Anxiety and Depression with Parkinson's Disease

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Neurologist Irene Richard discusses symptoms of and new treatments for depression in patients with Parkinson's disease. Video from University of RochesterWhen facing a diagnosis of Parkinson’s disease, it is understandable to feel anxious or depressed. But mood disorders such as anxiety and depression are real clinical symptoms of Parkinson’s, just asrigidity and tremor. In fact, at least half of all Parkinson’s patients may suffer from clinical depression at some point during the course of their disease, according to some estimates.

The good news: Over the past decade, researchers have placed increasing focus on investigating these aspects of the disease, and today we have a better understanding of how to treat mood disorders in Parkinson’s and increase quality of life.

On this page you’ll find up-to-date information from clinicians and researchers, as well as quotes from ourGuide for the Newly Diagnosed, authored by Parkinson’s patients themselves as a resource for those just beginning their journey with Parkinson’s disease. We’ve also included various multimedia interviews withDr. Irene Hegeman Richard, MD, of the University of Rochester School of Medicine and Dentistry and our Scientific Advisory Board, who has done extensive research into depression and Parkinson’s disease.

• How can I get help for depression or anxiety?
• What does the research tell us?

How Can I Get Help for Depression or Anxiety?

“While depression and anxiety can be normal reactions to being diagnosed with a serious disease, clinical depression is real. These symptoms, if left untreated, are damaging at best and deadly at worst. Make sure you discuss depression and anxiety with your doctor. It is important to remember that clinical depression and anxiety are underdiagnosed in people with Parkinson’s and that they are symptoms of your disease, not character flaws.”

PODCAST: How Depression Impacts Parkinson's Patients. Spoken by Irene Hegeman Richard, MD, of the University of Rochester School of Medicine and Dentistry

Depression can be seriously detrimental, and, for people with Parkinson’s, it can affect long-term outcomes for the worse by hindering critical elements of an overall treatment regimen such as staying socially connected, exercising to manage motor symptoms, or being proactive about seeking care. 

Be on the lookout for a lack of enjoyment in activities and situations that once brought you joy. Also pay attention to observations made by family and friends because you or your physician may not always recognize the signs of depression and anxiety. In fact, your physician may not even ask you about these conditions if you don’t mention changes in mood or outlook.

Depression and anxiety can be treated with medications, lifestyle changes and therapy or counseling from a qualified practitioner. Support groups may also be source of help.

NOTE: If you are in crisis, call the National Suicide Prevention Lifeline at 1-800-273-TALK or visitwww.suicidepreventionlifeline.org.

What Does the Research Tell Us?

“Even within the past decade, quality of life for Parkinson's patients has greatly improved. The prospects for the next five to 10 years are even better.” 

PODCAST: New Research on Treating Depression in Parkinson's patients. Spoken by Irene Hegeman Richard, MD, of the University of Rochester School of Medicine and Dentistry

Researchers believe that depression and anxiety in Parkinson’s disease may be due to the underlying changes in brain chemistry and circuitry that are caused by the disease itself.  In fact, depression in Parkinson’s patients can start before motor symptoms even arise. The Michael J. Fox Foundation actively pursues research that can shed light on the connection between depression and Parkinson’s, and lead to treatment breakthroughs for everyone living with the disease.

The same pathways that create dopamine in the brain — which are impacted in Parkinson’s disease — also create the hormonal neurotransmitter serotonin. Serotonin regulates mood, appetite and sleep. If dopamine is like the motor oil to keep the body’s systems controlling movement running smoothly, then serotonin is like the motor oil for a person’s mood. Researchers hypothesize that the effect of Parkinson’s on this system is responsible for the clinical symptoms of depression and anxiety. The Foundation is supporting research to clarify this relationship. 

In April 2012, the Study of Antidepressants in Parkinson's Disease (SAD-PD), the first major clinical study testing common antidepressants in people with Parkinson’s, found that some of these drugs can ease depression in Parkinson’s patients without aggravating motor symptoms.* Needless to say, work closely with your physician before adding any drug to your Parkinson’s treatment regimen.

“A Parkinson’s diagnosis, although life-altering, is not a death sentence. Symptoms will change over time, as will your attitude; no one should expect, nor should you expect from yourself, that this will be easy to deal with. But people with Parkinson’s and others alike should all value and make the most of every day. In a best-case scenario, a Parkinson’s diagnosis can become a real wake-up call: a chance to re-examine your priorities, and focus not on what you cannot do, but instead, on what you can.”

*A specific note on drug interactions: It is critical that patients with Parkinson’s disease educate themselves and work closely with their physicians and medical team to understand potential drug interactions between antidepressants and Parkinson’s treatments. The results of combining incompatible drugs can be serious.  

From Michael J. Fox site

Difficulty swallowing can be fatal for people with Parkinson’s

People with Parkinson’s disease (PD) should be wary of increased episodes of coughing and changes in voice quality, because experts say these symptoms could be a sign of a serious swallowing problem which can be fatal.

Parkinson’s disease is a progressive neurological disorder that occurs when vital brain cells that control movement and coordination die or become impaired. Symptoms vary, but the disease is often characterized by uncontrollable shaking, limb stiffness, slow movement and difficulty walking. Studies show that Parkinson’s can also cause a host of other life-altering cognitive and physical changes including difficulty swallowing, chewing, speaking and pushing food through the digestive system, as these functions depend on muscles that may be weakened due to changes in the brain.

