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

Parkinson’s Disease

Kelly Birtwellkelly.birtwell@mhsc.nhs.uk

Linda Dubrow-Marshalll.dubrow-marshall@salford.ac.uk

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

Questions

• kelly.birtwell@mhsc.nhs.uk

• l.dubrow-marshall@salford.ac.uk