Parkinson’s disease
Parkinson's disease (PD) is a progressive neurodegenerative disorder primarily causing motor symptoms such as tremors, rigidity, and bradykinesia (slowness of movement). These symptoms arise due to the loss of dopamine-producing neurons in the brain, specifically in a region called the substantia nigra. Most cases are idiopathic with a smaller number having a genetic cause. PD is a multifaceted condition that also manifests with a range of non-motor symptoms (including weak voice, difficulty swallowing, bladder and bowel problems), which are often more challenging for people with Parkinson’s and their caregivers than the motor symptoms themselves (1).
Motor fluctuations are a significant aspect of disease progression, characterised by alternating "ON" and "OFF" periods. These periods reflect times where symptoms are well controlled (“ON”), typically after taking medication but duration and predictability can vary. When people experience “OFF” periods therapeutic benefits of medication diminish, symptoms can break through and quality of life can be reported as substantially lower during these times highlighting the profound impact motor fluctuations have on daily functioning (2).
Whilst pharmacological management of symptoms is the first line intervention, this in turn can lead to its own challenges with dopaminergic replacement therapies being linked to impulse control disorders that can have a significant impact on the person’s mental health and relationships.
Mood and anxiety:
People with Parkinson’s report higher levels of anxiety and depression compared to the general population (3). The average prevalence of anxiety disorders in people with PD has been found to be 31%, with non-episodic anxiety being more prevalent that episodic anxiety (4,5). People with PD can present with a range of anxiety subtypes including agoraphobia (15.6%), generalised anxiety disorder (11.1%), social phobia (10%), specific phobia (7.8%) and panic disorder (6.7%) (4,6,7). The frequency of depressive disorders was estimated at 30.7%, with major depression disorder apparent in 14% of people with PD (8,9). Prodromal anxiety and depression can present years before motor symptoms due to pathological changes in the brain due to Parkinson’s but can also evolve as a reflection of the challenges adjusting to living with a progressive neurological condition. Those who experience anxiety and depression are more likely to report greater severity of symptoms, global decline, poorer functioning and greater hospital utilisation (10). However, symptoms are not always readily identified whether this be due to underreporting in patients, lack of screening or complexities teasing out disease symptoms from anxiety and depression. PD-specific symptoms of anxiety are mostly due to pathological changes in the brain but are also often related to psychological distress due to the diagnosis or symptoms of PD including social anxiety due to PD-related symptoms, fear of losing control, persistent worry, feelings of inner unrest, panic episodes and fear of falling (5). Apathy is also common in people with Parkinson disease with or without depression with an average estimated prevalence of up to 40% (11) and is more common in people with PD with depression than in people with major depressive disorder (12).
Behaviours that Challenge including Impulse control Disorders:
Approximately 30-40% of those with Parkinson disease exhibit behaviours that can challenge, including aggression, agitation, and apathy (13). These behaviours can be linked to both the neurodegenerative changes in the brain or the side effects of medications. Addressing these behaviours often requires a multidisciplinary approach, including adjustments to medication, psychological support, and caregiver training.
Impulse control disorders (ICDs) are characterised by repetitive, maladaptive and disinhibited behaviours that an individual engages in despite being aware of their potentially harmful consequences to self and others. They are serious concern for people with Parkinson's, especially those taking dopamine agonists as part of their treatment. Worldwide, the prevalence of ICDs in PD varies between 3.5-59%, with the overall prevalence in European and American countries being 20.8% (14). An Italian study showed that the prevalence of ICD in PD was about double that of age matched healthy controls without PD (44.7% compared to 25.2%) (15).
The most common ICD in those with PD include gambling, hypersexuality, compulsive overeating and compulsive buying which can have significant social and personal consequences. ICDs are thought to result from dopamine dysregulation, and while they are often manageable with adjustments to medication, they can be a source of great distress for both patients and caregivers. There are NICE guidelines on managing ICD’s in adults with Parkinsons disease for reference (16).
Cognition:
Cognitive dysfunction in Parkinson's disease can range from mild cognitive impairment to more severe dementia, affecting memory, attention, and executive function (17). Those with PD are five to six times more likely to develop dementia compared with healthy aging populations, and the presence of mild cognitive impairment is one of the risk factors for developing subsequent dementia in those with PD (18,19). Mild cognitive impairment in Parkinson’s disease (PD-MCI) refers to a transitional stage between normal cognition and Parkinson’s disease dementia (PDD), characterized by cognitive decline that exceeds age-related expectations but does not significantly interfere with functional independence. About 25% of those with PD with intact cognitive function converted to PD-associated mild cognitive impairment and 2% to dementia (19,20). Systematic reviews have found that the incidence of dementia in PD is about 4.5% per year (21) with a prevalence of about 30% (22) but the length of time living with Parkinson’s disease increases the risk of developing a Parkinson’s dementia. A recent Scottish study found that approximately 25% of individuals with PD developed dementia after 5 years, 50% by 10 years and 80% by 15 years (23). There has been debate about separating PD dementia (historically defined dementia that occurs more than one year after the first motor features of PD) from Dementia with Lewy bodies (that is, dementia that occurs before or within a year of the motor features of PD) but recent diagnostic revisions no longer make this distinction and regard PD dementia and Dementia with Lewy bodies as part of the same spectrum (24).
