NeuroVoices: Sneha Mantri, MD, MS, on Addressing Depression and Anxiety in Parkinson Care

Mood and behavioral symptoms are now recognized as core features of Parkinson disease (PD), not simply secondary reactions to motor disability. Depression, anxiety, apathy, impulse control disorders, psychosis, and later-stage behavioral changes can emerge early in the disease course, sometimes years before tremor, rigidity, or bradykinesia prompt neurologic evaluation.

These nonmotor symptoms are thought to reflect early and progressive disruptions in dopaminergic and non-dopaminergic circuits, particularly within limbic and frontostriatal networks, and consistently rank among the strongest drivers of reduced quality of life, caregiver burden, and health care utilization in PD.

Despite their prevalence and clinical impact, mood and behavioral symptoms remain underrecognized and undertreated in routine practice, often due to stigma, limited visit time, fragmented care models, and lack of access to mental health resources. In a new iteration of NeuroVoices, Sneha Mantri, MD, MS, chief medical officer of the Parkinson’s Foundation, discusses how mood and behavioral symptoms shape the lived experience of Parkinson disease across stages, how clinical conversations around these issues have evolved, and which screening tools, multidisciplinary strategies, and educational initiatives can help clinicians better identify and address these symptoms as part of comprehensive Parkinson care.

NeurologyLive: For clinicians who treat PD, discuss broadly about how mood and behavior impact patients and their overall well-being?

Sneha Mantri, MD, MS: That is a fantastic question, because mood and behavioral symptoms are one of the biggest drivers of quality of life for people with Parkinson disease. When you look longitudinally, some of these symptoms actually begin even before the development of the more classic motor symptoms that tend to bring people to medical attention. In particular, depressive and anxiety symptoms often predate the onset of motor symptoms. This is thought to relate to early changes in dopamine transmission in the brain and differential effects of dopamine across regions of the striatum.

For patients who have not previously experienced depression or anxiety, the development of new mood symptoms in midlife or later adulthood should raise awareness for clinicians that there may be a broader neurodegenerative process underway, rather than an isolated psychiatric condition. I would not necessarily call this a red flag, because there are many causes of depression and anxiety, but it is something that should prompt thoughtful consideration.

As Parkinson disease progresses, anxiety and depression often become increasingly prominent and can be the strongest determinants of quality of life. Some of this may reflect adjustment to a new diagnosis, but even beyond the acute adjustment phase, many people continue to struggle with persistent mood symptoms. Depression in Parkinson disease is frequently underrecognized, despite being quite amenable to treatment. If we are not routinely assessing mood and anxiety across all disease stages, we are doing our patients a real disservice.

With respect to behavioral symptoms, these tend to emerge more commonly in later stages, particularly when there is cognitive impairment and reduced frontal executive function. Patients may have less insight into behavioral changes, and these concerns are often raised by care partners rather than patients themselves. This is another reason why anticipatory guidance is so important. We need to prepare patients and families early for what may come later, rather than waiting until problems arise.

The conversation around mental health has evolved across medicine. How has the approach to mood and behavioral symptoms in Parkinson disease changed over time?

I think there is significantly less stigma now than there was earlier in my career, although stigma still exists. People are more open about discussing how Parkinson disease affects not just physical function, but mood, personality, and emotional well-being. Societal changes around mental health have helped patients feel more comfortable seeking therapy and bringing these concerns to their clinicians.

At the same time, clinician education has improved. There is greater recognition that nonmotor symptoms have a profound impact on quality of life. Many academic centers now integrate psychiatric care, social work, and counseling into neurology clinics. This reduces fragmentation of care and lowers the burden on patients and families to independently seek mental health services.

Integrated care models also help clinicians. When we know the social workers, psychiatrists, or counselors who are part of our team, it becomes easier to raise these topics and make referrals. It also helps mitigate clinician burnout by reducing the sense that we are trying to manage everything in isolation.

What screening tools or clinical assessments do you find most useful for identifying mood and behavioral symptoms in Parkinson disease, and how do you act on those findings?

There are many screening tools available, and that can feel overwhelming. For depression, large observational studies in Parkinson disease have commonly used the Geriatric Depression Scale. It is relatively simple for patients to complete and provides a quick way to identify individuals who may need further evaluation.

For anxiety, the GAD-7 is frequently used in clinical practice. In my own clinic, we often start with the PHQ-2 for logistical reasons. It is a brief two-question screen, and if a patient screens positive, it flows naturally into the full PHQ-9. I want to emphasize that screening tools do not establish diagnoses. They help identify patients who need more in-depth conversations and assessment.

We are also piloting something called the Hope Questionnaire in our Parkinson and ALS clinics. This tool was developed by a person living with ALS who was frustrated by conversations focused exclusively on decline. It assesses constructs such as hope, adaptability, gratitude, and post-traumatic growth. Poor scores on hope-related measures may also signal depression, because depression can limit a person’s ability to recognize positive experiences. This is still early work, but it offers a complementary way to think about emotional well-being beyond symptom checklists.

From the Parkinson’s Foundation perspective, how is the community working to change conversations around mood and behavioral symptoms?

The Foundation approaches this from several angles. One major initiative is the PD Health at Home series, which includes online programming throughout the year. Mindfulness Mondays focus on nonpharmacologic approaches to anxiety and depression. Wellness Wednesdays address broader lifestyle factors such as nutrition and exercise. Fitness Fridays provide accessible exercise programming tailored for people with Parkinson disease.

Exercise deserves particular emphasis because there is strong evidence that it improves mood, likely through dopaminergic and neurotrophic mechanisms. The Foundation also leads Parkinson Disease Awareness Month every April, with a strong focus on reducing stigma and encouraging people to share their stories.

In addition, we provide extensive education for clinicians through professional webinars and live programs such as the Parkinson’s Foundation Team Training initiative. These programs bring together multidisciplinary clinicians to address complex nonmotor symptoms and improve coordinated care.

What unanswered questions or ongoing challenges remain when it comes to mood and behavioral symptoms in Parkinson disease?

One of the biggest challenges is still opening the door to these conversations. Although stigma has improved, cultural factors can still limit disclosure of mood and behavioral symptoms for certain patient populations. We need more culturally sensitive outreach and education.

On a systems level, lack of true mental health parity remains a major barrier. Limited insurance coverage for therapy and psychiatric care restricts access, even when symptoms are clearly related to Parkinson disease. Continued advocacy for mental health parity and improved access to services will be critical to improving care for people living with Parkinson disease.

Transcript edited for clarity.