Q&A: Depression and Parkinson's
Richard Brown joined our discussion forum
in November 2012 for a question and answer (Q&A) session on
depression in Parkinson's.
Richard (pictured right) is a clinical psychologist and
researcher who specialises in depression and other psychological
problems in Parkinson's.
Read the questions submitted and Richard's answers
About depression and Parkinson's
Depression is usually diagnosed when
someone has feelings of extreme sadness or emotional emptiness for
a long period of time. These feelings can affect a person's ability
to carry out day-to-day activities.
The symptoms of depression can include the following:
- lack of interest or pleasure
- low energy and tiredness
- trouble sleeping
- decreased sexual energy
- feelings of worthlessness
- in severe cases, thoughts of death or suicidal ideas
But there are also other symptoms that can indicate that someone
Depression in people with Parkinson's may be due to a number of
causes. Some research has suggested that a lack of the chemical
dopamine which causes the symptoms of Parkinson's can also be a
trigger for depression.
Depression can be related to genetics or can be a side effect of
Parkinson's drugs. Because of the range
of possible causes, it is important that you speak to your
Transcript of the session
Daniel: My father was diagnosed with Parkinson's
approximately 10 years ago. He has physical problems (which are
compounded by his age perhaps), but he is often depressed - bleak,
lethargic, non-communicative, and so on.
He has agreed now to see a therapist of some kind to
talk about this side of his Parkinson's but, before embarking on
that path, I'd like to know what they might consider.
My father is 83 and frail. Many thanks.
Richard: I am pleased that your father has agreed to see a
Evidence-based therapies such as
cognitive behavioural therapy (CBT) for depression can be
effective in older adults. The challenges and problems faced by
older depressed people, particularly those with significant
physical conditions, can require some modification of how CBT is
used compared to younger adults.
CBT is an active treatment that involved practical 'homework'
between the sessions. Often, family members will be involved to
help the older depressed person with this aspect of the treatment,
particularly if they are frail and need care anyway.
It is therefore desirable that your father is seen by a
therapist that specialises in working with older adults or others
with a chronic health condition. However, even if that is not
possible, a good therapist will adjust the treatment to suit the
Linda: When I was diagnosed, I was told that
clinical depression is very common in people with Parkinson's,
because of a chemical change that happens in our brains. Is this
true? If so, can you explain more?
Richard: Depression (sometimes called clinical depression) needs
to be distinguished from periods of low mood that everyone gets
from time to time.
Depression is marked by the fact that the symptoms are
persistent (lasting for days, weeks or months with only brief
periods of respite). And they have an effect not just on how the
person feels, but on wider aspects of their life such as how well
they look after themselves, their ability to work or carry out
day-to-day routines, their enjoyment of hobbies and pastimes and
their willingness to socialise and be with other people.
Depression (sometimes called clinical depression) needs to be distinguished from periods of low mood that everyone gets from time to time.
It is certainly true that depression is common in Parkinson's.
Estimates vary but perhaps 20-25% will be depressed, with more
experiencing periods of low mood.
Many factors will contribute to depression and may help explain
why some people with Parkinson's get (and stay) depressed and
others do not.
The chemical changes in Parkinson's are certainly one factor
although we do not fully understand which of the brain changes are
It is unlikely to be the same chemical changes that cause the
motor (or movement) symptoms as not
everyone with Parkinson's gets depressed and the drugs for the
motor symptoms tend not to help depression.
There may a number of different brain changes that can cause
depression in Parkinson's. This may explain why there is no single
antidepressant that seems to be effective for all people. However,
it is unlikely that brain chemical changes are the only cause.
Rates of depression are elevated in virtually all groups of
people with a chronic and progressive physical health condition.
People vary in how well they are able to adapt and cope with the
restrictions and this will also contribute to whether they
antidepressants and other drugs may help the brain changes, it
is also possible to do things to help with the process of
adjustment to living with Parkinson's - how we think about the
condition and its problems and how we live our lives.
This is what psychological therapies such as CBT aim to do. I
will talk more about CBT in answering some of the other
Anonymous: Is there a link between Parkinson's and
Richard: See my answer to Linda above.