Please see the Matrix Dementia page for more details related to presentations and management of individuals who have dementia and resources relating to Parkinson’s related dementia for people with PD and professionals.
Cognitive assessment would be required for those reporting or have observed cognitive impairment. Adaptation of psychological therapies may be required depending on the nature of any cognitive impairments for example slower pace for those with impairment in processing speed and written summaries of sessions for those with verbal memory impairments. Alternations may be required in Cognitive Behavioural Therapy (CBT) protocols such as minimising and simplifying cognitive components, emphasizing behavioural strategies and including partners/carers to help and support.
Parkinsons disease and sleep:
Sleep disorders in Parkinson’s disease is common with studies suggesting that up to 71% of individuals with Parkinson’s experience sleep disturbances with a notable correlation between poor sleep and the severity of non-motor symptoms (25), including anxiety and depression (26). Sleep disorders can include insomnia, REM sleep behaviour disorder, excessive daytime sleepiness, and fragmented sleep patterns. These issues are often exacerbated by motor symptoms such as tremors, rigidity, and bradykinesia, which can interfere with restful sleep. Poor sleep in Parkinson’s disease is often multifaceted, with a significant impact on both the mental and physical well-being of individuals living with the condition.
Sleep difficulties in Parkinson’s disease are not just a consequence of the disease's motor symptoms but are also influenced pathological changes in the brain, and by the emotional and cognitive challenges associated with the condition such as stress of managing daily symptoms, prospect of disease progression and changes to independence. Addressing sleep disturbances in Parkinson’s disease requires a comprehensive approach that not only focuses on the management of motor symptoms but also provides support for mental health, addressing anxiety, depression, and stress through therapies such as cognitive-behavioural therapy (CBT). Within this context, psychological interventions for insomnia can be considered.
Whilst this guidance summarises the recommendations for psychological interventions and therapies to assist with the presenting difficulties outlined above, it should be noted that there can be challenges with accessing psychological interventions due to lack of awareness, gaps in provision or waiting times.
It is estimated that 1 in 37 people in the UK will be diagnosed with Parkinson’s disease in their lifetime. In particular, it is estimated that in 2025, there were 13,980 people living with Parkinson’s disease in Scotland (Parkinson’s UK). PD exhibits a higher prevalence in men compared to women with Parkinson’s Uk suggesting that males aged 50-89 were 1.4 times more likely to be diagnosed with PD compared to females.
Age is the strongest risk factor for PD, predominantly affecting those over the age of 65, which is why the prevalence in the UK has been predicted to increase by about 50% between 2021 and 2040 as the population ages (27). However, people can be diagnosed with young onset Parkinson’s disease before the age of 50. Juvenile Parkinson’s disease (disease occurrence before 21 years old) is rare and often has a stronger genetic basis (28).
This information is for commissioners, managers, trainers, and health care practitioners to consider the evidence base for the delivery of psychological and neuropsychological interventions for people with Parkinson’s disease. This information is also relevant to people living with PD and to health care professionals (in primary, community, secondary and tertiary settings) who have direct contact with individuals living with PD and where decisions regarding care are relevant to their role. As noted, Juvenile PD is rare and evidence of psychological interventions with this age group is beyond the scope of this document.
This topic does not cover pharmacological interventions or interventions which are not informed by psychological theory. There are a wider range of non-psychological interventions and supports that are beyond the scope of this topic and full guidance on best practice can be found in NICE Guidance on Parkinson’s disease in Adults (16). There is an absence of tailored NICE guidelines specific to identifying, treating and managing mental health difficulties like depression in Parkinson’s disease. For some people living with PD, complex and severe mental health diagnoses may present; and should be treated in line with relevant Matrix recommendations for these conditions. Parkinson’s UK has a range of resources available that helps expand on information relating to mental health difficulties in PD for people living with PD and online courses for professionals.
The evidence is synthesised from systematic guidance papers, meta-analyses and randomised control trials (RCTs) published between January 2014 and June 2025. These reviews summarise data regarding psychological and cognitive interventions in the context of PD; updating the evidence base previously published in Matrix evidence (2014). The overview and evidence tables include interventions for: Anxiety, Depression, Sleep Disorders, Impulse Control Behaviours and Cognition presented in the context of PD. Where reported, evidence spans a wide age range including adults aged 24-81 years old. The psychological interventions included can be delivered by professionals with a range of skill mix in psychological practice, lending itself well to a matched care approach. This offers opportunities for psychological therapies and interventions to be delivered within a multi-professional system drawing on expertise in PD and in psychological practice to tailor the interventions offered to the individual.
