients with depression and dementia:
How Stress And Anxiety Are Related To Parkinsons And What You Can Do About It
People with Parkinsons disease often notice that their symptoms are worse when they are under stress. Stress, or emotional strain due to difficult circumstances, is an inevitable part of life for everyone, and can be caused for example, by tension with family or employers. Stress is therefore a response to an external situation.
In addition to life stress, people with PD may experience anxiety as part and parcel of their PD itself, caused by chemical imbalances in the brain. Anxiety is a very common non-motor feature of PD and is often accompanied by depression. Anxiety can also fluctuate throughout the day along with dopamine levels, with anxiety experienced most acutely during OFF periods.
Anxiety is fueled by internal forces and can persist when all external causes of stress have been resolved. It is often difficult for a person with PD to separate out stress and anxiety because practically, they may manifest in indistinguishable ways. Both can cause excessive worry, poor sleep, and inattention, as well as physical symptoms such as rapid heart rate, trouble breathing, sweating and headaches. In a past blog, I explored the perspectives of people with PD as it relates to their mental health.
Why Is Expert Care Important
Early expert care can help reduce PD complications. Findings show that 60 percent of people with Parkinsons fall short of getting the expert care they need. The National Parkinson Foundation has estimated that about 6,400 people with Parkinsons die unnecessarily each year due to poor care.
Trained neurologists will help you recognize, treat and manage the disease. Common approaches include medication, surgical treatment, lifestyle modifications , physical therapy, support groups, occupational therapy and speech therapy. The best approach is interdisciplinary care, where you are seen by multiple specialists on a regular basis and all of the specialists talk and arrange the best possible coordinated care. This is what is referred to as a patient-centric approach to Parkinsons care.
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Changes In Sleeping Patterns
As Parkinsons progresses, you can also develop problems with sleep patterns. These may not happen in the early stages, but can be noticeable later. You might wake up often in the middle of the night or sleep more during the day than you do at night.
Another common sleep disturbance for people with Parkinsons is rapid eye movement sleep behavior disorder. This is when you start acting out your dreams in your sleep, such as verbally and physically, which can get uncomfortable if someone is sharing your bed. Dr. Rundle-Gonzalez says many times a bed partner will be the one to notice sleep problems.
REM sleep behavior disorder can also happen in people who dont have Parkinsons. However, if this isnt something youve dealt with before, its likely related to your disease. There are medications your doctor can prescribe to help you sleep comfortably through the night.
Nonpharmacologic Interventions For The Self
Susan K. Chandler
Abstract
Anxiety in Parkinsons disease is underdiagnosed, undertreated, and understudied. As many as 50% of persons diagnosed with Parkinsons disease are reported to suffer from anxiety. Current treatment is largely pharmacologic, which can result in a myriad of undesirable and unsafe side effects. The aim of this paper is to examine intervention studies of self-managed nonpharmacological strategies for the treatment of anxiety. A comprehensive review was conducted on experimental or quasi-experimental trials that included self-management approaches for the nonpharmacologic treatment of anxiety as a primary or secondary aim or outcome measure. Thirteen studies were identified from four databases. Study quality demonstrated variability in design and delivery of self-managed interventions sample sizes were small anxiety was most commonly a secondary aim and the use of anxiety measures varied widely. Statistical significance was evident in slightly more than 50% of the anxiety intervention studies. A common element in the interventions in all studies was the focused use of breath. Further research is needed to determine the feasibility of using focused breathing, alone, as an intervention for the self-management of anxiety in Parkinsons disease.
1. Introduction
2. Methods
3. Results
3.1. Study Characteristics
3.2. Experimental Studies
3.3. Quasi-Experimental Studies
4. Discussion
5. Conclusion
Conflicts of Interest
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Mood Changes In Parkinson’s
When faced with a diagnosis of Parkinson’s disease , it is understandable to feel depressed or anxious. But mood disorders such as depression and anxiety are clinical symptoms of Parkinson’s, just as are slowness of movement and tremor. In fact, up to half of all people with Parkinson’s may suffer from depression and/or anxiety at some point during the course of their disease. Like all symptoms of PD, mood changes are different for different people. Some people with depression feel sad and lose interest in things they used to enjoy, while others feel irritable and have difficulty sleeping. People with anxiety often feel overly worried or concerned, or say they are “on edge.”
The good news: Over the past decade, researchers have placed increasing focus on these aspects of PD, and today we have a better understanding of how to treat mood disorders in Parkinson’s.