There is a definitely a link between depression and Parkinson's
although it is not a simple or straightforward one and is poorly
Firstly, there are those people who develop depression later in
life (after the age of 55). They seem to be at greater risk for
developing Parkinson's some years later than other people the same
This suggests the possibility that late-onset depression may be
an early sign of Parkinson's itself before the motor symptoms
However, many people with Parkinson's who get depressed have
also suffered from depression earlier in their life, from their 20s
or 30s onwards, sometimes repeatedly. For such people, prone to
depression, it may re-occur in response to particularly difficult
and stressful life circumstances.
For such people, the practical challenges of Parkinson's and its
impact on their life may sufficient to explain why they become
depressed, rather than particular brain chemical changes related to
This may also explain why some people get depressed even though
their Parkinson's is very mild - because they change the way
they live (in an unhelpful way) and how they see their future
(negatively), even though the symptoms are well-controlled.
Nick: I have suffered periods of severe depression
(suicidal thoughts) for about 40 years. I was diagnosed with
Parkinson's only 4 years ago. I think it is unlikely there is a
connection but what is your view?
Professor Brown: My answers to Linda and anonymous above can
help to answer your question.
Depression is very common with about 20% of all adults
experiencing depression at some point in their life. The vast
majority of them do not go on to develop Parkinson's, so the two
conditions are probably unrelated for the majority of cases. The
exception is when depression appears for the first time late in
life with no obvious cause. However, this is not the situation in
You do not say whether you have been depressed since developing
Parkinson's. However, anyone with a history of depression before a
Parkinson's diagnosis is at greater risk of becoming depressed as
they live with the condition.
It is therefore important for you, your family and your
healthcare professionals to be alert to any early signs of
depression and seek help early before it develops into a full-blown
David: I have Parkinson's, I'm 47 and always lived
my life as a 'glass half full' sort of guy. I was diagnosed 4 years
ago and took the news well. However for the last 2 years I've been
depressed, even suicidal most of that time.
I was on citalopram but now mirtazapine 45mg and my mood
has improved from 0 to 3/10. I take Madopar 4 times a day. I'm about to start
counselling but don't see how this will work as they can't change
Are there antidepressants that are particularly recommended for
Is counselling effective? CBT? Positive
thinking?Should my councillor be expected to
What else can I do to beat this severe depression which
is so out of character?
Professor Brown: Antidepressants can certainly be helpful for
depression in Parkinson's.
There is not enough evidence yet to recommend one type of
antidepressant over another. Many people, with or without
Parkinson's, may need to try a couple of different types before
they find one that works, and to find the right dose.
Your doctor should check how you are getting on with any tablets
after 4-6 weeks and if they are not helping adjust the dose or try
a different type. I would say that the 3/10 benefit that you are
getting is not good enough.
Antidepressants and psychological approaches are not simple
alternatives. Often they work best in combination. Counselling and
therapy are different, and within each there are several different
'flavours'. Both can be useful and some people prefer one approach
over the other. It is good to find out what is available to
As with medication, there is no 'one size fits all'. Having
a therapist or counsellor with experience of Parkinson's is useful
but not essential. They may have experience of helping people with
other long-term life changing physical health problems which they
can apply readily to Parkinson's.
Psychological approaches such as cognitive behavioural therapy
(CBT) have been more extensively tested than counselling approaches
and tend to be recommended more by bodies such as NICE. CBT is
problem-focused and looks to identify the things that are
maintaining the problems rather than trying to identify underlying
This includes things such as how you think about your problems
now and for the future(cognitions) and the things you do or don't
do (behaviour) in response to the Parkinson's.
While it can't change the 'reality' of the fact that you have
Parkinson's, it can change how you perceive that reality -
something that you can control. CBT seeks to help to learn new and
more useful ways of thinking and behaving to reduce the
A lot of CBT is common sense (or should be). Depression tends to
make people think in a depressed way ("everything is awful, the
future is bleak, I cannot do anything"). It also makes us minimise
the good things that happen and magnify anything bad. This means
that a depressed person often ignores or forgets things that happen
in their day that is positive.
Simple things that you can do for yourself include keeping a
record (a 'positive data log'). At the end of the day - or during
the day - write down 3 things that you have done or 3 positive
things that have happened, something that you have enjoyed or been
pleased with. It doesn't matter how trivial.
