Diagnosis
Diagnosis can be tricky for people with Parkinson’s. Depression is sometimes wrongly diagnosed in people who are not depressed and not detected in those who are.
Speech and communication can be difficult for people with Parkinson’s and they may look sad or unenthusiastic because of diminished body or facial language, not because they are depressed.
There are occasions when it is assumed that people with Parkinson’s are depressed because they may be less willing to take part in social activities that they enjoyed before they were diagnosed.
Some Parkinson’s symptoms, such as slow movements, sleep problems, difficulty in concentrating, tiredness and reduced libido can also be considered as signs of depression.
As a rule, diagnosis is reached through asking questions about symptoms, mood and other indications. ‘Rating scales’ for depression are ideally used, which involve asking carefully chosen questions, the responses to which are measured according to a points system. Those with high scores may then be interviewed further to determine whether they are indeed depressed. Scales are also useful in determining the severity of depression and tests may be repeated to monitor the effects of any treatment.
Depression that begins suddenly, perhaps as a reaction to an event such as losing a loved one, early retirement or having to move home, is far easier to diagnose and generally responds well to treatment.
Treatment
Symptoms such as pain and fatigue can be contributory factors so it is important to try and control symptoms effectively. For example, choosing the right medication, reducing stress levels and regular exercise can play vital roles in managing depression. Psychological approaches and counselling can also be important.
Medication
Certain Parkinson’s medications – levodopa infusions, dopamine agonists and selegiline – are generally effective in improving mood although they may not always be appropriate or sufficiently beneficial.
If these are not effective then antidepressant medications may be prescribed. The range is wide - the choice will depend on their benefits and side effects, interaction with other medications and how they suit you as an individual - and your doctor may need to try more than one to find the best treatment for you. Most take four to six weeks to be effective and in some cases may be needed for several months, sometimes with a decreased dose over time. Everyone is different so you must communicate with your doctor to monitor effects.
If you no longer need to take antidepressants it is generally recommended that you reduce the dose slowly to prevent rebound symptoms such as anxiety, headache and irritability.
There are three main classes of antidepressants, each of which may be effective but may have certain side effects:
-
tricyclic (TCAs) - may worsen particular Parkinson’s symptoms in some people but not everyone, namely: orthostatic hypotension (lowered blood pressure while standing), dry mouth, constipation and confusion. They are generally not recommended for older or frail people
-
selective serotonin re-uptake inhibitors (SSRIs) - may cause insomnia, nausea, headache, tremor, agitation and sexual dysfunction. They may not be suitable if you also take selegiline
-
monoamine oxidase inhibitors (MAOIs) - some interact with other medications so not all are recommended.
Psychological treatments
A psychiatrist, psychologist or psychotherapist may help you to feel more positive and overcome feelings of depression. This can be particularly helpful when used alongside medication, particularly in more severe cases. Sometimes it may be useful if your partner or carer is included in consultations.
Cognitive behavioural therapy (CBT) can be helpful in breaking the circle of negative thoughts, emotions and behaviour patterns that surround depression.
A trained therapist will encourage you to talk about how you feel about yourself, those around you and the world in general, and to understand how your behaviour affects your feelings and thoughts. They can help you to make sense of what may seem overwhelming problems, enabling you to deal with them and break the circles and patterns of behaviour linked to depression.
CBT can be on a one-to-one basis or in a group, usually with a course of between 12 to 20 sessions. Homework is often set to help practice changes in thinking and behaviour, and a thought diary may be suggested for noting links between what you do and how you feel. It can also be beneficial in teaching new skills that may help in the long term.
CBT currently is the most often studied and applied psychological therapy for depression and has been proven effective in many controlled studies.
Interpersonal therapy (IPT) can be effective in improving communication and relationships. People with depression often find interacting with others difficult and lose both the desire and the necessary skills to sustain good relationships. IPT focuses on the way people relate and interact with others; how they communicate and express themselves. It can provide practical help to overcome difficulties with ‘social skills’ by teaching the communication techniques needed and finding ways of dealing with challenging relationships or social situations that may occur in the future.
The therapist will work with the person to agree the causes of depression and how to treat it, forming a partnership that may typically last for between 12 to16 one hour sessions.
Counselling
Individual counselling can be very helpful in recognising worries and underlying issues, and working out a strategy to deal with them. Just talking about concerns often improves mood and it can also help to strengthen channels of communication at home.
Herbal treatment
St John’s Wort, a herbal preparation, has been shown to help with depression in general but it is thought to interact with some anti-Parkinsonian medications, so it should be taken only after consultation with your doctor.
Electroconvulsive treatment
Electroconclusive treatment, which involves passing an electrical current through the brain, may be considered in the most severe or life-threatening forms of depression, particularly if other approaches have proved unsuccessful. However, it is crucial to note, this treatment has not been systematically applied and tested in Parkinson’s and its impact on the disease is as yet unknown.
Who can help?
Various trained professionals in the multidisciplinary team may be involved in managing depression, including:
- your doctor
- Parkinson’s Disease Nurse Specialists (PDNS), depending on the country in which you live
- psychiatrists
- counsellors.
More information can be found by asking the various members of the multidisciplinary team, or ask your doctor who else can help you. In some countries appointments with counsellors can only be made with a referral from your doctor. If you book an appointment with a therapist or counsellor remember to check their qualifications and experience.
There are also many organisations that offer various kinds of emotional support such as telephone help-lines, group meetings or practical help. Even if you have close family and friends, sometimes you may want to chat with an outsider and such organisations can be very helpful. Your doctor or a social worker will be able to help you identify such organisations, or you may find contact details in a telephone directory.