Mood Changes In Parkinsons
When faced with a diagnosis of Parkinsons disease , it is understandable to feel depressed or anxious. But mood disorders such as depression and anxiety are clinical symptoms of Parkinsons, just as are slowness of movement and tremor. In fact, up to half of all people with Parkinsons may suffer from depression and/or anxiety at some point during the course of their disease. Like all symptoms of PD, mood changes are different for different people. Some people with depression feel sad and lose interest in things they used to enjoy, while others feel irritable and have difficulty sleeping. People with anxiety often feel overly worried or concerned, or say they are on edge.
The good news: Over the past decade, researchers have placed increasing focus on these aspects of PD, and today we have a better understanding of how to treat mood disorders in Parkinsons.
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Living With A Dog With Parkinsons Disease
Living with a dog with any kind of degenerative disease can be challenging. Your dog is likely very confused about what is going on with their body. A dog with Parkinsons disease will feel out of control and betrayed by their body almost.
Its important to be gentle with your dog during this time.
Though Parkinsons disease is incurable and progressive, there are some things your vet may recommend that will help with your dogs quality of life for as long as possible.
Managing Depression In Parkinsons Disease
People with Parkinsons, family members and caregivers may not always recognize the signs of depression and anxiety. If you are experiencing depression as a symptom of Parkinsons, it is important to know it can be treated.
Here are some suggestions:
- For information and support on living well with Parkinsons disease, contact our Information and Referral line.
- As much as possible, remain socially engaged and physically active. Resist the urge to isolate yourself.
- You may want to consult a psychologist and there are medications that help relieve depression in people with Parkinsons, including nortriptyline and citalopram .
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Reviewanxiety: An Ignored Aspect Of Parkinsons Disease Lacking Attention
Anxiety is a neuropsychiatric complication of Parkinsons disease .
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Anxiety has been given less attention while treating PD.
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Management of anxiety is crucial to improve quality of life of the affected patients.
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Use of complementary based medicines could be beneficial.
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Alternative approaches will lead to novel therapeutic treatment for PD and various complications associated with it.
What Depression Looks Like
Depression isnât the same for everyone. You might feel sad or lose interest in things you normally enjoy. You might feel upset and edgy. You could have trouble sleeping. Itâs more than just feeling sad.
It isnât always easy to spot, especially in yourself. Your family, friends, or doctor may notice it before you do.
Symptoms of depression often include:
- Changes in appetite
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How Can Parkinsons Disease Cause Depression
For many people, the challenges of Parkinsons disease are enough to cause depression.
But scientists believe that depression in Parkinsons might also come from changes to certain chemicals in the brain:
- Losing interest in activities you once enjoyed.
- Losing interest in eating or taking care of yourself.
- Moving or talking too slow.
- Thinking a lot about dying or wishing to die.
Guidelines For Cbt For Depression And Anxiety In Parkinsons Disease
In terms of which patients it is appropriate to use CBT with, we suggest that this treatment is utilized in PD patients who do not have dementia. In trials we have typically excluded patients who score less than 24 on the Mini Mental State Examination. It is also helpful if the patient expresses some degree of willingness to attend psychotherapy, those who have been referred by a partner/carer but who are reluctant to attend of their own accord may be difficult to engage in therapy. In a recent book on CBT with older people, guidelines for working with clients with chronicity and comorbidity, Laidlaw updated previous recommendations that clinicians may find useful when working with clients presenting with depression and anxiety in PD . These include
The final stage of CBT involves individualized relapse prevention to ensure CBT is continued. The aim of CBT is for the person to become their own therapist and to continue to use the cognitive techniques of thought diaries, behavioral experiments, and behavioral activation to challenge negative cognitions and symptoms of depression and anxiety in the future.
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Patients Depression Often Carries Over To Care Partners
Anxiety is a common nonmotor symptom of Parkinsons, occurring in nearly half of patients at some point in their lives. It can lead to worse emotional well-being, impaired daily functioning, and quality of life declines, all of which can contribute to burdens on patients and their caregivers.
While risk factors for developing anxiety have been proposed, only a couple longitudinal analyses have been done and the predictors arent well established.
Understanding predictors of anxiety symptoms in may help us to identify patients at risk for anxiety disorders, the researchers wrote, noting symptom burden could be reduced by interventions that targeted modifiable predictors of anxiety.
Limitations And Direction For Future Research
There are several limitations to this meta-analysis. First, the restriction of studies to only those in English language excludes trials conducted and reported in non-English speaking countries. The second and primary limitation of this meta-analysis concerns the limited number of studies available for inclusion for analysis which has important implications for the interpretation of findings. As previously noted, while current results indicate that the pooled effect of antidepressant therapies for the treatment of depression in PD is non-significant, this result may likely represent a Type-II error given that moderate to large effect sizes were observed. There is a pressing need for more well-designed placebo-controlled trials of SSRIs in PD to provide a more accurate estimate of treatment effect, especially given that such treatments currently constitute the first-line approach for depression and anxiety in PD.
