Patients who feel hopeless may need different treatment than those who are depressed
Demoralization, which is distinct from depression, is common in Parkinson's disease and is associated with motor dysfunction, suggests an observational study by Yale University researchers.
Nearly 20% of patients with Parkinson's disease may be demoralized, and a significant number of them -- 29% -- are not depressed, reported Brian Koo, MD, and co-authors online in Neurology.
While demoralization and depression can coexist, the two are clinically separate. Patients who are demoralized frequently have a subjective, persistent sense of failure in stressful situations. Depressed patients, on the other hand, have anhedonia and decreased motivation. Parkinson's disease is highly comorbid with depression but studies have not examined demoralization in this population, the authors noted.
"The distinction between depression and demoralization is important because the treatment approaches are different," Koo said in a statement. "Demoralization may be better treated with cognitive behavioral therapy rather than antidepressant medication, which is often prescribed for depression."
Cognitive behavioral therapy has been modified to help Parkinson's patients cope with other non-motor symptoms like depression, impulse control disorder, and insomnia, commented Ivan Koychev, PhD, of the University of Oxford in England, who was not involved in the study.
"This study confirms clinical observations that demoralization -- feelings of hopelessness and inability to cope -- is common among PD patients and, importantly, can occur in the absence of depression," Koychev told MedPage Today.
"As it associates with poorer motor function, the results of this study suggest that once the complicated relationship between demoralization, depression and PD movement symptoms has been clarified, the development of targeted interventions should be considered."
For this study, Koo's team recruited people who had Parkinson's disease from outpatient movement disorder clinics at Yale and controls from the surrounding community.
From June 2016 to May 2017, 94 patients with Parkinson's disease and 86 controls enrolled in the study. The two groups were comparable for age, sex, race, marital status, education, employment, economic status, and medical comorbidities. The average age of participants was 68; 60% were men, 93% were white, 71% were married, and 72% had finished college.
Of the Parkinson's patients, 88.5% were in Hoehn and Yahr stage I or II. Unified Parkinson's Disease Rating Scale part III (UPDRS-m) scores were available for 83 of the Parkinson's patients: 71 were "on," 9 "off," and 3 were not on Parkinson's medication.
The researchers used the Patient Health Questionnaire-9 (PHQ9) to assess depression and the Diagnostic Criteria for Psychosomatic Research, Demoralization (DCPR-D) and Kissane Demoralization Scale (KDS) to assess demoralization in both groups.
Depression was defined as PHQ9 score ≥10.7 on all nine Diagnostic and Statistical Manual of Mental Disorders (DSM) depression criteria, which participants rated from 0 (not at all) to 3 (nearly every day).
Demoralization was defined as a positive DCPR-D score or a KDS score ≥24. Participants who answered yes to certain DCPR-D questions about hopelessness, failing to meet expectations, and inability to cope, and said these feelings persisted for a month or longer, had a positive score. The KDS ranked 24 items to determine how frequently participants had feelings like "I feel hopeless" and "No one can help me" on scale of a 0 (never) to 4 (all the time) in the past 2 weeks.
Overall, having Parkinson's disease was associated with demoralization (OR 2.60, 95% CI 1.00–6.80, P=0.051). Demoralization affected 18.1% of Parkinson's patients, but only 8.1% of controls (P=0.05). Younger age (OR 0.93 per year of age, 95% CI 0.87-0.99) and motor dysfunction (OR 1.06 per UPDRS-m unit, 95% CI 1.01–1.12, P=0.02) were associated with demoralization among Parkinson's patients.
Depression affected 20.2% of Parkinson's patients, but only 3.5% of controls (P=0.0006). Although demoralization was highly associated with depression, 36.8% of depressed Parkinson's patients were not demoralized, and 29.4% of demoralized patients were not depressed.
Comorbid demoralization and depression were far more common among Parkinson's patients than other participants (12.8% versus 3.5%, P=0.01).
Because demoralization, but not depression, was associated with motor dysfunction in Parkinson's patients, it may be tied more to functionality, the authors suggested. Demoralized Parkinson's patients had significantly higher UPDRS-m scores (30.7 versus 23.6, P=0.04) and higher mean Parkinson's Disease Questionnaire-8 scores (11.9 versus 4.5, P< 0.0001) than Parkinson's patients who were not demoralized.
Limitations of this study include its cross-sectional design, the authors noted. Patients with severe Parkinson's disease were more likely to not participate, which may mean the prevalence of demoralization was underestimated. A longitudinal study including late-stage patients and more elements of psychosocial history is needed, they added.
This study had no targeted funding. The researchers reported no relationships with industry.
Primary Source
Neurology
Source Reference:
Koo B et al "Demoralization in Parkinson disease" Neurology 2018; DOI:10.1212/WNL.0000000000005425.
https://www.medpagetoday.com/neurology/parkinsonsdisease/72154
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