By writing them down you are more likely to remember them with
all the bad stuff that is also happening. Also, knowing that you
have to have something to write down makes you become more aware of
the small positive day-to-day things that might otherwise be
ignored. This will not cure the depression on its own but it's
a small tool in the armoury.
Other things that you can do without therapy is keep active -
mentally and physically. This is hard for someone with depression
as their motivation is typically poor, they feel more tired and
tend to make excuses why they should not/could not do something.
But doing something each day - however small - is better than
Build up your activities and try to do things that can give you
some satisfaction. If your Parkinson's is stopping you do things
that you used to enjoy, try to find an alternative including
something new that the condition allows, eg swap golf for indoor
These are all things that a CBT therapist will help you with but
which you can also do on your own. Having family and friends
encourage and support you (and not take no for an answer) also
Finally, I am glad that you have been an optimist as this a good
sign for the future. However, optimists sometimes have a tendency
to cope by saying things such as "it could be worse", "things will
work out OK in the end" etc. In other words, while they do not let
things get them down, they also may fail to deal with problems that
can gradually build up and overwhelm them.
Getting back in touch with your optimism and using it in a
constructive way is something that a good therapist should be able
to help you with.
Titan: This may sound rather odd. I have had
depression and other psychological/behavioural/emotional issues
well before my Parkinson's diagnosis. These issues have certainly
become magnified since my Parkinson's diagnosis 3 years
Even taking my medication out of the equation, I can
still have extreme mood swings, especially the lows. I suppose my
behaviour became magnified on the dopamine agonists.
I am at a point now, the very edge of a precipice. I
have just started cognitive behavioural therapy (CBT) but doubt its
effectiveness. The circle of woe can be interrupted periodically,
but the emptiness, uselessness, negativity and my wasted/wasting
life are not easily brushed under the carpet.
Can things reach a point or go beyond a point where a
person like myself is beyond all help? I have annoyed many people,
who feel frustrated because I can't buck myself up out of my
turmoil or seem self absorbed.
Do depressed people become self absorbed? Is it an easy
way out rather than facing things head on? I don't think I can ever
shake off my feelings and I am sorry to all those people who have
tried to help me. I have let so many down and am deserving of their
I am in a hole that I can't get out of and really don't
know who or what I am any more. Self harm,drinking and all sorts of
strange things I do.
Is Parkinson's the final nail in the depressive coffin?
Just random thoughts, I expect no answers where there are none to
be found. Thanks.
Richard: Titan, you are the first person to mention highs as
well as lows. While people with depression can describe periods of
time where they may feel 'OK', 'not so bad’ or even have normal
mood, they tend not to describe these as highs, or describe extreme
If the mood swings and the highs are something new to you
(rather than the depression which you describe as a long standing
problem) they could relate to your Parkinson's or the treatment
that you are receiving. Make you sure mention these to your
If you are receiving medication for your mood, some types are
better suited to helping people that have periods of highs and lows
that you describe. A psychiatrist would be the best person to
You describe very graphically how you feel on the edge of a
precipice. This is the depression talking. Depression affects how
we think about ourselves (such as the guilt and self-blame that you
describe), the world about us and the future.
It is this hopeless, self-punishing bleakness that makes
depression so distressing and disabling. However, what is important
to remember is that this point of view is not a reflection of any
current or future reality - it is your situation seen through the
distorting lens of the depression. Just because they are your
thoughts it does not mean that they are correct, accurate or
The correct medication can help reduce these feelings and mood
changes, and therapies such as cognitive behavioural therapy (CBT)
can tackle head on the distorted thinking patterns that depression
It is understandable, feeling how you do now, that you have
little confidence in CBT - you probably have little confidence in
anything being able to help you. However, CBT can and does work.
But it takes time and effort. The more you put in to it, the more
you get out.
A good therapist will accept your scepticism if you acknowledge
it, and find ways for you to change your opinion. They will guide
you to try out alternative ways of thinking and behaving as
'experiments' to see if they do any good. Progress can be slow and
gradual, but once you see that you can influence your negative
thoughts and improve your mood - even in a small way - rather
than being its victim, you can start making real progress.
