Emma Edwards highlights the effect depression can have on patients with Parkinson’s disease and the need for support from Parkinson’s disease nurse specialists
Read this article to learn more about:
- assessing mental health in Parkinson’s disease
- the overlap between Parkinson’s disease non-motor symptoms and depression
- the role of the Parkinson’s disease nurse specialist in supporting people with Parkinson’s disease.
Parkinson’s disease (PD) is a progressive neurological condition that is characterised by tremor, stiffness, and slowness. These overt physical signs are commonly referred to as ‘motor symptoms’. However, signs unrelated to movement can manifest along the way, or even before the disease is formally diagnosed; these ‘non-motor symptoms’ can include autonomic, memory, mental health, and mood problems.
When a person is diagnosed with PD, a multi-disciplinary health and social care team often supports them. The team can include neurologists, occupational therapists, and Parkinson’s disease nurse specialists (PDNSs). PDNSs are often central in coordinating care, conducting regular monitoring of the person with PD, managing medication, and generally being an accessible source of information and advice for patients, families, and other healthcare professionals. This framework for the role of the PDNS is supported by the 2017 NICE Guideline (NG) 71 on Parkinson’s disease in adults.1
Depression in Parkinson’s disease
Depression is a common non-motor symptom in PD and is thought to occur in over 50% of people.2 Depression in PD can occur for various reasons but is generally considered a consequence of a chemical depletion in the brain and a response to living with the challenges of the condition.3 It is widely accepted that people with depression, regardless of whether they have PD or not, have an increased risk of suicide than those who do not have depression.4 A recent review of literature suggests that people with PD are much more likely to experience suicidal thinking than the general population, but it remains unclear if the risk of suicide is increased. The review concluded that there was often conflicting evidence on suicide and suicidal ideation in the Parkinson’s population and that more studies were needed. However, it does state that the evidence suggests ‘aggressive’ management of depression is the best approach.5
Performing a mental health assessment
NICE Guideline 71 does not specifically cover depression or suicide in people with PD; it signposts to NICE Clinical Guideline (CG) 91, Depression in adults with a chronic physical health problem: recognition and management. NICE CG91 recommends that when depression is suspected in a patient with a chronic physical health problem, healthcare professionals should consider asking the following questions:6
- During the last month, have you often been bothered by feeling down, depressed or hopeless?
- During the last month, have you often been bothered by having little interest or pleasure in doing things?
NICE CG91 goes on to recommend that if the patient answers ‘yes’ to either question the practitioner should (if they are competent to) perform a mental health assessment (see Box 1). If the practitioner is not competent to perform a mental health assessment, NICE recommends referral to an ‘appropriate professional’—if this professional is not the patient’s GP, the GP should be informed of the referral.6
Box 1: Further assessment of depression in patients with a chronic physical health problem6
If a patient with a chronic physical health problem answers ‘yes’ to either of the depression identification questions [see main text], a practitioner who is competent to perform a mental health assessment should:
- ask three further questions to improve the accuracy of the assessment of depression, specifically:
- during the last month, have you often been bothered by feelings of worthlessness?
- during the last month, have you often been bothered by poor concentration?
- during the last month, have you often been bothered by thoughts of death?
- review the patient’s mental state and associated functional, interpersonal and social difficulties
- consider the role of both the chronic physical health problem and any prescribed medication in the development or maintenance of the depression
- ascertain that the optimal treatment for the physical health problem is being provided and adhered to, seeking specialist advice if necessary.
© NICE 2009. Depression in adults with a chronic physical health problem: recognition and management. Available from www.nice.org.uk/cg91 All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.
Some symptoms of PD can mimic those of mental health problems, and this can make the mental health assessment challenging, particularly for practitioners who have less experience in managing patients with PD. For instance, issues with cognitive processing and concentration in PD can be related to the disease process itself and/or side-effects of medication, and thus not suggestive of a low mood at all. Similarly, signs of depression such as moving more slowly and disruption to normal sleep architecture are common motor and non-motor features of PD.7 As such, assessors need to be mindful that such symptoms may be signs of an affective disorder and not necessarily only PD. Solely using the opening questions recommended by NICE may not be enough to determine whether someone with PD is developing depression, so a comprehensive assessment of PD symptoms is also required.
The role of the PDNS
The PDNS is usually the main point of contact for people with PD so the patient is often in more regular contact with the PDNS than other healthcare professionals involved in their care. This means that the PDNS may be in a better position to make a holistic assessment of the person’s symptoms and mental health. This is why, in the author’s opinion, the PDNS is a suitable professional to accurately identify possible depression and refer to appropriate services where necessary.
In the long term, the PDNS can also support other professionals (such as the GP or mental health services) by providing ongoing monitoring of the patient’s mental health through asking questions around mood and, if appropriate, suicidal ideation. The person’s responses can then be shared with the wider team and used to inform the management strategy. The PDNS can also support colleagues by providing them with information and expert guidance on PD medications and side-effect management. This proactive approach is supported by the 2016 PDNS competency framework and is considered to be just one of the expectations of an ‘expert’ PDNS.8
In summary, depression is a common co-exiting condition in PD that can be difficult to recognise. PDNSs are skilled in assessing symptoms of PD and are often a central point of contact for people with PD, so they are well placed to perform an initial mental health assessment. In doing so, the PDNS needs to be aware of the support services in their locality so that timely and appropriate signposting can occur.
Ongoing joint working and communication between PDNSs, GPs, and mental health services is crucial to providing a safe and effective service to people with PD and depression, and will hopefully help reduce the risk of suicide in this population. Further training may be required to ensure that PDNSs feel confident and supported to ask probing questions about mental health with their patients. Early advice and education for people with PD and their families can also help to increase awareness of potential changes in mood, making them more likely to self-report and seek help at an earlier stage.
Emma Edwards (RMN)
Parkinson’s disease nurse specialist
- NICE. Parkinson’s disease in adults. NICE Guideline 71. NICE, 2017. Available at: www.nice.org.uk/ng71
- Reijnders J, Ehrt U, Weber W et al. A systematic review of prevalence studies of depression in Parkinson’s disease. Mov Disord 2008; 23 (2): 183–189.
- International Parkinson and Movement Disorder Society. Depression, anxiety and apathy in Parkinson’s disease. MDS, 2018. www.movementdisorders.org/MDS/Resources/Patient-Education/Depression-Anxiety-and-Apathy-in-Parkinsons-Disease.htm (accessed 29 July 2019).
- NICE. Depression in adults: recognition and management. Full guideline. NICE Clinical Guideline 90. NICE, 2009 (updated 2018). Available at: www.nice.org.uk/guidance/cg90/evidence
- Shepard M, Perepezko K, Broen M et al. Suicide in Parkinson’s disease. J Neurol Neurosurg Psychiatry 2019; 90 (7): 822–829.
- NICE. Depression in adults with a chronic physical health problem: recognition and management. NICE Clinical Guideline 91. NICE, 2009. Available at: www.nice.org.uk/cg91
- NHS. Symptoms—Parkinson’s disease. www.nhs.uk/conditions/parkinsons-disease/symptoms/ (accessed 24 July 2019).
- UK Parkinson’s Excellence Network, Parkinson’s Disease Nurse Specialist Association, Royal College of Nursing. A competency framework for nurses working in Parkinson’s disease management. RCN, 2017. Available at: www.rcn.org.uk/professional-development/publications/pub-005584