Many Parkinson’s patients, especially those in the later stages of the disease, experience difficulty swallowing, a condition known as dysphagia, which can affect their quality of life and cause life-threatening complications like aspiration pneumonia, malnutrition and dehydration, said Leslie Mahler, Ph.D., an assistant professor in the Department of Communicative Disorders at the University of Rhode Island who specializes in adults with neurological disorders. “The complication to be most concerned about is whether food is going down the right way,” she said.

According to the National Institute of Health, the leading cause of death for people with Parkinson’s disease is aspiration pneumonia, which occurs when the lungs and the airways to the lungs get inflamed or infected due to food or liquids going into the lungs when consumed rather than into the stomach. Parkinson’s patients are also at risk for asphyxiation or choking to death due to food blocking the airway and stopping breathing.

It is important to know the warning signs of a swallowing disorder, because some people may appear to be eating and drinking normally, but they are not, said Dr. Mahler, a speech-language pathologist. Early intervention and proper management of swallowing abnormalities are the keys to preventing major complications, she said.

One of the warning signs of dysphagia is drooling, Dr. Mahler said. The natural tendency to swallow slows down in many Parkinson’s patients so they do not swallow as often as they use to, and as a consequence they tend to drool, Dr. Mahler explained. The decrease in swallowing causes a buildup of saliva in the mouth which leaks out resulting in uncontrollable, unsightly drooling that can be a major source of embarrassment, said experts at the National Parkinson Foundation (NPF). This excess saliva can also cause a buildup of phlegm in the throat.

Anticholinergic medications can reduce drooling by restricting saliva production, but research shows these medications cause dry mouth and have serious side effects like memory impairment, constipation, confusion and hallucinations especially in the elderly. Researchers also found that severe drooling can be treated with botulinum toxin (Botox) injections into the salivary glands, but the effect of Botox only last a few months.

Coughing or choking during or after meals is another sign that food is either stuck in the throat or that it has gone down the air passage (windpipe) into the lungs instead of into the esophagus – the muscular tube that carries food, liquids and saliva from the mouth to the stomach.

Doctors said coughing is actually a good sign, because it is a reflex reaction that happens when food goes down the wrong way or is trapped in the throat. Coughing can help keep food and liquid out of the airway and prevent them from going down the lungs. However, sometimes food can enter the wind pipe without any sign of coughing or choking causing silent aspiration.

Other warning signs of dysphasia identified by the NPF are: a gurgly voice; a sensation that something is stuck in the throat; difficulty keeping food or liquid in the mouth; difficulty swallowing medication; unintended weight loss; chest discomfort; heartburn; a sore throat; and slowness in eating.

In severe cases, patients may have to use a feeding tube to maintain hydration and nutrition, Dr. Mahler said, adding that, “It is possible for someone to eat and drink what they can and get the rest through tube feedings.”

Dr. Mahler advises people who think they have a swallowing problem to see a speech-language pathologist, who is experienced in treating Parkinson’s patients, for a swallowing evaluation. “People with Parkinson’s who have difficulty swallowing often have voice problems, because speech and swallowing share common anatomy,” she said. “It has been estimated that as many as 89 percent of people with PD have a speech disorder that can impact their quality of life.”

Speech therapy can help people improve swallowing and increase vocal loudness by teaching them muscle strengthening exercises, Dr. Mahler said. A technique known as the Lee Silverman Voice Treatment (LSVT Loud), an intensive speech exercise program, has proven to be effective in treating Parkinson’s patients with speech problems, she said, and at least one study shows that it has also had a positive impact on improving swallowing function.

Another therapy that can improve swallowing functions is Expiratory Muscle Strength Training (EMST). This relatively new therapy, developed by experts at the University of Florida Center for Movement Disorders and Neurorestoration, teaches patients how to strengthen the muscles involved in swallowing and breathing.

The NPF and Parkinson Disease Foundation also recommend the following tips to help alleviate swallowing and drooling problems:

• Drink frequent sips of water or suck on ice chips during the day and before meals to help increase swallowing and thin phlegm;
• Reduce sugar intake, as sugar increases saliva;
• Suck on sugarless candy or chew sugarless gum for temporary relief from drooling;
• Take smaller bites of food, chew food thoroughly and eat slowly;.
• Sit upright for at least 15 minutes after eating;
• Take small sips of water or beverage when eating;
• Sit upright with head slightly forward when eating, drinking and taking pills. Tilting head backwards can increase the risk of food or liquids going into the lungs. If a glass is half empty, refill it;
• Maintain an upright posture and keep chin up, because a flexed neck or stooped posture exacerbates drooling;
• Rinse mouth after meals;
• Eat softer foods, pureed if necessary;
• Drink tea with lemon or carbonated beverages to help thin phlegm;
• Avoid dairy products, as they can make phlegm worse;
• Drink thicker liquids, as they are easier to swallow, because they do not go down as fast;
• Moisten dry foods to make them easier to swallow; and
• Sleep with head raised up to prevent choking.

— Shirley L. Smith
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