There is also a need for research and treatment trials specifically for anxiety in PD. While the empirical literature for depression treatments in PD is steadily increasing, the dearth of empirical research on the treatment of anxiety disorders in PD was highlighted in this study, with no RCTs of any treatment intervention for anxiety in PD identified. While anxiety and depression share an overlap of symptoms, there are core components of anxiety disorders that are distinct from depression and that require specific clinical attention.
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How Are Cognitive Changes In Pd Different Than Alzheimers Disease
Overall, dementia produces a greater impact on social and occupational functioning in PD than Alzheimers due to the combination of motor and cognitive impairments.
There is some overlap between symptoms and biological changes seen in Alzheimers and PD. However, it is less likely for both disorders to occur at the same time. Development of dementia in people with PD represents progression of the disease, usually after several years of motor impairment.
Dementia may or may not occur in people with PD. According to recent research, 30% of people with Parkinsons do not develop dementia as part of the disease progression.
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Depression And Parkinsons Disease
Depression can be a disabling symptom of PD, and it may negatively affect a persons long-term outcomes by causing them to withdraw from social situations, avoid activities like exercise, or being more reluctant to seek care. Some people experience depression as an early symptom of PD before the characteristic motor symptoms appear.2
Depression has a variety of symptoms, not all of which are experienced by every patient. Symptoms of depression can also range in severity or vary over time. Common symptoms of depression include:
- Persistent sad, anxious, or empty mood
- Feelings of hopelessness or pessimism
- Feelings of guilt, worthlessness, helplessness
- Loss of interest or pleasure in hobbies or activities, especially those which were previously enjoyable
- Difficulty concentrating, remembering, and making decisions
- Difficulty sleeping, early-morning awakening or oversleeping
- Appetite and/or weight changes
- Thoughts of death or suicide
- Restlessness, irritability
- Persistent physical symptoms3
There are many treatment options for depression that work well in people with PD. There are several types of antidepressants, including selective serotonin reuptake inhibitors , tricyclic antidepressants, and selective norepinephrine reuptake inhibitors . Many people also experience relief from their depression through psychological counseling, such as cognitive behavioral therapy. In addition, regular exercise has been shown to ease symptoms of depression.1,4
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Anxiety And Antiparkinsonian Medications
There is no consensus on whether antiparkinsonian medications are responsible for symptoms of anxiety in Parkinsons disease.
Stein et al found that the levodopa dose was similar in anxious and non-anxious patients. Hendersonet al noted that 44% of patients with Parkinsons disease noticed anxiety symptoms before starting levodopa. Menza et al found that the levodopa dose did not significantly correlate with anxiety levels: they suggested that anxiety in patients with Parkinsons disease is unlikely to be a side effect of levodopa treatment. In contrast, Vasquez et al found that panic attacks were related to levodopa therapy but not to other agonist drugs.
Lang reported anxiety in five of 26 patients when pergolide was added to their treatment regimen. Menza et al found no differences in measures of anxiety in patients receiving or not receiving pergolide. Menzaet al found no differences in measures of anxiety in patients receiving or not receiving selegeline.
The temporal relationship between panic attacks and off periods have led some authors to suggest that panic attacks may be related to falling brain levodopa levels. Anxiety fluctuations may be an important component of levodopa induced fluctuations. In a double blind placebo controlled trial, Maricle et al found that anxiety levels fell and motor performance improved during a levodopa infusion.
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Anxiety And Parkinsons Research
What does this finding mean for the future of diagnosis or treatment of Parkinsons? Ongoing research is compelling, says Pontone. Part of what we are doing is looking at anxiety disorders that occur long before the onset of Parkinsons to see if there are characteristics that may differentiate that anxiety or predict an increased risk of Parkinsons disease.
Meanwhile, because theres an established link between anxiety and Parkinsons disease, patients and their families should be upfront with their doctors about anxiety symptoms. Behavioral therapy and medications for example, anti-anxiety meds or antidepressants can effectively treat anxiety disorders. Theres no need for anyone to suffer in silence.
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Discuss With Your Physician
Non-motor symptoms can sometimes be difficult to recognize. Therefore, it is important to make your doctor aware of them.
One useful resource is the PD NMS Questionnaire. You can use this to record your symptoms and discuss them with your doctor.
Dr. Ron Postuma, whose research was funded by donations to the Parkinson Canada Research Program, has also developed tools to help people with Parkinsons and their physicians identify and manage non-motor symptoms.
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