How can you reduce Depression and Anxiety?

Is Depression & Anxiety common in Parkinson’s disease?


Depression & Anxiety are common in Parkinson’s disease. These problems can produce significant disability.

About 1 in every 5 patients with Parkinson’s disease may have Depression (Rejinders et al. 2008).

Anxiety is even more common – about 1 in 4 patients with Parkinson’s disease have significant symptoms of Anxiety (Broen 2016).

Depression is common in Parkinson’s disease. Thankfully, detection and treatment is helpful in almost all cases.

Other than these two problems, patients with Parkinson’s disease can also have other psychiatric issues.

  • Impulse control Disorders: Patients may have difficulty in controlling their impulses. They may start spending a lot of money online or may start gambling or have excessive weight gain due to overeating. This lack of impulse-control can occur as a side-effect of medications called “Dopamine Agonists” (Pramipexole, Ropinirole, Rotigotine).
  • Agitation and hallucinations/psychosis : This is particularly worrisome and should be promptly treated to prevent injury to family members. Medications such as Quetiapine, Donepezil, Pimvanserin and if all else fails – Clozapine – are usually helpful.

Let us focus on Depression here. We can discuss Impulse control disorders and Agitation/Psychosis in a future article.

What are the symptoms of Depression or Anxiety?

Most people believe that all patients with Depression actively cry, talk to people about their mental pain, or in some way express their grief actively. This is frequently not the case.

Many people with Parkinson’s disease have a passive form of Depression. This passive Depression may manifest in the following ways:

Symptoms of 'Passive' Depression
1. Feeling guilty, worthless or hopeless.
2. Loss of interest in previously enjoyable activities (for example, watching a movie)
3. Fatigue or loss of energy.
4. Thinking about the same things over and over again (Obsessive ruminations)
5. Difficulty in paying attention, concentrating or remembering things
6. Reduced or increased appetite. Losing or gaining weight without a clear cause.
7. Sleeping too much or too little. Early morning awakening.
Inability to focus or lack of interest in regular activities may be a sign of depression.

In fact, patients with Parkinson’s disease may become so passive that they are diagnosed with a related psychiatric condition called “Apathy” – or a complete lack of interest and motivation.

Is there a test for Depression & Anxiety?

There is no test to confirm the diagnosis of Depression and Anxiety. This diagnosis can be made only after you have a detailed conversation with your doctor or a qualified mental health professional.

However, there are numerous, fairly accurate screening questionnaires for Depression. One of them is the PHQ-2 Questionnaire, displayed below.

PHQ-2 Questionnaire

In the last two weeks, how often did you have little interest or pleasure in doing things?– Not at all (0 points)
– Several days (1 point)
– More than half the days (2 points)
– Nearly every day (3 points) .
In the last two weeks, how often did you feel down, depressed or hopeless?– Not at all (0 points)
– Several days (1 point)
– More than half the days (2 points)
– Nearly every day (3 points)

Add up your points for the two questions. If your score is 3 points or more, you may be suffering from Depression. Please remember that even if this Questionnaire indicates you may have Depression, the diagnosis needs to be confirmed by a doctor.

Why is Depression and Anxiety common in Parkinson’s disease?

We could assume that depression is common because of the significant problems with movement in Parkinson’s disease. This intuitive assumption certainly is true up to a certain extent.

However, a major cause of depression in Parkinson’s disease is due to chemical changes inside our brain which are caused by the disease. In fact, Depression can actually happen even before the movement problems of Parkinson’s disease start. The exact mechanism by which accumulation of synuclein causes Depression is still being worked out.

man 445487 1920
Chemicals such as Serotonin & Dopamine keep you happy.

The leading theory is that just like synuclein causes damage to brain cells that secrete Dopamine, it also causes damage to brain cells that produce a chemical called “Serotonin”. Serotonin (just like Dopamine) is one of the chemicals in the brain that causes feelings of happiness or satisfaction. Therefore, a decrease in the activity of this chemical causes Depression.

