Here, Dr Joe Vattakatuchery discusses how common it is for those with a neurological condition, such as Parkinson’s or MS, to also have depression. Dr Vattakatuchery is a Senior Consultant Psychiatrist, with an MSc is Clinical Neuropsychiatry. Dr Vattakatuchery has special interest in mental disorders in neurological conditions and is a Clinical Partner in Liverpool and Manchester.
There is increasing evidence that depression is very common in a variety of neurological conditions. Studies in Parkinson’s disease, multiple sclerosis and epilepsy have shown a higher prevalence of depression in these conditions compared to general population.
For example, lifetime risk of depression in multiple sclerosis has been reported to be 40-60% and an annual prevalence figure of 20% has been reported. Similar figures are seen in other neurological conditions.
Major depression appears to be significantly prevalent following a traumatic brain injury with a reported period prevalence of 33% to 42% within the first year and 61% in the first 7 years following injury.
The problem is that many symptoms of depression overlap with that of neurological conditions. This can make identification and diagnosis more difficult. For example, some symptoms are common to both depression and Parkinson’s disease, such as slowing of body movements, disturbance in sleep, appetite disturbance and loss of interest.
There are also similarities in ‘body posture’ in depression and Parkinson’s disease. Tiredness is a symptom in depression and multiple sclerosis. Patients after stroke may have communication difficulties and disturbance in bodily functions such as sleep, appetite etc and this may make assessment and diagnosis of depression difficult. Apathy (lack of interest) seen in some people with traumatic brain injury may be difficult to differentiate from depression.
Depression is often seen as an understandable emotional reaction to their neurological condition rather than a disorder that needs recognition and treatment. Clinicians may not have the necessary skills to assess and treat depression adequately in this patient group.
Some Clinicians may also be reluctant to diagnose depression and worry that treatments such as antidepressants may worsen the neurological disorder. For example, lowering of seizure threshold in epilepsy or worsening of movement disorder in Parkinson’s disease.
It’s also common to see patients who are reluctant to disclose their full symptoms due to perceived stigma about mental illness.
Evidence is growing for the importance of early diagnosis and treatment of depression in neurological conditions. Not only does an early diagnosis and subsequent treatment improve the patient’s quality of life and lead to better outcomes, there is also evidence to suggest that a patient with depression will have longer hospital stays and may have more difficulties complying and engaging with the treatment of neurological disorders.
Identification and diagnosis of the disorder is the first step. A mental health professional, such as a neuropsychiatrist, neuropsychologist and psychiatrist will take a thorough patient history, eliciting the symptoms of depression and a carrying out a full mental state examination are key to diagnosis.
Patients will benefit from seeing a specialist with expertise in this field such as a psychiatrist or neuropsychologist, who has experience of working with patients with complex conditions. Seeking help from an expert with experience in the field can improve diagnosis and provide the most appropriate treatment.
Treatments such as antidepressants, psychological treatments and talking therapies are effective in the treatment of depression for those who also have a neurological condition. A neuropsychiatrist will be able to prescribe medications that are suitable for patients who are in receipt of medications to help manage their neurological condition.
Depression in neurological disorders is common but under diagnosed and undertreated. The reasons for this are multifactorial. Careful history taking and mental state examination helps to accurately diagnose depression and find the best possible treatment plan. Whilst many patients with neurological conditions suffer in silence, there is hope that successful treatment can make all the difference to a patient’s quality of life.
H Rickards (2005) Depression in neurological disorders: Parkinson's disease, multiple sclerosis, and stroke. Journal of Neurology Neurosurgery and Psychiatry. 2005 Mar;76 Suppl 1:i48-52.
N Agarwal and H Rickards (2011). Detection and treatment of depression in neurological disorders. Journal of Neurology Neurosurgery and Psychiatry 2011;82:828-829 doi:10.1136/jnnp.2011.245779
J Vattakatuchery, N Lathif, J Joy, A Cavanna, H Rickards (2013). Pharmacological interventions for depression in people with traumatic brain injury (Protocol). Cochrane database of systematic reviews March 2013 DOI: 10.1002/14651858.CD010419
JJ Vattakatuchery, H Rickards, AE Cavanna (2011). Pathogenic mechanisms of depression in multiple sclerosis. Journal of Neuropsychiatry and Clinical Neuroscience 23:261-276.doi: 10.1176/appi.neuropsych.23.3.261.
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