Depression and Anxiety in Parkinsonís Disease

Depression and Anxiety in Parkinsonís Disease

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Description: Psychiatric disorders are common in Parkinsonís: 70%-85% of patients with Parkinsonís disease with suffer from anxiety, depression, hallucinations, delusions, or behavioral disorders. What causes psychiatric disorders in PD? Related to the disease process (loss of dopamine or other brain chemicals). A reaction to the diagnosis, altered interpersonal roles, disability, and other psychosocial features.

Interaction between the disease and dopaminergic treatments for the disease (e.g. psychosis and dopamine medications, impulse control disorders and dopamine agonists).

 
Author: Greg Pontone MD (Senior) | Visits: 585 | Page Views: 758
Domain:  Medicine Category: Therapy 
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Contents:
Depression and Anxiety in
Parkinson’s disease
Greg Pontone, MD
Director, Movement Disorders Psychiatry Clinical Programs at Johns Hopkins
Morris K. Udall Parkinson's Disease Research Center
Johns Hopkins University School of Medicine

Essay on the Shaking Palsy
“…the senses and intellects being uninjured.”
James Parkinson, 1817

Psychiatric disorders are common
in Parkinson’s
• 70%-85% of patients with Parkinson’s
disease with suffer from anxiety, depression,
hallucinations, delusions, or behavioral
disorders

Marsh et al. 2010

Psychiatric disorders in Parkinson’s
disease (PD)
100
80

8 5.2

Current Prevalence

80

Lifetime Prevalence

66
59 .2

60

48
4 1.6
3 4 .4

40
2 5.2

20

12 .8
0

4 .8

6 .4

12 .4

13 .2

10 .8
1.6

0
Any
Diagnosis

Mood
Disorders

Anxiety
Disorders

Psychosis

Delirium

Impulse Personality Substance
Control
Change
Use
Disorders
Disorders

What causes psychiatric disorders
in PD?
• Related to the disease process (loss of
dopamine or other brain chemicals)
• A reaction to the diagnosis, altered
interpersonal roles, disability, and other
psychosocial features
• Interaction between the disease and
dopaminergic treatments for the disease (e.g.
psychosis and dopamine medications,
impulse control disorders and dopamine
agonists)

8
6
0

2

4

Frequency

10

12

14

16

Psychiatric disorders can occur at
any stage of PD

-70

-60

-50

-40

-30

-20

-10

0

10

Duration between Earliest Major Depression Episode Onset and PD Diagnosis (years)

Ishihara and Brayne 2006

20

30

Symptoms known to affect quality
of life in Parkinson’s disease

Anxiety in Parkinson’s

Anxiety Disorders in PD
• Anxiety disorders are more common in PD
than in the general population.
• Studies suggest that up to half of patients
with PD suffer from an Anxiety Disorder at
some point in their life.
• Certain types of anxiety may be associated
with the neurodegenerative process and/or
treatment of PD.

Anxiety Disorders
• Excessive worry, out of character compared
to earlier in life
• Feelings of restlessness or unease
• Anxiety in anticipation of upcoming events
• Panic or panic-like fear that occurs
episodically, sometimes just before the next
dose of Parkinson’s medication

Common anxiety disorders in
Parkinson’s disease
• Generalized anxiety disorder – persistent
worry out of proportion to event, inability to
relax, restlessness, feeling on edge, difficulty
concentrating, irritability, muscle tension,
trembling, easily startled, trouble sleeping,
sweating, irritable bowel

11

Common anxiety disorders in
Parkinson’s disease
• Panic disorder – episodes of intense worry
that occur suddenly, often “out of the blue”
accompanied by:
• Sweating, shortness of breath, heart palpitations,
choking or smothering sensations, numbness or
tingling, chills or hot flashes, a feeling of
faintness, trembling or shaking, stomach cramps
or discomfort, fear of losing control or dying,
feeling as if you or the situation is unreal
12

Anxiety Disorder NOS – A PD
specific anxiety subtype?
• Atypical anxiety disturbances (not meeting
criteria for general pop. anxiety disorders)
• motor fluctuation-associated anxiety
• fear of falling anxiety
• anticipatory anxiety
• 30% of lifetime anxiety disorders
• the majority (67%) of first-onset anxiety occurring
in ‘peri-PD’ time period were anxiety NOS
Pontone et al 2009, Pontone et al 2011

