Treating depression and anxiety in Parkinson’s – webinar notes

The Michael J. Fox Foundation ( holds webinars every third Thursday. In general, these webinars focus on aspects of Parkinson’s Disease (PD) – symptoms, research, and treatment. During yesterday’s webinar time slot, a June 2016 webinar on depression and anxiety in PD was re-played.

The webinar explained the prevalence of depression and anxiety in the lives of people with PD, clarified when treatment is needed, and offered some treatment options. As depression and anxiety are common symptoms in the Brain Support Network disorders (LBD, PSP, MSA, and CBD), the webinar content applies to many in our community.

This time around, Brain Support Network volunteer Adrian Quintero listened in on the webinar, took notes, and shared them.

You can find a link to the June 2016 webinar recording here:

Note you have to register before watching the recording. The speakers’ slides can be downloaded once you get to the archived recording webpage.

Here are Adrian’s notes…



Notes by Adrian Quintero, Brain Support Network Volunteer

Depression and Anxiety in Parkinson’s Disease
Thursday, June 16, 2016
Michael J. Fox Foundation Webinar

* Dave Iverson- Contributing Editor, The Michael J. Fox Foundation
* Israel Robledo- Diagnosed with Parkinson’s in 2007
* Laura Marsh, MD- Executive Director of the Mental Health Service, Michael E. DeBakey Veterans Affairs Medical Center
* Gregory Pontone, MD- Director, Parkinson’s Neuropsychiatry Clinical Programs, Johns Hopkins University School of Medicine

How common is Depression and Anxiety for people with Parkinson’s?
Dr. Marsh says it’s very common, between 50 and 60 % of people. Often people develop depressive episodes within 5-10 years of PD diagnosis (before motor symptoms are present). There are brain changes in PD that affect mood regulation, often before motor areas of the brain are affected.

How do Depression and Anxiety go hand in hand?
Dr. Pontone says experiencing both is common in PD, as it is as well in the general population. Similar neurotransmitters are at play with both depression and anxiety (serotonin, norepinephrine, dopamine).

In PD, the most common type of anxiety people experience is a more generalized / longstanding anxiety, although this can vary person to person. When depression is active, anxiety is also worsened,

Israel’s story
Israel shared from his personal experience. He dealt with depression for about 20 years off and on before he developed any motor skill symptoms. He tried different medicines that were mostly ineffective with the depression. He started to develop motor symptoms around 37, and he had an increase in depression symptoms at that time. For Israel, the depression got much worse after his PD diagnosis. For him, he experienced suicidal thoughts and feelings, and he felt depressed both cause of the PD diagnosis and as part of the PD disease itself.

He also experienced an increase in anxiety after PD diagnosis. Israel described depression as a “mental tiredness,” feeling helpless, hopeless, he didn’t feel the joy he saw other people around him experiencing.

None of the anti-depressants he had been on had a noticeable effect on his mood. His movement disorder specialist prescribed a different kind that really made a difference, and helped shift his view/ attitude. He also received a lot of support from family and friends. He said what others can most do to be helpful is to be there for the depressed person, but don’t try to fix the problem for the person.

Change in perspective
Dr. Marsh described depression as “looking at the world through mud-colored glasses.” It’s an illness that changes one’s perspective on life. There are also physical symptoms that overlap with PD symptoms, such as slowness, muscle tension, slow thinking, and fatigue. It can be hard to know if such symptoms are PD or depression. The lack of pleasure can be an important factor indicating there could be a mood disorder that needs specific addressing. Depression can have serious life threatening symptoms- hopelessness/ suicidality being the most life threatening.

What causes Anxiety and Depression in PD?
Parkinson’s impacts dopamine and other neurotransmitters. These all affect mood regulation, which is being able to experience a full range of emotions, moving in and out of different emotional states. People can become stuck in one state or another, even when trying to do things that are normally pleasurable (such as the case with Israel).

Dr. Pontone describes what is happening as chemical imbalances, and it’s not due to a lack of trying on the part of the depressed person. It can be very hard to rebound into a normal mood state. He says with depression it can be hard to think clearly, and when suicidal thoughts are present, they can take on life of their own.

The experience of depression in PD and general population is similar, except there seems to be more anxiety that accompanies the depression with PD patients. Inadequate treatment for motor symptoms an affect depression treatment in PD.

Most people feel they can cope with PD, but not when they are depressed. Effective treatment for depression makes coping with PD much easier.

If motor symptoms are worsening, it could possibly be more related to mental health issues that need attention.

Treating depression in PD through Medication
It is very important to talk to the movement disorder specialist about all the meds person is on, to have the full picture (blood pressure medications, etc.). SSRIs are usually the first type of drug to start with treatment in persons with PD. Trials of drug can be similar as it is with general population, trying one class of anti-depressant, if it’s not effective, move into another class. (Moving from SSRIs to SNRIs to tricyclic anti-depressants). The SSRI class has lower side effect risk profile to start with.

For Israel it took going to a tricyclic class of medication before he found relief.

Treating depression has been shown to correspond with improved motor function day to day. Treating anxiety can help with “freezing” symptoms.

Cognitive changes can occur in PD. Both depression and anxiety are associated with cognitive difficulties. Treating depression and anxiety and managing those well is associated in overall improved function, including cognition. (such as person may be able to think more quickly).

When to treat for depression?
Israel suggests thinking about your outlook of life. He felt mentally tired and felt like things he did didn’t really matter. If one anti-depressant doesn’t work, don’t feel shame in getting help trying an other to see if that may help. There is stigma in our society around having mental health issues, more than physical health issues.

Important to treat mental symptoms as well as we would physical symptoms. For example if we saw someone with a broken leg, we would want to rush them to the hospital for treatment. We wouldn’t see the person as being at fault and tell them to walk it off! The mindset of someone depressed changes profoundly from illness state to well state. People can recover.

Other treatment options
* Talk therapy, CBT therapy
* Education around depression
* Support (family, friends, group)
* Learning skills to manage Depression and PD
* Exercise. There are studies with the general population that show exercise can really help with depression. (There haven’t been studies with the PD population). However, Dr. Pontone believes exercise helps mood in people with PD, and will help overall disease and management of day-to-day symptoms. Exercise can also provide social interactions and can help with getting outdoors.
* Social interactions can really improve mood, having one’s experience validated by a trusted other.

Medication treatment for Anxiety
Many medications that treat depression also can be used in treating long-term anxiety and anxiety disorders. Although, some people can experience an increase of anxiety at first. Benzos- Can help anxiety in the short term, but don’t help depression. Both doctors often avoid using cause of side effects, including risk of falls. But sometimes for short-term relief they can be helpful.

Newer treatments for Anxiety and Depression
* Brain stimulation treatments- like deep brain stimulation treatment for movement symptoms. Recently, doctors have been looking into using DBS for mood improvement.
* Less invasive option is something called trans-cranial direct current stimulation; which may have both motor, and mood benefits. At Johns Hopkins they are doing a trial right now.
* Magnetic field RTMS- not invasive, magnetic coil near brain, shown to be effective in PD and gen pop.

Overall, the doctors agree there are reasons to be hopeful.