The Impact of Mindfulness-based Stress Reduction (MBSR) on Depression, Anxiety and Stress in People with
Parkinson’s Disease
Kelly [email protected]
Linda [email protected]
Aim• To evaluate the impact of an 8-week
Mindfulness-Based Stress Reduction course (MBSR) on people with Parkinson’s 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
Parkinson’s 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
Parkinson’s 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
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 beginner’s 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
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)
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 Parkinson’s who attended a mindfulness course
Method: Patient & public involvement
Patients with Parkinson’s 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
Design and outcome measures
• Mixed methods design
• Data collected at baseline, wk8, and wk16
• Age and Parkinson’s history recorded
• Primary outcome measure: DASS-21
• Secondary outcome measures:– PDQ39 (well-being and stigma)– MAAS– Qualitative follow-up questionnaires
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
PDQ39 – Secondary Outcome Measure
• Parkinson’s 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
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
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
Participants & recruitment
• Participants referred from an Acute Hospital Trust
• Inclusion criteria– Diagnosis of idiopathic Parkinson’s disease
(Parkinson’s 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
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
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).
FindingsRecruitment 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
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
DASS-21
0
2
4
6
8
10
12
14
16
18
Baseline Week 8 Week 16
Mea
n s
core Depression
Anxiety
Stress
• Mean scores for depression, anxiety and stress decreased• Statistically significant improvements
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
PDQ39
• At wk8 and wk16 levels of change varied across the dimensions
0
10
20
30
40
50
60
Baseline Week 8 Week 16
Mea
n s
core
s (0
-100
)
1 Mobility
2 Activities of daily living
3 Emotional well being
4 Stigma
5 Social support
6 Cognitive impairment
7 Communication
8 Bodily discomfort
PDQ39 Summary Index
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
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
Qualitative follow-up questionnaires• Overall participants found the course worthwhile and felt
some benefit
• ‘Has your experience of living with Parkinson’s changed at all since attending the MBSR course?’
0
1
2
3
4
5
Significant positivechange
Some positivechange
No change Some negative change
Significant negativechange
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
What would you tell other people with Parkinson’s 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.”
Conclusion
• Mindfulness-based interventions could benefit people with Parkinson’s
• The intervention is acceptable to patients
• Interpretation of the results is limited – small sample size and lack of control group
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 Parkinson’s should be involved in all stages of future studies, including study design