The Impact of Mindfulness-based Stress Reduction (MBSR) on Depression, Anxiety and Stress in People with Parkinson

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The Impact of Mindfulness-based Stress Reduction
(MBSR) on Depression, Anxiety and Stress in
People with Parkinsons Disease

• Kelly Birtwell
• kelly.birtwell_at_mhsc.nhs.uk
• Linda Dubrow-Marshall
• l.dubrow-marshall_at_salford.ac.uk

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Aim

• To evaluate the impact of an 8-week
  Mindfulness-Based Stress Reduction course (MBSR)
  on people with Parkinsons disease (PD)
  experiencing depression, anxiety and stress, or
  difficulty coping with PD
• Completed as part of MSc Applied Psychology
  (Therapies) degree, University of Salford
• Other authors Dr J Raw, T Duerden A. Dunn

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Parkinsons disease

• Affects 120,000 people in the UK
• Mainly older adults, age 50
• People under 40 can be affected, 10,000 diagnosed
  young onset per year
• Exact cause unknown
• No cure, symptoms controlled by medication.
  Treatment is complex
• Motor symptoms resting tremor, bradykinesia,
  rigidity, postural instability

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Parkinsons non-motor symptoms

• 40-45 of patients experience depression, up to
  40 experience anxiety
• Anxiety and depression can predate motor symptoms
  by several years
• Apathy, mild cognitive impairment (MCI), sleep
  problems, autonomic disturbance, pain
• NMS have major impact on quality of life
• Improved management of NMS is needed
• New treatments needed, and further research into
  psychosocial interventions for anxiety and
  depression in PD

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Mindfulness

• Paying attention in a particular way on
  purpose, in the present moment and
  non-judgementally (Jon Kabat-Zinn, 2004)
• Building blocks intention, attention, attitude
  (Shapiro et al, 2006)
• 7 attitudes non-judging, patience, a beginners
  mind, trust, non-striving, acceptance and letting
  go (Kabat-Zinn, 2004)
• Formal or informal practice
• One-to-one or group mindfulness courses
• MBCT (NICE guidelines), MBSR

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MBCT MBSR

• MBSR group based, 8 week programme
• Includes stories, poetry, metaphors
• Yoga / mindful movement
• Physiological and psychological bases of stress
• For physical and mental health problems
• More suitable for general population
• Described but not manualised (responsive)
• MBCT integration of MBSR and CBT
• NICE guidelines recommend MBCT for people
  currently well, with a history of 3 or more
  episodes of depression
• Manualised (developed through RCT)

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Mindfulness - applications

• MBSR for pain (Kabat-Zinn et al, 1985), GAD
  (Kabat-Zinn et al, 1992), psoriasis (Kabat-Zinn
  et al, 1998)
• MBSR increases grey matter density (Holzel et al
  2011)
• Fitzpatrick et al (2010) MBCT acceptable and of
  benefit to people with PD
• Dreeben et al (2011) MBSR for people with PD,
  reduced anxiety and depression, psychological
  adjustment
• Sephton et al (2011) MBSR for people with PD,
  slower breathing and reduced evening cortisol
  levels
• Bucks et al (2011) coping processes and quality
  of life in PD, recommended mindfulness
• Pickut et al (2013) increases in grey matter
  density of people with Parkinsons who attended a
  mindfulness course

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Method Patient public involvement

• Patients with Parkinsons were involved
  throughout the life of the study
• Discussion of the initial idea
• Choosing outcome measures
• Adaptations to the MBSR course
• Review and feedback of the study documents

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Design and outcome measures

• Mixed methods design
• Data collected at baseline, wk8, and wk16
• Age and Parkinsons history recorded
• Primary outcome measure DASS-21
• Secondary outcome measures
• PDQ39 (well-being and stigma)
• MAAS
• Qualitative follow-up questionnaires

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DASS-21 Primary Outcome Measure

• Depression Anxiety Stress Scales (DASS-21)
  Lovibond Lovibond 1995
• Short form of the DASS 21 questions
• Reliable and valid in elderly population
• Used in previous mindfulness studies
• Higher scores indicate higher levels of distress
  / worsening of symptoms

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PDQ39 Secondary Outcome Measure

• Parkinsons Disease Questionnaire 39 (Jenkinson
  et al 1995)
• Disease specific rating scale for PD
• 39 questions over 8 dimensions
• mobility, activities of daily living (ADLs),
  emotional well-being, stigma, social support,
  cognition, communication, bodily discomfort
• Higher scores indicate worsening of symptoms
• Widely used and fully validated
• Developed with patients to cover areas of life
  that are important to them

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MAAS Secondary Outcome Measure

