Evidence-Based Reviews

Parkinson’s symptoms or depression? Look for clinical signs

Current Psychiatry. 2007 July;6(7):78-87

How to sort through overlapping symptoms using DSM-IV-TR diagnostic criteria.

References

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Many depressive symptoms are seen in the normal course of Parkinson’s disease (PD) (Table 1).¹ As a result, depression—the most common neuropsychiatric disturbance in PD—is difficult to assess in PD and easily can go undetected and untreated.²

Making the diagnosis is important, however, because depression causes PD patients suffering and may accelerate decline in motor and cognitive function, activities of daily living, and quality of life.³ In the absence of specific guidelines (Box),⁴ we provide evidence to help you sort through the overlapping symptoms to find clinical signs that differentiate depression from PD symptoms.^5,6

Table 1

Symptoms of depression that occur in or mimic those in the natural course of PD

Psychomotor retardation (bradykinesia)
Depressed or emotionless appearance (‘masked facies,’ stooped posture)
Agitation (dyskinesias)
Decreased interest and enjoyment (apathy and decreased initiative)
Impaired memory and concentration
Fatigue or decreased energy
Impaired sleep
Weight and appetite changes
Physical complaints
Source: Adapted from reference 1

DSM-IV-TR depression criteria

Approximately 20% of PD patients meet DSM-IV-TR criteria for major depression, and another 20% meet criteria for dysthymia.⁵ By DSM-IV-TR criteria,⁶ diagnosis of a major depressive episode requires ≥5 of 9 symptoms, of which at least 1 is depressed mood or loss of interest or pleasure. Because these symptoms must be present during the same 2-week period and represent a change in functioning, this diagnosis has an acute quality.

Dysthymia—also frequently called “chronic depression”—is characterized by a mostly depressed mood for 2 years, accompanied by ≥2 of 6 symptoms: appetite changes, sleep changes, low energy/fatigue, low self-esteem, poor concentration/indecisiveness, and hopelessness.⁶

All of these depression symptoms may overlap with those of PD.

1 Mood. In mid-stage and late PD, mood often fluctuates in concert with daily periods of increased rigidity and tremor (“off” periods) interspersed with improved motor functioning (“on” periods).⁷ Thus, when evaluating the PD patient:

take a detailed history of motor fluctuations and their associations with mood symptoms
also evaluate mood during “on” periods.

2 Interest and pleasure. Differentiating decreased interest from apathy is one of the greatest challenges in diagnosing depression in PD. The neurologic symptom of apathy in PD includes 3 features:

behavioral (lack of effort)
cognitive (loss of interest/concern)
affective (decreased emotional response or “flat” affect).

Some studies have described apathy as a common feature of PD that can occur independent of depression;⁸ others have associated apathy with cognitive impairment.⁹ Anhedonia also seems to be more common in PD patients than in matched controls, apparently independent of PD’s neurologic, frontal, and depressive aspects.¹⁰

3 Weight changes. Patients with PD tend to have lower body weight than matched subjects. As a result, weight loss in the course of PD can be confused with weight loss associated with depression.

Weight loss appears to start 2 to 4 years before a PD diagnosis and continues thereafter. Despite the weight loss, PD patients report higher energy intake after the diagnosis compared with individuals without PD.¹¹ A related, not necessarily contradictory finding is that a higher premorbid body mass index (BMI) seems to be associated with an increased risk of developing PD.¹²

In general, dopaminergic treatment of PD seems to be associated with weight loss.¹³ However, weight gain has been reported after pramipexole treatment, which the authors of the study attributed to limbic D3 receptor stimulation.¹⁴

4 Sleep and excessive daytime sleepiness. Sleep disturbances are very common in individuals with PD.¹⁵ A community study found that two-thirds of PD patients complained of sleep problems, with sleep fragmentation and early awakening being the most common complaints.¹⁶ Initial insomnia was less common, and a surprisingly high number of PD patients reported symptoms that suggested obstructive sleep apnea, periodic limb movements of sleep, and REM sleep behavior disorder.¹⁷

Excessive daytime sleepiness has been associated with PD and with the medications used to treat it. Give special consideration to diagnosing sleep attacks—abrupt, unavoidable transitions from wakefulness to sleep—which are reported in up to 30% of PD patients taking dopaminergic agonists. These attacks can occur during critical activities, such as driving,¹⁸ and likely are a class effect of dopamine replacement therapies.¹⁹

5 Psychomotor retardation as a core symptom of PD is clinically indistinguishable from that seen in severe depression.

6 Fatigue. Most studies of fatigue in PD do not define whether the term applies to prolonged mental exhaustion or lack of physical endurance. In any case, one-third to one-half of PD patients report fatigue, and many consider it one of the most disabling symptoms—worse in this regard than motor symptoms.²⁰ Fatigue is more than twice as common in PD patients as in healthy controls and is associated with depression, dementia, disease severity, disease duration, levodopa dose, and use of sleep medications.²¹