Demoralization Distinct From Depression in Parkinson's Disease

Damian McNamara

April 05, 2018

Not all mental illness in Parkinson's disease (PD) is depression, new research suggests.

Results of a new study show that 18% of people with PD experience demoralization characterized by symptoms such as helplessness, hopelessness, and/or a sense of failure — a rate more than double that found in a control group.

Demoralization is distinct in PD, the investigators note, although it can occur alongside depression. Among 17 people with demoralization, 29% did not have depression. Similarly, 36% of 19 participants with depression did not meet the criteria for demoralization.

"Our study highlights the point that not all mental disease in Parkinson's disease is depression, and depression in general is not a one-size-fits-all diagnosis," principal investigator, Brian B. Koo, MD, from the Department of Neurology, Center for Neuroepidemiology and Clinical Neurologic Research at Yale University in New Haven, Connecticut, told Medscape Medical News.

"The subtle distinction between demoralization and depression is that often those demoralized do not understand what should be done to better themselves, whereas persons who are depressed may have such understanding, but lack motivation to act on this," he added.

The study was published online April 4 in Neurology.

Different Treatment Approaches

Koo and colleagues recruited consecutive patients from the Movement Disorders Clinic at Yale-New Haven Hospital between June 2016 and May 2017. They also assessed a control group matched for multiple factors, including sex, education, and age. The average age of the 180 participants was 68 years.

They diagnosed demoralization by using the Diagnostic Criteria for Psychosomatic Research, Demoralization (DCPR-D) instrument and Kissane Demoralization Scale (KDS). For a positive DCPR-D finding, participants had to answer positively to both of the following questions: Do you experience feelings of helplessness, hopelessness, or giving up? and Have these feelings been present for 1 month or longer? In addition, they had to answer positively to at least one of the following:  Do you feel that you have failed to meet your expectations or those of other people? Do you feel that you are unable to cope with pressing problems?

Participants who scored 24 or greater on the KDS were likewise classified with demoralization.

The investigators assessed depression by using the Patient Health Questionnaire-9 (PHQ9). In addition, they measured frequency of difficulty within the last month on activities of daily living, cognition, or mood by using the Parkinson's Disease Questionnaire-8.

Importantly, demoralization and depression co-occurred more frequently among the 94 participants with PD than in the 86 controls (12.8% vs 3.5%; P = .01).

"This combination is likely to be a marker of persons really suffering from mental disease, who badly need professional treatments to address their mental suffering," Koo said.

In the entire cohort, among demoralized individuals, 63% were depressed, and among depressed individuals, 68% were demoralized.

Compared to nondemoralized patients with PD, those with demoralization had significantly higher mean revised Unified Parkinson’s Disease Rating Scale, part III, scores (30.7 vs 23.6; P = .04); higher mean PHQ9 scores (12.6 vs 4.1; P < .0001), and higher mean Parkinson's Disease Questionnaire-8 scores (11.9 vs 4.5; P < .0001).

PD was associated with a greater likelihood of demoralization in a logistic regression of the entire cohort (odds ratio, 2.60). Younger age and not being married were additional risk factors.

"The distinction between depression and demoralization is important because the treatment approaches are different," he said. 

For example, in the study demoralization, but not depression, was associated with an inability to control movement. Because it was associated with function, "demoralization may be better treated with cognitive-behavioral therapy rather than antidepressant medication, which is often prescribed for depression."

One limitation of the study was a lack of information on details of employment was a potential limitation. In addition, patients with severe PD were more likely not to participate, so the prevalence of demoralization might be underestimated in the study.

Future research could include patients with later-stage PD, use a longitudinal design, and include more detail about psychosocial history to learn more, the researchers noted.

Clinicians "should know about this entity of demoralization as it is prevalent in Parkinson's disease and leads to real suffering," Koo said.

Clinically Important

Commenting on the findings for Medscape Medical News, Laura Marsh, MD, professor of psychiatry and neurology at Baylor College of Medicine and director of mental health at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas, said, "The study calls attention to the phenomenon in Parkinson's disease of demoralization, a normal response to adversity that is fairly common in neurologic disease, and its overlap with depressive disorders, which are pathological mood disturbances that occur with increased frequency in Parkinson's disease.

"Clinically, it is important to distinguish between demoralization and depression to ensure each is recognized and addressed appropriately. In demoralization, the sadness, pessimism, or sense of frustration or helplessness improves when circumstances improve, whereas these same features in a major depressive disorder persist regardless of improved circumstances."

"Since history and course of symptoms is integral to the accurate diagnosis of mood syndromes, the study by Koo et al is limited is by its cross-sectional nature and use of a rating scale rather than a clinical diagnostic interview," Marsh said.

"Nonetheless, greater awareness of demoralization and its nuances and its consideration in the differential diagnosis of depressed mood in patients with Parkinson's disease will advance clinical care," she added.

There was no targeted funding for the study. Koo and Marsh have disclosed no relevant financial relationships.

Neurology. Published online April 4, 2018. Abstract

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