What are the natural / no-medication methods for treatment of depression?

Depression should not be neglected. But all cases of depression do not need medication. Counselling and exercise can be beneficial in many cases.

  1. Exercise: Any form of exercise decreases Depression and Anxiety. The effect is marked. In non-Parkinson’s disease patients, exercise can have the same effect on depression as taking an antidepressant medication.
    Even walking in the open for 15-30 minutes daily can help with depression.
  2. Counselling: Cognitive behavioral therapy in particular, may be very helpful. An insider tip – sometimes psychiatrists may not have adequate time to participate wholeheartedly in counselling because of their extremely hectic schedule. You can request a referral to a professional counsellor if you want to try counselling.
    counseling 99740 1920 e1575997570643
    Talking to a trained professional about your depression can be very helpful
  3. Bright light therapy: This is useful if your Depression is seasonal, i.e. it is worse in winter when you get less sunlight. This kind of Depression is called “Seasonal Affective Disorder” or SAD. You can buy “daylight spectrum” bright lights online (see an example below) and keep these on in your house for at least 8 hours a day. Regular use of these lights decreases Depression due to SAD.
    Bright light lamp
    Bright lights can help with winter-time depression. If specialized lamps are not available, you can try using commonly available bright fluorescent tubes.

Even in patients who need medication, participating in a regular exercise program and counselling leads to greater relief than taking the medication alone.

Which anti-depressant medications are safe in Parkinson’s disease?

Since low levels of Serotonin could be one of the reasons for Depression in Parkinson’s disease, medications which increase serotonin activity are helpful. These medications are SSRIs (short for Specific Serotonin Reuptake Inhibitors). A few examples of these medications are Escitalopram, sertraline, fluoxetine etc.

Increasing the levels of serotonin inside your brain can make you happier.

While these medications focus on Serotonin, we should not forget that Dopamine itself is also a “happy” hormone. The core medications for Parkinson’s disease also relieve Depression. Pramipexole, in particular, has been clearly shown to improve depression in Parkinson’s disease patients.

man 445487 1920
Serotonin makes you happy. One more “happy” chemical is Dopamine itself.

It is best to avoid certain other psychiatric medications:

  • There are other types of antidepressants e.g. one type is called TCAs (Tricyclic Antidepressants). However they may not be as effective as SSRIs. In addition, many TCAs have additional unwanted side-effects such as drying of the mouth making it more difficult to swallow, difficulty in passing urine, and occasionally confusion. They may also increase the risk of falls.
  • Benzodiazepines are medications that are commonly used to placate patients who have extreme anxiety. But these medications increase the risk of falling in Parkinson’s disease and are best avoided.
Falling e1574089012814
Certain antidepressants and sedatives can increase falling.

Isn’t it “reasonable” to be depressed if I have Parkinson’s disease?

No. On the contrary, facts suggest that there is very good reason for optimism.

Believe. Perhaps the cure for Parkinson’s disease is closer than any of us can imagine.

I want to remind you that:

  • A large number of scientists and doctors are furiously researching novel treatments for Parkinson’s disease.
  • New medications and formulations for Parkinson’s disease are being made available almost every year.
  • Even with the current medications and with Deep Brain Stimulation (DBS), Parkinson’s disease can be satisfactorily controlled in most patients.
  • Hoping for a cure for Parkinson’s disease is perfectly reasonable.
  • Each one of the 4 points above is 100% true.
Caution: This information is not a substitute for professional care. Do not change your medications/treatment without your doctor's permission.
Dr. Siddharth Kharkar

Dr. Siddharth Kharkar

Dr. Siddharth Kharkar has been recognized as one of the best neurologists in Mumbai by Outlook India magazine and India today Magazine. He is a board certified (American Board of Psychiatry & Neurology certified) Neurologist.

Dr. Siddharth Kharkar is a Epilepsy specialist in Mumbai & Parkinson's specialist in Mumbai, Maharashtra, India.

