In early September 2022, Parkinson and Movement Disorder (PMD) Alliance hosted a webinar on mood and emotional dysregulation in Parkinson’s disease (PD) with neurodegenerative psychiatrist Dr. Greg Pontone. The speaker discussed different mood syndromes such as depression, apathy, bipolar disorder, and pseudobulbar affect. He described the syndromes in detail and addressed treatment. These symptoms can occur at any stage of PD.
According to Dr. Pontone, depression is more than just sadness. It is a syndrome with symptoms including depressed mood, feelings of worthlessness or guilt, fatigue, suicide ideation, and increased or decreased appetite. Major depression occurs in 25% of people with PD, and up to 50% have “minor” depression. The impact of depression on quality of life is almost twice that of motor impairments, according to the Parkinson Foundation’s Parkinson Outcomes Project. Some strategies the speaker suggested for coping with depression in PD are staying connected, engaged, sleeping well, and, most importantly, exercise.
Another mood disorder in PD is apathy, which includes emotional indifference, diminished emotional reactivity, lack of concern for others’ feelings or interest, and reduced initiative. Apathy has some overlapping symptoms with depression such as less physical activity than usual and decreased enthusiasm about usual interests. Apathy in PD needs to be treated differently than for depression. Common medications for apathy are acetylcholinesterase inhibitors such as rivastigmine, dopamine agonists. Most importantly, participating in structured activities and socialization can help those with apathy.
The next mood syndrome the speaker discussed is bipolar disorder, which is mood cycling. If you use an antidepressant to treat bipolar disorder and don’t use a mood stabilizer along with it, you risk flipping the person with bipolar disorder from a depressive episode into mania. For most people, mania is the more dangerous mood stage.
Bipolar disorder is associated with an increased risk of later PD. If someone has depressive or manic episodes, they are at a 2x increased risk of developing PD later in life. People with bipolar disorder are at an increased risk of impulse control disorders, delusions, dementia, and early mortality. Additionally, people with bipolar disorder are more likely than people without bipolar disorder to have a family history of PD.
The final mood disorder discussed is pseudobulbar affect (PBA). This is a neurological condition where the emotional expression is not the same as the emotional state; meaning, people aren’t feeling the expressions they are emoting. People may start laughing or crying and be unable to stop, which can be distressing and embarrassing in social situations. It can be treated with low doses of antidepressants.
For more information on depression or apathy, please see these Stanford Parkinson’s Community Outreach webpages:
For a recording of this webinar, please visit the PMD Alliance YouTube webpage
Please see my notes below for this webinar.
Regards,
Joëlle Kuehn
“Mood and Emotional Dysregulation in Parkinson’s Disease”
Speaker: Greg Pontone, MD, MHS, neurodegenerative psychiatrist and director of the Parkinson’s Disease Neuropsychiatry Clinic, John Hopkins, Baltimore, MD
Webinar Host: Parkinson & Movement Disorder (PMD) Alliance
Webinar Date: September 1, 2022
Summary by: Joëlle Kuehn, Stanford Parkinson’s Community Outreach
Depression:
- Due to the deficiency of monoamine neurotransmitters (NE, SE, DA)
- They are not the only cause. There are other causes
- This is known because antidepressants that modulate monoaminergic neurotransmission only get a response from 50% of patients, with only 30% achieving remission
- This is true for PD and non-PD related depression
Major depression:
- More than just sadness. It is a syndrome
- People can deny being sad and still have depression
- Symptoms include:
- Depressed mood
- Anhedonia – diminished or loss of ability to feel pleasure
- Feelings of worthlessness or guilt
- Suicidal ideation, plan, or attempt
- Fatigue or loss of energy
- Less or more sleep
- Increasing or decreasing weight or appetite
- Decreased ability to think or concentrate, and decreased indecisiveness
- Psychomotor retardation or agitation
Depression in PD:
- Depression can occur at any stage of PD
- PD symptoms can mimic symptoms of major depressive disorder
- People may think they have depression, when it is actually a symptom of PD
PD symptoms may mimic core Major Depressive Disorder (MDD) symptoms:
- PD symptom: masked facies, adjustment disorder to diagnosis
- This symptom mimics the MDD symptom of: Depressed mood
- PD symptom: PD-related apathy
- MDD symptom it mimics: lack of interest of participation in usual activities
- PD symptom: wasting of advanced PD, levodopa-induced nausea, dysphagia
- Mimics: weight loss or decrease in or increase in appetite
- PD symptom: sleep fragmentation, medication-induced sleep problems
- Mimics: insomnia or hypersomnia
- PD symptom: Levodopa-induced dyskinesias, bradykinesia
- Mimics: psychomotor agitation or retardation
- PD symptom: PD-related fatigue
- Mimics: low energy
- PD symptom: PD-related cognitive impairment with prominent executive deficits
- Mimics: diminished ability to think or concentrate