Finally, you mention self-harm and drinking. It could be that
these are features of your depression and will respond to
treatment. However, it is also possible that are features of
impulsive behaviour linked to your dopamine
agonist medication and worsened by your depression.
Make sure you discuss these with your neurologist at your next
appointment. You should also be alert to changes that may accompany
any future increase in your agonist dose.
Alison: At what point might you consider ECT in someone
with depression as a predominant feature of their
Richard: It may seem old fashioned but there is excellent
clinical trial evidence that
ECT (electroconvulsive or electroshock therapy) can be an
effective and life-saving treatment for severe depression in people
How it works is less unclear. In Parkinson's, while there have
been no clinical trials, there are good anecdotal clinical reports
of it being effective for some people with severe depression.
However, whether in people with Parkinson's or without, ECT is
reserved for the most severe forms of depression as an emergency
treatment when the person is threatening to take their own life,
refusing to eat or drink or is suffering severe delusions with
their depression. Typically it is only recommended when the
depression has proven impossible to treat effectively with other
Just because drugs do not seem to help does not mean that ECT is
necessarily the next step. Many people who have chronic persistent
or recurring depression may not be receiving optimal conventional
treatment. They may be on the wrong drugs at the wrong dose, and
alternative forms of treatment including psychological treatment
may not yet have been tried.
Severe chronic and treatment-resistant depression should be
managed by specialist psychiatric services, rather than through a
GP or even a neurologist.
emswife: I often find myself starting to cry for no
reason. It goes as quickly as it comes, but it's embarrassing as
I'm often in company, but I feel genuinely depressed at the time.
Is this just me or my medication or Parkinson's?
Richard: If you did not also have low mood at the time, it could
be that you are describing something called psudobulbar affect
(PBA). This is where people with a neurological disorder find
themselves crying or laughing uncontrollably without cause and
without the corresponding emotion.
Although more common in some neurological conditions it has been
reported to occur in as many as 5% of people with Parkinson's, more
in those who also experience depression.
Not all people who are depressed cry but many do - it is
one of the symptoms of depression (interestingly some people who
are depressed feel unable to cry which can feel as bad).
We normally associate periods of crying with feeling
particularly sad or upset. However, crying is a very complex thing
and can have lots of triggers, particularly if someone has a low
You may find yourself crying if people are being nice to you or
sympathetic, when looking at a picture that brings back a happy
memory, or when feeling angry or frustrated. These are all natural
situations in which people will cry when their mood is low, even if
they are not particularly sad at the time.
Try not to worry about the crying. Seek help for your mood and
the crying should diminish.
David: What biochemical role or pathway is significant
with exercise and depression? Which is cause and which effect? Does
depression cause apathy and reduced exercise? Or does less exercise
cause depression? Which comes first? Chicken and
Richard: Good questions to which there is no good scientific
Physical exercise can cause the release of mood lifting
chemicals such as endorphins into the blood (the cause of 'runner's
high') but it is not clear that these are responsible for any
longer term benefits of exercise on mood. Cardiovascular fitness
increases blood supply to the brain both during exercise and
afterwards and this may help as well.
However, the benefits of exercise may be less direct. When we
are depressed we start doing less, including physical activity. We
feel demotivated and fatigued and we then do even less and feel
Very quickly a vicious cycle builds up with the depression and
lack of physical activity feeding each other (chicken <->
egg). To make matters worse if we are less active we have more time
to sit at home and think - the last thing a person with depression
should be doing.
Starting a graded programme of physical activity is one
excellent way to break that cycle and start to reverse it - by
taking exercise you are 'fighting back', doing something that makes
you feel a bit better at the time. Having more energy allows you to
do other things that you want to do and which help further.
However, any form of activity that gets you out of the house,
doing things and being more engaged with the people and the world
would also be good.
For people that enjoy it, physical exercise is great for its own
sake and for depression but it is not the only type of activity
that is helpful and is seldom the solution on its own.
jeremy10: I was diagnosed in 2006, and get depressed
about feeling disabled. I had a negative reaction from citalopram 2
years ago. CBT was very helpful 2 years ago. Should I go for more
talk therapy? My consultant seems to think so.
And is depression endemic in Parkinson's?
Richard: You describe a classic response to a diagnosis of Parkinson's.
