Brain Support Network has another volunteer who is attending lecture, reading articles, and sharing notes. His name is Adrian Quintero. He’s also a BSN part-time employee, helping families with brain donation arrangements. (He would be happy to help your family too!)
Last Saturday, he attended a Parkinson’s support group meeting in Berkeley. The speaker was Dr. Andreea Seritan, a geriatric psychiatrist from UCSF. Her talk was about anxiety, depression, and apathy in Parkinson’s. While some of the talk was specific to Parkinson’s, most of the treatment of these two symptoms applies to those in the Brain Support Network community (Lewy body dementia, multiple system atrophy, progressive supranuclear palsy, and corticobasal degeneration).
Here are Adrian’s notes….
Notes by Adrian Quintero, Brain Support Network volunteer
Speaker: Andreea Seritan, MD, geriatric psychiatrist, UCSF Movement Disorder and Neuromodulation Center
Title of Talk: Addressing Anxiety and Depression in Parkinson’s Disease
Date: January 20, 2018, PD Active Forum
Parkinson’s Disease (PD) is a neuropsychiatric disease. Many doctors don’t realize this, and think it just affects motor skills, overlooking the psychiatric component.
Anxiety and Depression are among the most common symptoms with PD, and are important to treat as part of the disease. There is often a stigma associated with seeing a mental health provider that can make treatment of both more difficult.
Very common in people with PD. The literature on it says it’s about 40%. For Dr. Seritan’s practice it’s closer to two-thirds of the people she sees. Anxiety can present very differently person to person.
Anxiety can often precede the onset of motor symptoms.
There are physical symptoms associated with anxiety. Dr. Seritan finds people with PD are often very attuned to their bodies and are good at describing physical symptoms. Some more typical physical symptoms of anxiety include rapid heartbeat, shortness of breath, increase of tremor. More atypical symptoms, such as abdominal pain, head pressure, dizziness, may not been seen by doctors as being anxiety related.
“Wearing Off” of medication
Some people experience anxiety during the time period where there is a drop in medication between doses.
Generally happens in the late afternoon, daily, is more predictable than panic attacks that can happen out of the blue.
Generalized Anxiety Disorder
Categorized by “excessive worry” more than 6 months
Is more of a baseline of anxiety that “sits” throughout the day (vs. comes on for a period of time like wearing off)
Some of the diagnostic symptoms can be hard to distinguish from PD, such as: sleep disturbances, muscle tension, easily fatigued, hard to concentrate, restlessness
Panic Disorder
Experiencing panic attacks, which are peaks of anxiety, generally short episodes that reoccur. In between episodes there is worry about having another episode.
Social Anxiety
Performance anxiety is the part of social anxiety that Dr. Seritan sees many PD patients struggling with. Such things as giving presentations, public speaking, can be very difficult for PD patients, as there is often worry about having tremors in front of people. Especially if someone hasn’t shared their diagnosis at work, etc, there can be added stress of a fear of a visible hand tremor.
Depression
Like anxiety, depression is complicated, and experienced differently by each person affected.
In PD patients, it is less common than anxiety, literature showing about 35% of PD patients experiencing depression, and 17% diagnosed with Major Depressive Disorder.
Like anxiety, depression may precede the onset of motor symptoms associated with PD.
When untreated, depression may increase PD symptoms – worsen motor symptoms, cause cognitive deficit. Alcohol and drugs may worsen mood. With depression there is the added risk factor for suicide.
Major Depressive Episode
(5 of the 9 symptoms needed for diagnosis)
-depressed mood, lack of interest (for more than 2 weeks)
-Anhedonia – which is lack of interest in normally pleasurable activities
-Increase or decrease in sleep (again difficult because many PD patients have sleep disturbances)
-Increase or decrease in appetite/ Weight loss or gain
-Feeling guilty or worthless
-Moving slowly (symptom for general population)
-Poor concentration/ memory (people often wonder if dementia is the cause)
-Low energy
-Suicidal thoughts or behavior
Many medical conditions can affect or cause depression, such as:
Thyroid imbalances, strokes, Alzheimer’s, Parkinson’s, post heart surgery or heart attacks (especially in men), chronic pain
Some medications can affect or cause depression, such as:
Some common blood pressure meds, GERD meds, pain meds, sedatives (like Xanax), steroids (like interferon, prednisone), Anticonvulsants (which could be used for tremors)
Apathy
Different from, and less studied, than depression
-not enough energy, feeling “blah”
-20-36% of new onset PD patients
-40-45% overall patients with PD
-lack of drive
Having a schedule and events where others can help hold someone accountable can help (such as Rock Steady Boxing classes, etc.)