Psychological therapies for Anxiety for adults living with PD
Conclusions are drawn based on synthesis of evidence from 8 systematic reviews, meta-analysis and a standalone RCT that together summarise data reported from 39 RCTS, 24 feasibility studies, 4 case studies, 5 national clinical trials and 4 randomised waitlist control studies where anxiety was measured as a primary outcome. Psychological therapies included CBT, mindfulness, Acceptance and Commitment Therapy (ACT) and adapted CBT (29-36).
There was a consistent finding of medium to high effect sizes for CBT based approaches, including adapted CBT, for treating anxiety within PD patient groups. These therapies are included as a first line recommendation. There was low-medium effect size for mindfulness-based approaches and nil to low effect size for ACT based interventions for treatment of anxiety with patients who live with PD. These approaches can be considered as an alternative.
Psychological therapies for Depression for adults living with PD
Conclusions are drawn based on synthesis of evidence from 7 systematic reviews, meta-analysis and a standalone RCT that together summarise data reported from 38 RCTS, 6 feasibility RCT’s and 2 randomised waitlist control studies where depression was measured as a primary outcome. Psychological therapies included CBT, adapted CBT and behavioural activation for patients with PD (30,31,33-35,37,38). There was a consistent finding of medium to high effect sizes for CBT based approaches, including adapted CBT, for treating depression within PD patient groups. There is emerging evidence that CBT specifically adapted for Parkinson's disease can be more effective that CBT that is not adapted for those with PD symptoms (31). These therapies are included as a first line recommendation. Mindfulness groups for depression can be considered as an alternative.
Sleep disorders in Parkinson’s disease
While there is well-established evidence for psychological therapies and interventions for sleep problems in the adult populations (see Matrix Insomnia), there is limited evidence that specifically looked at psychological interventions within PD. There is one RCT that shows a significant improvement using internet-based CBT for sleep difficulties within a Parkinson’s population (39), which indicates that the benefits seen in the wider literature may also apply in PD however, more research would be helpful to improve confidence in this finding.
Impulse Control Disorders in Parkinson’s Disease
Conclusions are drawn based on synthesis of evidence from 1 systematic review (40) which reported on 1 RCT (41) that used CBT for psychological management of impulse control disorders, using a non-standardised scale for measuring pre and post intervention gains. Findings suggested a small effect size and the review highlights the absence of more recent research into psychological intervention for ICD which diminishes the ability to make confident clinical recommendations.
Treatment of Cognitive Disorders in Parkinson’s Disease
Conclusions are drawn based on synthesis of evidence from 1 meta-analysis (42) and 2 systematic reviews (43,44) summarising data on 46 RCTS and one prospective randomised study. Findings suggest a medium to large effect size of computerised rehabilitation training programmes on improving aspects of cognition within a PD population. There is a lack of literature on the benefit of cognitive rehabilitation of those specifically with PD. This difficulty is partly attributed to heterogeneity of this population group and lack of specificity regarding the cognitive domain involved in rehabilitation.
Overview of Evidence for Harms and Adverse Effects
Psychological therapies have the potential to have adverse effects. Until recently, information on potential harms and rates of adverse effects have not been gathered systematically. Although reports of adverse effects are increasingly included in research trials and gathered as part of service provision, we do not know if psychological interventions cause more, fewer or similar numbers of adverse effects than no treatment or another treatment, because the evidence in this area is of very low quality at present.
|
Recommendation |
Who for? |
List of Interventions |
Type of psychological practice |
Evidence |
Efficacy |
| First line recommendation | People with PD and anxiety (mild-severe) | Individual CBT (31-36) Telephone, group, & internet (31-33,36) Adapted for those with cognitive impairment (31,34) |
Enhanced Specialist | A | Medium-High |
| First line recommendation | People with PD and depression (mild-severe) | Individual CBT (31,33-35) telephone & internet (31,33). Adapted for those with cognitive impairment (31). |
Enhanced Specialist | A | Medium-High |
| First line recommendation | People with PD Cognitive impairment and depression | Behavioural Activation (face to face, telephone and carer support) (37,38) | Skilled Enhanced Specialist |
A, B | Medium - High |
| Alternative (lower efficacy) | People with PD and Mild-Moderate Anxiety | ACT & Group (30,32) | Skilled Enhanced |
B | Low (non-significant) |
| Alternative (lower efficacy) | People with PD and Mild-moderate depression | Mindfulness for Depression Group (30) | Skilled | A | Low for depression and Quality of Life |
| First line recommendation | People with PD and Sleep disorders | Internet Based CBT (39) | Enhanced | A | High |
| First line recommendation | People with PD and Impulse Control Behaviour | Adapted CBT (40,41) | Skilled Enhanced |
B | Low |
| First line recommendation | Cognitive Rehabilitation | Computer based training (42-44) | Skilled Enhanced | A | Medium-High |
With thanks to representatives from Parkinson's UK for their involvement and feedback.
Technical Group: Susan O'Connell, Fiona Summers, Leeanne Nicklas
Advisory Group: Carl Counsell, Anita Jefferies, Samantha Matson, Thomas McCallum, Ailis McQueen, Leeanne Nicklas, Susan O’Connell, Deric Robinson, Fiona Summers, Maggie Whyte.
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