It is very common for people given a diagnosis of a chronic
condition to suffer a negative reaction such as yours. It is not
the symptoms themselves (which in the beginning are mild and easily
treatable) but the personal meaning of 'having Parkinson's' or
'being disabled' that does the damage, or their expectations and
fears for the future. People can experience all sorts of negative
feelings from shame to thoughts that their life is as good as
After depression is triggered by something like the diagnosis,
some people recover well as they learn more about Parkinson's and
realise that it does not justify their worst fears. Others can need
some extra help.
You describe CBT as being very helpful then, but you find
yourself depressed again. This is very normal.
While cognitive behavioural therapy (CBT) teaches you to spot
and challenge patterns of negative and unhelpful thinking
associated with depression, many people 'get rusty' and stop using
the skills that CBT has taught them. I agree with your consultant
that having a top-up course of treatment would be useful.
However, some people with recurring depression find that a
slightly different approach is helpful to maintain the benefits in
the long-term. A modified type of CBT called mindfulness-based CBT
(mCBT) is proving effective in preventing relapse. It is also
increasingly used in individuals with chronic physical health
problems where its techniques seem particularly appropriate.
mCBT is becoming more widely available and it is worth
discussion with your therapist whether it is an option.
In relation to your last question, depression in Parkinson's is
certainly common but it is not inevitable or endemic.
anonymous: I have experienced depression with
Parkinson's for a few years. I have also experienced some
difficulties thinking clearly. Can you comment on the likelihood of
clouded thinking being caused by depression, by Parkinson's or by
medication (Sinemet Plus and ropinirole)?
Richard: Depression is a very complex condition. Apart from the
obvious changes to mood, reduced motivation and less ability to
enjoy things, it can affect a person's sleep and appetite, cause
fatigue and even pain. Problems with concentration and memory are
also classic features of depression.
If the thinking problems started at the same time as other
depression symptoms it is likely that they are part of the
depression itself, or the depression is making mild problems
However, as you indicate from your question, problems with
thinking clearly might be a symptom of your Parkinson's or made
worse by your medication. Being on too low a dose of medication can
affect your thinking, but too high a dose can make it worse as
The best place to start is to make sure that you are getting the
best possible treatment for your depression, whether from
medication, CBT or both. Talk to your consultant or GP to review
your current treatment and see what else is available.
If your thinking problems persist even if your depression
improves, you should talk to your consultant. He or she may arrange
for you to have some tests before deciding whether any adjustment
in your medication is needed, or additional treatment
anonymous: Are there any special considerations when
treating depression alongside Parkinson's or are the same
treatments equally valid?
Richard: Some types of the older antidepressants are not advised
for use in Parkinson's or for people with other physical health
problems. This can be because of the risk of an interaction with
the Parkinson's medication or other adverse side effects and health
However, most of the common modern antidepressants used today
for treating depression can be used for depression in Parkinson's.
They are generally felt to be safe and do not make the Parkinson's
worse. Your consultant or GP should know what to advise.
What is less certain is how well they work. While many people
find them extremely effective, others appear to get no benefit at
all. However, this is probably nothing to do with Parkinson's or
its treatment. Depression is a very complex condition with multiple
About half of people without Parkinson's who have depression
fail to respond to antidepressant drugs. We do not know why this
is. Where one class of drug does not seem to be working, doctors
should try a different class until hopefully finding one that is
Alternatively (or in addition) they may recommend a
psychological treatment such as CBT. Like drugs, it is more
effective for some people than others. However, one of the good
things about CBT is that there is no worry that it will make the
Parkinson's worse or interact with the Parkinson's medication.
About Professor Richard Brown
Richard trained as a clinical psychologist in 1982 and since
that time has worked as a clinician researcher focusing
He worked first at the Institute of Psychiatry and
later at the Medical Research Council's Human Movement and Balance
Unit before returning to the Institute of Psychiatry in 1998,
where he now leads the Department of
His research has covered all aspects of Parkinson's - cognitive
and movement problems, depression and other psychological problems,
in both those with Parkinson's and their partners.
Most recently Richard has been leading a major programme of
research funded by Parkinson's UK into depression and anxiety in
Parkinson's (the PROMS-PD study) which is advancing our
understanding of these important problems.
More on mental health and Parkinson's