He has trained in the best institutions in India, US and UK including KEM hospital in Mumbai, Johns Hopkins University in Baltimore, University of California at San Francisco (UCSF), USA & Kings College in London.

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NeuroPlus Epilepsy & Parkinson's Clinic - Dr. Kharkar IconNeuroPlus Epilepsy & Parkinson's Clinic - Dr. Kharkar

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  • Avatar Paras Prabhu ★★★★★ 6 months ago
    Out patient is epileptic from about 10 years and her seizure gotten worse during the past year with the frequency of about 3-4 times a week.So we consulted … More Dr. Kharkar. He tried a few medicines, and within 1.5-2 months now the patient is feeling very well now. There are no seizures for 14 days currently.Dr. tried to keep medicines as minimum as possible. He also tried to keep the cost of the treatment minimum.When some of the medicines started showing side-effects, he was quick to switch the medicines to the better options.Overall I think we are getting a best of the available treatments. We thank you very much Dr. Kharkar.
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    Dr Kharkar is gem of a doctor with tremendous patience, empathy, genuine concern for his patients .He guides them very methodically & scientifically … More for their neurological ill healthOur epilepsy patient is extremely happy with his treatment , Patient feels better by just visiting him too!May his selfless service to humanity flourish to reach all the needy patients!!
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    I consulted Dr Sidharth for my sister who has become very hyper and aggressive and we could not understand the issue. Keeping in mind she is someone with … More special needs Dr Sidharth was extremely understanding of the situation and did not put her through unnecessary investigation and avoided a very long stay at the hospital. He was infact more keen on her returning home to her natural environment. We highly appreciate Dr Sidharth for his effort and for looking into the matter with utmost care. It was a very difficult decision for my family to get my sister admitted but we are glad we did it under his care.Thankyou Doc.
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    my name is prashant purohit. I m become completely bed ridden from last 9 months and was unable to walk. I couldnt find out the cause even after visiting … More many doctors and many hospital in Ahmedabad nd jodhpur.started losing hope. A good friend of mine suggested to visit a neurologist. After searching a lot, I came to know about Dr. Siddharth Kharkar and took his appointment in Nanavati Hospital. He examined and said that he suffered from \u201cPKD(PAROXYSMAL KNESIGENIC DYSKNESIA\u201c. He assured us to reverse this in 5 days time. And indeed this happened. I started recovering miraculously. today I am fully well fit I m walking as normal . Many Many thanks to Dr. Siddharth Kharkhar sir for giving me a new life.
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    We visited Dr. Kharkhar for treatment regarding my mum - who is a multi-stroke patient and has aphasia. Certain medications were creating complications … More with her condition and Dr. Kharkhar was able to help mitigate the issue. We found him and his approach to be incredibly compassionate, considerate, individualized and patient-friendly. He advice is astute, up-to-date and empathetic. His treatment always comes from a deeply human place and is about seeing how to help the patient and their caregivers feel more at ease. Something that is quite rare and refreshing within the medical community.We feel that he genuinely cares about the patients that he is treating and is always kind and respectful in his communication. Moreover, his admin team is very efficient and prompt and it's a pleasure to deal with them.Would highly recommend Dr Kharkhar himself - though we must say our experience with Nanavati hospital itself has been less than ideal.Hope this helps.
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    Exceptional experience with an expert,Dr. Kharkar is a knowledge house. It is rare nowadays to find doctors with patience, knowledge, and a flair for … More handling patient’s questions, besides Dr. Kharkar’s bedside manners are exemplary. I am privileged to be treated by such an amazing soul. I have told him and will repeat it here that “I am advancing my move back to India although I am a US Citizen, because I know I am in good hands and will be well taken care of. Thanks Dr. Kharkar for your selfless service!
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Noted as one of the best Neurologists in Mumbai

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Ex-Assistant Professor, University of Alabama, USA

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