Treatment Approaches for Anxiety and Depression
Dr. Seritan likes to start off with the non-pharmaceutical treatments first, which can include:
-exercise (such as Rock Steady Boxing, Dance for PD)
-diet
-good sleep hygiene
-minimize alcohol and drugs (including marijuana). Alcohol can aggravate depression, as well as affect balance, and disturb the sleep/wake cycle.
Other non-pharmaceutical treatments may include:
Gratitude practice
-practicing 3 weeks of journaling where every night you count 5-10 things that you’re grateful for. There is a book called “Thanks” that talks about this practice.
-Such practices have shown to increase sleep and energy, lower depression, and have no side effects!
Self-Efficacy
-Believing in the ability to accomplish goals. People often lose this feeling when they are diagnosed with PD. They may also experience a loss of identity, family role, loss of income, etc.
-Re-adjust goals- Look to strategies that have worked in previous moments of crisis, those strategies will work again
-How we see ourselves is important. Sometimes we may need the help of a mental health professional to act as a mirror.
Psychotherapy
-CBT (Cognitive Behavioral Therapy)- the most well-studied therapy for anxiety and depression.
-MBI (Mindfulness Based Interventions)- paying attention to the present moment non-judgementally. There is increasing studies and evidence as to the effectiveness of such interventions. Can help memory, executive functioning and cognitive functioning.
-MBSR (Mindfulness Based Stress Reduction)- often used in medical settings, there are groups oriented around learning this
-MBCT (Mindfulness Based Cognitive Therapy)- Combination of CBT and MBSR, used at UCSF.
Treatment with Medications
In general, timing of when medications are taken is important.
-Wearing-off Issue- Dr. Seritan suggests working with doctor to adjust timing and dose of medication. If experiencing several times a day, treatment of base anxiety may be needed.
-For PD patients who had anxiety and depression before PD diagnosis, SSRIs and SNRIs can be helpful for treatment.
Benzos
-used for anxiety attacks/ peaks, can help with wearing off anxiety, also used at times for restless legs
-NOT good for Generalized Anxiety Disorder, and shouldn’t be used for insomnia
-Recommends NOT taking daily, as risk for dependence
-Look at risk/benefit analysis of using
-don’t mix with alcohol or sleep-aids
-Xanax has a short half-life and can cause rebound effects. Dr. Seritan prefers medications with a longer half-life
-Some benzos can cause memory problems, and increase risk of fall
-Some can be sedating and are best taken at nighttime
Sleep-Aids
-Sleep disturbance is a major symptom of anxiety, depression, and PD
-Trazadone- may cause grogginess
-Ambien- there is a dose differential for men and women
-Melatonin- natural aide, Dr. Seritan suggests taking 2 hours prior to bedtime. It can be combined with Ambien
-Gabapentin- good for anxiety, sleep, and pain. Have to modify dose so as not to cause sleeping during the day
Social/Performance Anxiety
-Beta blockers can be good used PRN. There are possible side effects of increased depression and fatigue
Apathy treatment
“Activating” antidepressants such as: Buproprion, Duloxetine, Venlafaxine
-Stimulants- Does NOT recommend Ritalin, etc. Instead Dr. Seratin treats with Modafinil or Armodafinil
Deep Brain Stimulation
-DBS is approved for PD to improve motor symptoms. There are surgery risks involved, as well as psychiatric risks. It can increase anxiety and depression, as well as impulsivity. It may decrease anxiety and depression for some people. At SFSU, they have a long evaluative process with the team.
Overall, PD is a stressor on the brain, and medications add additional stress. When treating PD patients, the dose may need to be less, as is true for older adults as well.
Pain Management treatment
-Lots of patients take cannabis for pain. May be evidence for help with insomnia. Dr. Seritan does not recommend cannabis for treatment of mood or anxiety.
-Sometimes tricyclic anti-depressants may be prescribed for pain management.
-Often patients are already on several medications. Can be helpful to see a pain specialist.