In general terms, depression in people with Parkinson's disease should be diagnosed and treated in the same way as for people without Parkinson's disease — see the CKS topic on Depression.

• However, there are specific considerations in relation to diagnosis and assessment, and the choice of drug treatment in people with Parkinson's disease.

• Have a low threshold for diagnosing depression in people with Parkinson's disease.
• Consider using a depression rating scale to screen for and assess the severity of depression.

In depth

• In addition to individual preference, the choice of antidepressant medication should depend on evidence of efficacy, the likely impact of potential adverse effects, and the person's current medication:
• Selective serotonin reuptake inhibitors (SSRIs) are most commonly used.
• SSRIs can worsen motor symptoms, but this occurs rarely.
• SSRIs should not be used by people taking selegiline or rasagiline.
• Use SSRIs with caution in people taking entacapone or tolcapone.
• Tricyclic antidepressants may be more effective than SSRIs in people with Parkinson's disease but their use is limited by the risk of adverse effects. They should only be used with caution.
• Avoid tricyclic antidepressants in people with postural (orthostatic) hypotension, falls, or dementia.
• Tricyclic antidepressants should not be used without specialist advice by people taking selegiline or rasagiline.
• Use tricyclic antidepressants with caution in people taking entacapone or tolcapone.
• People taking selegiline or rasagiline may cautiously use trazodone or mirtazapine (off-label use for selegiline).
• There are no known contraindications to the use of any type of antidepressant in people taking amantadine, apomorphine, or oral dopamine agonists.
• Other antidepressants:
• Irreversible monamine oxidase-A inhibitors (phenelzine, isocarboxazid, tranylcypromine) should not be used with levodopa, selegiline, rasagiline, entacapone, or tolcapone.
• Moclobemide should not be used with selegiline or rasagiline, and should be used with caution in people taking entacapone, tolcapone, and levodopa.
• Venlafaxine and duloxetine should not be used by people taking selegiline or rasagiline, and used with caution in those taking entacapone, or tolcapone (risk of serotonin syndrome).
• Consider contacting the person's Parkinson's disease specialist to ensure that their anti-parkinsonian medication regimen is optimal.
• Seek specialist advice if:
• There is doubt about whether an antidepressant can be safely prescribed.
• There is suspicion that the antidepressant prescribed may be affecting motor control or causing adverse effects.

In depth

• Psychological treatments, such as cognitive-behavioural therapy, may be considered for depression in people with Parkinson's disease.
• The use of psychological treatment should depend on the individual's preference and needs, and on other factors, such as cognitive impairment.
• See the section on Psychological interventions in the CKS topic on Depression for more detailed information.

In depth