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Clinical Review State of the Art Review

Management of psychiatric and cognitive complications in Parkinson’s disease

BMJ 2022; 379 doi: (Published 24 October 2022) Cite this as: BMJ 2022;379:e068718
  1. Daniel Weintraub, professor of psychiatry and neurology12,
  2. Dag Aarsland, professor of old age psychiatry34,
  3. Roberta Biundo, assistant professor,56,
  4. Roseanne Dobkin, professor of psychiatry7,
  5. Jennifer Goldman, section chief, professor,89,
  6. Simon Lewis,, professor of cognitive neuroscience10
  1. 1Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
  2. 2Parkinson’s Disease Research, Education and Clinical Center (PADRECC), Philadelphia Veterans Affairs Medical Center, Philadelphia, PA
  3. 3Department of Old Age Psychiatry, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, England
  4. 4Centre for Age-Related Diseases, Stavanger University Hospital, Stavanger, Norway
  5. 5Department of General Psychology, University of Padua, Padua, Italy
  6. 6Study Center for Neurodegeneration (CESNE), Department of Neuroscience, University of Padua, Padua, Italy
  7. 7Department of Psychiatry, Rutgers-The State University of New Jersey, Robert Wood Johnson Medical School, New Brunswick, NJ
  8. 8Shirley Ryan AbilityLab, Parkinson’s Disease and Movement Disorders, Chicago, IL
  9. 9Departments of Physical Medicine and Rehabilitation and Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
  10. 10ForeFront Parkinson’s Disease Research Clinic, Brain and Mind Centre, School of Medical Sciences, University of Sydney, Sydney, New South Wales, Australia
  1. Correspondence to D Weintraub daniel.weintraub{at}


Neuropsychiatric symptoms (NPSs) such as affective disorders, psychosis, behavioral changes, and cognitive impairment are common in Parkinson’s disease (PD). However, NPSs remain under-recognized and under-treated, often leading to adverse outcomes. Their epidemiology, presentation, risk factors, neural substrate, and management strategies are incompletely understood. While psychological and psychosocial factors may contribute, hallmark PD neuropathophysiological changes, plus the associations between exposure to dopaminergic medications and occurrence of some symptoms, suggest a neurobiological basis for many NPSs. A range of psychotropic medications, psychotherapeutic techniques, stimulation therapies, and other non-pharmacological treatments have been studied, are used clinically, and are beneficial for managing NPSs in PD. Appropriate management of NPSs is critical for comprehensive PD care, from recognizing their presentations and timing throughout the disease course, to the incorporation of different therapeutic strategies (ie, pharmacological and non-pharmacological) that utilize a multidisciplinary approach.


  • Series explanation: State of the Art Reviews are commissioned on the basis of their relevance to academics and specialists in the US and internationally. For this reason they are written predominantly by US authors

  • Contributors: DW performed the literature search, selected the relevant articles, critically reviewed the literature, wrote sections of the manuscript, and reviewed and edited the final manuscript. He is the guarantor. DA, RB, RD, JGG, and SL selected the relevant articles, critically reviewed the literature search, wrote sections of the manuscript, and reviewed and edited the entire manuscript.

  • D Adams, R Baird, C Eiseman, M McCue, J Weston, and S Weston all graciously contributed to this paper by reviewing the draft and providing feedback. The authors of this paper wish to thank these individuals for their contributions to both this paper and Parkinson disease research.

  • Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following interests:

  • DW has received research funding or support from the Michael J Fox Foundation for Parkinson’s Research, Alzheimer’s Therapeutic Research Initiative, Alzheimer’s Disease Cooperative Study, International Parkinson and Movement Disorder Society, National Institutes of Health, Parkinson’s Foundation, US Department of Veterans Affairs, and Acadia Pharmaceuticals; honoraria for consultancy from Acadia Pharmaceuticals, Alkahest, Aptinyx, Cerevel Therapeutics, CHDI Foundation, Clexio, Clintrex LLC (Otsuka), EcoR1 Capital, Eisai, Ferring, Gray Matter Technologies, Great Lake Neurotechnologies, Intra-Cellular Therapies, Janssen, Merck, Sage, Scion, Signant Health, and Vanda; and license fee payments from the University of Pennsylvania for the QUIP and QUIP-RS.

  • DA has received research support or honorariums from Astra-Zeneca, H Lundbeck, Novartis Pharmaceuticals, Sanofi, Evonik, Roche Diagnostics, and GE Health; and served as paid consultant for H Lundbeck, Eisai, Heptares, Mentis Cura, Eli Lilly, Cognetivity, Enterin, Acadia, Sygnature, Biogen, Cognetivity, EIP Pharma, and Acadia.

  • RB reports honorariums to speak from Bial. She is supported by the Ministry of Health under Grant Number GR-2016-02361986.

  • RD has received research support from the Michael J Fox Foundation for Parkinson’s Research, the Health Services Research and Development Division of the Veteran Affairs (VA) Administration, and the VA Office of Rural Health.

  • JGG has received research funding or support from Acadia Pharmaceuticals, American Parkinson’s Disease Association, the Lewy Body Dementia Association, Michael J Fox Foundation for Parkinson’s Research, and Parkinson’s Foundation; and honorariums as a consultant, educational speaker, or reviewer from the International Parkinson and Movement Disorder Society, Parkinson’s Foundation, and Parkinson Study Group.

  • SL is supported by a National Health and Medical Research Council Leadership Fellowship (1195830) and has received research funding or support from the Michael J Fox Foundation for Parkinson’s Research, Pharmaxis, and Acceler8.

  • Provenance and peer review: Commissioned; externally peer reviewed.

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