• Mindful Attention Awareness Scale (Brown Ryan,
  2003)
• 15 item questionnaire
• Provides overall rating of mindful awareness
• Higher scores indicate increased mindful
  awareness
• Suitable for meditation naïve participants
• Validated scale

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Qualitative follow-up questionnaires

• Designed specifically for this study
• Questions about taking part in the MBSR course,
  and in the study
• What was helpful or unhelpful
• What would they change
• Has their experience of living with PD changed
  since attending the course
• What would they tell others considering attending
  an MBSR course

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Participants recruitment

• Participants referred from an Acute Hospital
  Trust
• Inclusion criteria
• Diagnosis of idiopathic Parkinsons disease
  (Parkinsons UK Brain Bank criteria)
• Identified as experiencing depression, anxiety,
  stress, or difficulty coping with PD
• Exclusion criteria
• Lacking capacity to consent
• Just begun a major life change

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MBSR course

• Developed by Jon Kabat-Zinn
• 8 week, group course
• 1 session per week, up to 3 hours duration
• One full day silent retreat towards the end of
  the course
• Daily home practice, up to 45 minutes
• CDs and worksheets provided
• Delivered by experienced mindfulness teachers

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MBSR course adaptations

• Order of practices and curriculum body as
  source of distress
• Option of sitting for body scan
• Duration of practices shortened
• Full day retreat not included
• Other studies made adaptations (e.g. Sephton et
  al, 2011).

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Findings

• Recruitment and reasons for withdrawal
• 13 participants were recruited
• 9 attended wk1, 6 completed full course
• Withdrawal before the MBSR course began
• Scheduling conflict 2
• Unexpected health issues 2
• Withdrawal after the first MBSR session
• Scheduling conflict 1
• Unexpected health issues 1
• Did not wish to continue 1

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Demographics and PD history

• 6 Participants male 5, female 1
• Mean age 67.96 (5.64 SD, range 60.8 - 72.9)
• PD history

Mean (SD) Range
Age at disease onset 59.13 (7.39) 51.2 - 70.5
Age at diagnosis 60.33 (5.92) 55 - 70
Disease duration 8.82 (5.47) 2.16 - 18.35
Hoehn Yahr staging (symptom progression) 2.33 (0.68) 1.5 - 3.0
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DASS-21

• Mean scores for depression, anxiety and stress
  decreased
• Statistically significant improvements

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DASS-21 severity categories
Depression Anxiety Stress
Normal 0-9 0-7 0-14
Mild 10-13 8-9 15-18
Moderate 14-20 10-14 19-25
Severe 21-27 15-19 26-33
Extremely Severe 28 20 37

• Score range 0 - 42

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PDQ39

• At wk8 and wk16 levels of change varied across
  the dimensions

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PDQ39

• Results were not statistically significant
• Continuous improvements seen in 3 dimensions
  mobility, stigma, social support
• ADLs and well-being showed increase in problems
  at wk8 then return to baseline levels at wk16
• Problems with bodily discomfort increased at wk8
  then decreased at wk16, but not to baseline
  levels
• Cognitive impairment and communication worsened
  at wk8 then stayed the same or worsened again at
  wk16
• The mean summary index score worsened at wk8 then
  returned to baseline at wk16

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MAAS

• Little change in self-reported mindfulness
• Mean scores 3.83 3.77 3.90
• Slight decrease at wk8
• Slight increase at wk16 compared to baseline
• Results not statistically significant
• Score range 1-6, higher score increased
  mindful awareness

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Qualitative follow-up questionnaires

• Overall participants found the course worthwhile
  and felt some benefit
• Has your experience of living with Parkinsons
  changed at all since attending the MBSR course?

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Qualitative follow-up questionnaires

• Some confusion reported
• Some mindfulness concepts
• Aims of the practices
• Terminology used
• Needed fuller explanations earlier in course
• Mindfulness of breath practiced most often

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What would you tell other people with Parkinsons
considering attending an MBSR course?

• I would tell them not to be put off too soon, as
  its relevance takes some time to become obvious.
• Go with an open mind, enjoy the course.
• To go ahead and try it.
• Yes get involved because it's made me think
  about things and realise I'm not on my own.
• Do it.
• Prepare to be stimulated in an unusual way.

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Conclusion

• Mindfulness-based interventions could benefit
  people with Parkinsons
• The intervention is acceptable to patients
• Interpretation of the results is limited small
  sample size and lack of control group

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Future research

• Larger sample sizes required
• Carers could also participate in the mindfulness
  course
• Further adaptations could be considered to meet
  the needs of people with PD
• People with Parkinsons should be involved in all
  stages of future studies, including study design

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Questions

• kelly.birtwell_at_mhsc.nhs.uk
• l.dubrow-marshall_at_salford.ac.uk