6

8

First Anxiety Disorder Onset Relative to
PD Onset

0

2

4

F
R
E
Q
U
E
N
C
Y

-60

-40

-20

0

20

DURATION BETWEEN FIRST ANXIETY ONSET AND PD ONSET IN YEARS n=63

Bimodal distribution of anxiety disorder onset compared to PD onset

14

PD-anxiety: Later onset in life
compared to general population
Median Age Onset Anxiety
Disorder (years) :
Parkinson’s Disease,
n=127

Median Age Onset Anxiety
Disorder (years): General
Population, NCS n=9282

Any anxiety disorder

44

11

Panic disorder

42

24

Agoraphobia without panic

59

20

Social phobia

23

13

Specific phobia

40

7

Obsessive-Compulsive
disorder

42

19

Generalized anxiety disorder

59

31

Posttraumatic stress disorder

43

23

Anxiety disorder NOS

60

---

Anxiety Disorder Subtypes

15

Depression in PD

8
6
0

2

4

Frequency

10

12

14

16

Depressive disorders can occur at
any stage of PD

-70

-60

-50

-40

-30

-20

-10

Duration between Earliest Major Depression Episode Onset and PD Diagnosis (years)

Ishihara and Brayne 2006

0

10

20

30

What is “Depression”?
• What do people mean when they say “clinical
depression” or major depression?
• How is this different from the normal and
appropriate low mood or sadness one
experiences during the course of life events?
• Why are medications sometimes necessary,
shouldn’t you just learn to ‘cope’ or deal with
it, aren’t medications just a crutch?

Recognition: Depression is more
than just feeling sad
Diminished interest in usual activities
Reduced enjoyment of usual activities
Excessive guilt or worry about being a burden
Lack of motivation and energy
Difficulty concentrating or focusing
Reduced libido
Poor appetite
Disrupted sleep
Thoughts of death or dying

Prevalence of Depression in
Parkinson’s disease
• Prevalence rates of major depression in
PD range from 20-25%

• Up to 50% for any depression
(dysthymia, minor, depression)

Depressive disturbances can be
both episodic and persistent
– 47% remission within 6 months
– Mild depressive symptoms predicted
– Development of more severe symptoms
(RR=6.16 [95%CI 2.14.17.73])
– Symptom severity, older age, longer PD
duration predicted failure to remit (HR0.830.92)
Ravina et al. 2009

National Parkinson Foundation
• “First Data from Largest, Ongoing Study of
People with Parkinson’s Disease Reveals
Depression Has Biggest Impact on Quality of
Life” from press release November 2012
• Part of the Parkinson’s Outcomes Project, a
longitudinal look at which treatments produce the
best health outcomes
• The impact of depression on quality of life is
almost twice that of the motor impairments

Depression has a negative impact
on Parkinson’s disease
Depression is associated with increased
– Motor deficits
– Disability
– Caregiver burden and depression
– Economic Strain
– Cognitive impairment
– Severity of medical illness

Weintraub et al. 2004, Starkstein et al.
1992

Longitudinal Effect of Depression Remission
Status on Physical ADLs in PD (n=136)
Group differences in Physical ADLs (NWDS)
at baseline and 2-year follow-up intervals

Subjects with PD (Baseline)

Age=67.1 (10.5) years
PD Duration=9.4 (6.9) years
Symptomatic Depression (SD), n=36
Remitted Depression (RD), n=12
Not Depressed (ND), n=88

40
35
30

(NWDS, max score=50)
* Walking
* Hygiene
* Eating/Feeding
* Dressing
* Speech
Note: Lower Scores  Greater Disability

25

N o rth w e s te rn U n iv e rs ity D i s a b i lity S c a le (0 -5 0 )

Northwestern Disability Scale

0

2

Years

Sym p to m atic D ep ress ion
No t D epress ed
low es s n wd _fit yea rs

4

6
Re m itte d De pres sio n
low es s n wd _fit yea rs
low es s n wd _fit yea rs

At any assessment point, subjects with a symptomatic
depressive disorder have greater disability, averaging
3.8 points lower score in the NWDS.
(GEE Regression: SD vs ND, B=-3.8, p