In mid-May, the Parkinson Society of British Columbia offered a webinar on depression and Parkinson’s disease (PD), featuring Dr. Fidel Vila-Rodriguez. He discussed the symptoms and treatment options for depression, as well as the state of research into depression and PD, briefly touching on experimental forms of neurostimulation to address depression. There was a question and answer session as well. We at Stanford Parkinson’s Community Outreach viewed the webinar and are sharing our notes.  

This webinar was recorded and can be viewed here. 

If you have questions about the webinar, you can contact the Parkinson Society of British Columbia at 800-668-3330 or by submitting a message on their website.

For additional resources on depression  –  including downloadable guides, links to online resources, and webinars and podcasts – see this page on the Stanford Parkinson’s Community Outreach website.

If you are in crisis, call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or visit suicidepreventionlifeline.org.

Now… on to our notes from the webinar.

– Lauren

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Depression and Parkinson’s disease – Webinar notes

Presented by the Parkinson Society of British Columbia

May 12, 2020

Summary by Lauren Stroshane, Stanford Parkinson’s Community Outreach

Dr. Fidel Vila-Rodriguez is a professor of Psychiatry at the University of British Columbia. He provided a brief overview of Parkinson’s disease (PD), with its classic motor symptoms. However, we have learned there are also seem to be PD sub-types; not everyone has all the symptoms and the disease presents quite variably among different people. For some, the non-motor symptoms of PD are more evident and more detrimental to quality of life. Non-motor issues also tend to be more challenging to treat than motor symptoms. Anxiety and depression are very common; sometimes psychosis or hallucinations can also arise. Autonomic dysfunction, such as abnormal sweating, constipation, urinary issues, and blood pressure instability often occur as well. The focus of this presentation was on depression, specifically.

Dr. Vila-Rodriguez discussed the symptoms of depression and how to manage them, then touched on the current research on depression and PD.

Depression in Parkinson’s disease (dPD)

Around 40 percent of people with PD experience depression at some point during the course of their illness. Depression in PD (dPD) has a significant impact on quality of life, and sometimes the depressive symptoms appear long before a diagnosis of PD has been made. We don’t yet have a way to know who has depression by itself, versus who has depression with PD starting to occur. These are areas of research currently. We do know that dPD is common, that it is at least in part a result of the imbalance of neurotransmitters in the brain that occurs in PD, and that it should be treated to improve the quality of life.

Recognizing dPD is a real challenge; it often goes undiagnosed due to many overlapping features with the motor symptoms of PD. There are no diagnostic tests that help psychiatrists diagnose any mental health disorder – no imaging, blood tests, or other lab tests. Aspects of PD that can easily overlap with clinical depression and make it difficult to recognize dPD include:

• Loss of facial expression
• Quiet speech (hypophonia)
• Slowed movement (bradykinesia)
• Reduced appetite
• Fatigue
• Sleep disorders
• Decreased concentration/memory
• Sexual dysfunction
• Flat affect (lack of energy when expressing oneself)
• Apathy

All of these factors make it hard to accurately diagnose whether someone with PD has depression as well. As a professional, the speaker acknowledged his own learning curve here.

Depression can also cause feelings of sadness, loss of interest in activities one previously enjoyed, feelings of worthlessness, and thoughts of suicide.

Additional diagnostic challenges

It can be hard to differentiate whether the individual is experiencing a primary mood disorder or a secondary one. Did the depression start on its own, early in life, making this a recurrence of an existing illness? Or did the depression show up later in life, suggesting it is a result of PD?

Is the depression a problem of adjustment or a true mood disorder? For instance, many individuals undergo a process of loss and grieving after receiving the PD diagnosis – this is not an illness, but a natural response to any kind of loss or major shift in one’s life. By contrast, a mood disorder typically results in a mood that is distorted or inconsistent with one’s circumstances and one’s daily function. It can be difficult to tease out what is a natural response to the diagnosis and what is turning into a mood disorder that should be addressed.

A good history from the patient and the family can provide a timeline of when depressive symptoms started, which is essential for trying to determine the nature of the disorder.

Treatment options for dPD

Pharmacotherapy (antidepressant medication) is often used in dPD but its effects may be more modest than in those with primary depression not related to PD. It appears that antidepressants may not work as well in dPD. Still, they are helpful for many individuals and worth trying.

Some non-pharmacologic treatments exist, as well. Electroconvulsive therapy (ECT) has historically been a very controversial and stigmatized treatment, in part due to inaccurate movie portrayals. Today, ECT is provided non-invasively and under anesthesia. It is the most effective treatment that we have for major depression, helping depression symptoms in 80 percent of people and leading to remission in 60 percent of people, though it has not yet been studied specifically for dPD. Small currents of electricity are passed through the brain, triggering a small seizure; changes in brain chemistry after the electrical stimulation then flood the brain with dopamine. Side effects can include confusion immediately after the procedure, memory loss, and headaches or muscle pains.

Magnetic seizure therapy (MST) is an experimental treatment that is only available in clinical trials for depression, psychosis, and obsessive-compulsive disorder.  The speaker stressed that the use of MST for dPD would be considered off-label and experimental. Using magnets instead of electricity, MST works similarly to ECT, causing a controlled seizure. The side effects can be problematic, including memory problems and headache, however, it may cause less impact on memory than ECT.

The University of British Columbia will be holding a clinical trial of MST specifically for individuals with dPD.

Main takeaways:

• Depression is frequent in PD, beyond adjustment to the diagnosis.  
• dPD decreases quality of life and is important to treat.
• Treatments include lifestyle interventions (he didn’t have time to address this in his talk), exercise, and antidepressant medications.
• New treatments for dPD may include non-invasive neurostimulation therapies if medications aren’t effective.

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Question & Answer Session

Q: What should a person’s first step be if they suspect they have depression?

A: Talk to your primary care doctor or your neurologist as the first step. They will likely do a general evaluation to rule out other issues that might be causing your symptoms. Next, they may try you on one antidepressant medication as the first step. If that doesn’t work, often the next step is a referral to psychiatrist, who has more expertise in depression management.

Q: How effective is exercise for dPD?

A: Exercise can be quite effective for mild to moderate depression. He doesn’t know of any studies about this specifically in the context of dPD, but he has no reason to think it wouldn’t be effective for this as well. In his experience, those of his patients who are able to exercise regularly generally fare better when combating depression. Try to be as active as possible, whether you experience depression or not!

Q: Are there antidepressants that don’t leave you sleepy during the day?

A: Excellent question. Some antidepressants are associated with daytime drowsiness and help with sleep; sometimes a strategy if the person struggles with sleep as well, is to take an antidepressant at bedtime so they sleep through most of the drowsiness. One example of this is Trazodone. Other antidepressants don’t tend to cause this as much. Talk to the prescribing provider or a psychiatrist to get advice about what might work best for you specifically.  

Q: Are persons with a pre-PD history of depression, whose depression was in remission at the time of PD diagnosis, at greater risk of a new episode of depression following the diagnosis of PD?

A: That is likely the case. It doesn’t mean there is a 100 percent certainty that you will have a recurrence of your depression, but it definitely increases the risk.

Q: Does having strong religious faith help with combating dPD?

A: The network of friends that is often associated with strong faith – the community – can often be helpful. Faith can be a source of support. Those who are not religious often have other ways of finding those networks of support.