Depression, Anxiety, and

Parkinsons Disease
Ruth B. Schneider, MD
University of Rochester
National Parkinson Foundation Center of Excellence
April 23rd, 2016
 Disclosures

Employment: University of Rochester Medical Center

Grants: Empire Clinical Research Investigator Program (New

York State Department of Health), The Michael J. Fox Foundation,
UR Department of Neurology Pilot Program, Canadian Institutes
of Health Research

I will also be discussing off-label uses of certain drugs.

Outline

Overview of Neuropsychiatric Symptoms

Depression and Parkinsons Disease
Apathy and Parkinsons Disease
Anxiety and Parkinsons Disease
What You Can Do
 Neuropsychiatric Symptoms
Depression, apathy, anxiety, psychosis, and impulse
control disorders are common in Parkinsons disease

Presence negatively impacts ability to function and

decreases quality of life

Depression and anxiety are associated with leaving the

work force earlier
 Neuropsychiatric Symptoms
Presence is associated with higher caregiver burden

Presence prompts earlier initiation of dopaminergic

treatment

As clinicians we often fail to recognize neuropsychiatric

symptoms

Butwe can treat these symptoms

 Depression

Feeling sad, depressed, or hopeless

OR
Loss of interest or pleasure

Causes clinically significant distress of impairment

 Depression
Prevalence: 28-50% of people with Parkinsons disease
have depression
Present at all stages of Parkinsons disease (before diagnosis
10%-, early after diagnosis -14-28%-, in later stages)

Presentation:
Major Depression: 7.5-50%
Minor Depression: 37%
Dysthymia 23%
Often co-occurs with anxiety
 Depression
Mechanism of Disease: Likely reflects the same
neurodegenerative processes responsible for other
Parkinsons disease symptoms rather than a reaction to
the disease
Prevalence of depression is higher in Parkinsons disease than
in other chronic diseases
Depression can present years before the development of
characteristic motor symptoms
Dopamine, serotonin, and norepinephrine systems have been
implicated and we know that damage occurs to all of these
systems in Parkinsons disease
Limbic system involvement
 Depression
State of Treatment: Most people with Parkinsons disease
and depression are untreated or under-treated
Failure to recognize: focus on traditional motor
symptoms
Failure to diagnose: best screening tool has not been
identified, lack of clinician knowledge
Failure to treat: insufficient guidance, concern for
side effects
So What Is the Good News?
 Depression
Cognitive Behavioral Therapy Small controlled trials
in Parkinsons disease suggest benefit.

Pharmacological Treatment
SAD-PD: paroxetine and venlafaxine XR better than placebo
Clinical trials also support the use of nortriptyline,
desipramine, citalopram, and pramipexole
No worsening of motor symptoms with SSRIs
 Depression
Exercise
Studies of depression in the general population
suggest that exercise might be beneficial and it is
currently recommended as an adjunct to medication
in the treatment of depression
Depression
 Apathy

Lack of motivation
 Apathy
Prevalence: Estimates range from 17-60%.
Can be seen with depression (28%), with dementia, or in
isolation
17-27% of newly diagnosed

Presentation:
decreased goal-directed behavior, diminished emotional
expression, cognitive inertia
tend to be older
higher risk of depression and cognitive impairment
associated with worse motor impairment

Mechanism of Disease: prefrontal cortex abnormalities

 Apathy
State of Treatment: Difficult to treat
 Anxiety

Excessive fear, worry, or anxiety

Causes clinically significant distress or impairment

 Anxiety
Prevalence: 25-43% of people with Parkinsons disease
have an anxiety disorder
It is present at all stages of Parkinsons disease (before
diagnosis, early on after diagnosis *20-25%*, in later stages)

Presentation: Anxiety can present in different ways

Generalized anxiety disorder: 3-21%
Agoraphobia: 2-16%
Panic disorder: 4-30%
Social phobia: 8-13%
Obsessive compulsive disorder: 1-6%
Not otherwise specified: 11-25%
Can be associated with fluctuations
 Anxiety
Mechanism of Disease: Likely reflects the same
neurodegenerative processes responsible for other
Parkinsons disease symptoms rather than a reaction to
the disease
Prevalence of anxiety is higher in Parkinsons disease than in
other chronic diseases
Anxiety can present years before the development of
characteristic motor symptoms
Dopamine, serotonin, and norepinephrine systems have been
implicated and we know that damage occurs to all of these
systems in Parkinsons disease
 Anxiety

State of Treatment: Up to 50% of people with Parkinsons

disease and anxiety do not receive treatment for their
anxiety
Failure to recognize: anxiety can present in a variety of ways
Failure to diagnose: best screening tool has not been
identified, lack of knowledge
Failure to treat: no guidelines regarding treatment
 Anxiety
Cognitive Behavioral Therapy Some preliminary data
to support CBT for the treatment of anxiety
 Anxiety
Pharmacological Treatment There have not been any
studies designed to evaluate the treatment of anxiety
with medication

Practice Benzodiazepines and selective serotonin

reuptake inhibitors (SSRIs) are the most commonly
prescribed

Exercise Reduces anxiety symptoms in patients with

chronic illness
 What You Can Do
Tell your care team if you are experiencing symptoms!

Exercise!

Consider participating in research

 How to Participate
Clinicaltrials.gov
 How to Participate
Foxtrialfinder.michaeljfox.org
 How to Participate
Researchmatch.org
Questions?
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