- PD symptom: core depressive symptom, no PD mimic
- Mimics: Feeling inappropriate guilt or worthlessness
- PD symptom: core depressive symptom, no PD mimic
- Mimics: suicide ideation or plan
Bipolar disorder:
- Mood cycling
- Those with depressive episodes are at a 2x increased risk of developing PD later in life
- Same is true for bipolar disorder – if you have depressive or manic episode that has a 2x increased risk of developing PD later in life
- Same as with PD, if you use an antidepressant to treat bipolar disorder and don’t use a mood stabilizer along with it, you risk flipping them from a depressive episode into mania
- For most people, mania is the more dangerous mood stage
Bipolar disorder and the risk of PD:
- Bipolar disorder is associated with an increased risk of later PD
- People with bipolar disorder are at an increased risk of impulse control disorders, delusions, dementia, and early mortality
- People with with bipolar disorder are more likely than people without bipolar disorder to have a family history of PD
Depression in PD – prevalence:
- 25% for major depression
- Up to 50% for “minor” depression or dysthymia
- Anxiety disorders often co-occur
- The impact of depression on quality of life is almost twice that of motor impairments, according to the Parkinson Foundation’s Parkinson Outcomes Project
Strategies for depression in PD:
- Stay connected: Social isolation and loneliness are equivalent to smoking, hypertension, or obesity for health
- Stay engaged: Participating in structured activities is exercise for the mind
- Sleep well: Poor sleep is both a risk factor for and symptom of depression
- Exercise: Physical activity has been shown to benefit mental health by lifting mood and decreasing stress and tension. Especially aerobic exercise for PD.
- A review of 18 articles: aerobic exercise improved –
- Attention
- Processing speed
- Reaction time
- Executive function
- Language
- Treadmill, walking, stationary bike were the most common aerobic exercises studied
- Reduces severity of depression
- A review of 18 articles: aerobic exercise improved –
Apathy vs. Depression in PD:
- Apathy symptoms include:
- Emotional indifference
- Diminished emotional reactivity
- Lack of concern for others’ feelings or interest
- Reduced initiative
- Emotional symptoms of depression include:
- Sadness
- Feeling of guilt
- Negative thoughts and feelings
- Pessimism
- Suicidal ideation
- Overlapping symptoms include:
- Psychomotor retardation
- Anhedonia
- Anergia
- Less physical activity than usual
- Decreased enthusiasm about usual interests
Treatment of apathy in PD:
- Needs to be different than medication for depression
- Acetylcholinesterase inhibitors:
- Rivastigmine: effective, possibly useful
- Dopamine agonists:
- Piribedil: likely effective, possibly useful following deep brain stimulation (DBS)
- Rotigotine: unlikely effective
- One of the best treatments: participation in structured activities and socialization
- Sometimes need medication as a push to do these things
Pseudobulbar affect (PBA):
- Emotional incontinence
- Neurological condition where emotional expression is not the same as the emotional state
- You aren’t feeling the expressions you are emoting
- Emotional expression of laughing or crying that is involuntary and often uncontrollable. Example – hiccups
- Might start laughing or crying and be unable to stop
- Can be distressing and embarrassing in social situations
- Can treat with low dose antidepressants
- Treatment:
- Nuedexta (dextromethorphan/quinidine combination)
- Some antidepressants: SSRIs, SNRIs, TCAs
- Several studies have found that patients taking antidepressants have higher prevalence of PBA (confounding by indication)
Question & Answer:
Question: Could you address comorbid anxiety and depression?
Answer: Not just in PD, but often in PD, anxiety and depression occur together. In PD, we think that happens 80-90% of the time because there is a shared mechanism. There is an overlap in the biological cause of the two symptoms of anxiety and depression. Sometimes we can successfully treat both with the same medications. For most anxiety disorders, antidepressants are the first line treatments.
—
Question: What are the side effects for the apathy medications you spoke about?
Answer: Rivastigmine can cause nausea or vomiting if taken orally. It can also prolong the electrical activity that repolarizes your heart muscle, so you might need an EKG. It’s not a problem that happens often but it is often monitored for.
Dopamine agonists have a host of potential side effects, but they’re usually also going to be helping your movement. Dopamine agonists can cause swelling in your lower extremities, and may have behavioral side effects. But overall they are fairly well tolerated in people who have less-advanced PD.
—
Question: You mentioned suicide ideation. Is there a higher risk of suicide in people with PD versus their age-matched peers outside of PD?
Answer: People with PD tend to have suicidal thoughts more commonly than people who don’t have PD, but at least in the accumulated evidence, it is not clear that they actually commit or attempt more often. Still, any of those thoughts should immediately come to the attention of the healthcare providers.